a 64-year - old man with a 15-year long history of hypertension was presented to the emergency room with a 24-hour history with symptoms of cyanosis and pain on the right upper extremity , consistent with acute ischemia .
the major physical findings revealed that the right upper extremity was pale , cold , and exhibited reduced sensation and power .
blood pressure was 130/80 mmhg and heart rate was regular at 64 beats per minute .
laboratory values indicated an increase in white blood cell count of 11,400/ul , normal hemoglobin value of 15.5 g / dl and elevated creatininc kinasl mb ( ck - mb ) value of 33.2 ng / ml ( normal , 0 - 5 ng / ml ) .
the increased levels of bun ( 31.9 mg / dl ) ( blood urea nitrogen ) and serum creatinine ( 1.8 mg / dl ) returned back to baseline value within three days .
iu / l ) and alanine aminotransferase ( range , 28 - 79 ) were increased .
a right transfemoral approach was performed with placement of a 6-f sheath . a 5-f angiographic catheter ( h1
angiogram obtained after injection of contrast medium in right axillary artery revealed a smooth , tapered narrowing of the brachial artery without opacification of radial and ulnar artery ( figs .
1a , b ) . at the time of angiography , passing of guide wire across the narrowing and occlusive segment was attempted , but these efforts were unsuccessful .
the diagnosis of unusual pattern of raynaud 's disease was initially made , eventually incorrect .
a fear of gangrenous changes in right upper extremity , he had undergone intraarterial papaverine injection of 30 mg and a right axillary - radial bypass surgery . over a period of approximately two hours , there was a dramatic improvement in the color of the patient 's upper extremity and radial pulses became palpable , but cyanosis and pain persisted at phalangeal area .
in addition to intravenous infusion of prostaglandin e1 and heparin , two days later , the patient underwent ipsilateral sympathectomy with the subsequent disappearance of cyanosis and pain on phalangeal area .
arteriography examination demonstrated normal arterial anatomy of the right arm as well as the patent graft ( figs .
the patient 's postoperative recovery was uneventful , and he was discharged in a good condition .
eight days later , the patient returned for the same ischemic symptoms of the right upper extremity .
repeated angiography revealed the similar findings which had been demonstrated during first angiography and also occlusion of graft was noticed .
the diagnosis of ergotamine - induced vasospasm was made only after that and treatment was initiated by discontinuing the intake of offending drug and an intravenous infusion of nitroprusside was initiated at a rate of 4 g / kg / minute .
the drug infusion was continued over four days until there was relief from pain and cyanosis .
we noticed that for over a period of 10 years the patient had been prescribed ergotamine for the treatment of migraine .
people who consumed the fungus contaminated grain suffered from limb ischemia and discoloration of extremities .
most of the cases of ergotamine toxicity are due to medication ingestion , either acutely or chronically ( 2 ) .
this particular alkaloid can cause intense peripheral vasoconstriction which can lead to gangrene and amputation .
ergotamine - induced vascular ischemia is rare , but potentially serious complication may be induced through two mechanisms : vasospasm and thrombus formation .
the latter may be caused by stasis and a postulated direct endothelial damage may be caused by ergotamine .
toxicity can occur from chronic use of therapeutic doses , acute ingestion of excessive amounts , and acute ingestion of normal doses in hypersensitive patients .
a number of conditions are known to potentiate the vasospastic effects of ergotamine like , fever , sepsis , malnutrition , thyrotoxicosis , pregnancy , liver and renal insufficiency , coronary artery disease , and peripheral vascular disease ( 3 ) .
the triggering factor for the development of ergotamine toxicity in the present case is still uncertain , but a possible reason could be hepatitis ( elevated liver enzyme ) with transient renal dysfunction .
drugs may also be responsible for an increase in the side effects of ergotamine ( 4 , 5 ) : oral contraceptives , xanthine derivatives , antiviral agents , antibiotics interfering with the liver metabolism of ergotamine ( i.e. clarithromycin , ampicillin , erythromycin , and troleandomycin ) .
recently , baldwin et al . described a case of ergotamine toxicity in an human immunodeficiency virus infected patient treated with antiviral protease inhibitor ( 6 ) .
ischemia caused by ergotamine intoxication affects the lower extremities more commonly than the upper extremities .
the external carotid arteries are often involved with a rare involvement of coronary , mesenteric , renal , and retinal arteries .
the diagnosis of this rare condition requires a high index of suspicion in patients with migraine and a careful inquiry about their medication history .
the angiographic findings of the affected vessels reveal thin , threadlike and smooth tapered narrowing of the arteries with or without collateral formation ( 7 ) .
thrombus results from stasis distal to arterial spasm with either bilateral or symmetrical involvement , and the areas of stenosis may be diffused or localized .
many therapeutic modalities can be used to reverse the vasoconstriction ( 8 , 9 ) .
the first step of the treatment is discontinuation from the offending drug . when vascular thrombosis is suspected , heparin , a low molecular weight dextran and streptokinase has been suggested to reduce tissue loss .
nitroprusside , a direct acting vasodilator , is effective but can be used only for shorter periods of time and prompt recurrence of symptoms have been reported after discontinuation .
nifedipine is the most potent peripheral vasodilator of the group and has been successfully used to treat ergotamine toxicity . in severe forms of ischemia refractory
to pharmacologic treatment , surgical sympathectomy or intraarterial balloon dilatation can be effective ( 10 ) , and the management depends on early diagnosis of the symptoms . in our case ,
uninterrupted medication for migraine is thought to play a significant role in the development of recurrent symptoms .
the present case emphasizes the importance of acquiring a detailed medication history . combination of heparin , prostaglandin e1 , and sympathectomy did not prevent the progression of cyanosis in our case , but intravenous injections of nitroprusside could relieve the symptoms .
an understanding of the clinical features and angiographic findings of ergotamine - induced ischemia is essential in early diagnosis and treatment to prevent irreversible complications .
 ergotamine - induced limb ischemia is an extremely rare case . 
 we present a case of a 64-year - old man , who developed ischemia on the right upper extremity due to long - term use of ergot for migraine headache . 
 angiography revealed diffused , smooth , and tapered narrowing of the brachial artery . 
 the patient was successfully treated with intravenous nitroprusside . 