Do no harm to the arm!: hypertension and unilateral hand rash.To the Editor: Sophisticated monitoring may not always be better for the patient.... Ambulatory blood pressure monitoring ambulatory blood pressure monitoring, n measurement of a patient's blood pressure at regular intervals while the patient carries out daily activities. is often utilized in the healthcare setting for a multitude of indications including the evaluation of episodic hypertension. It is a convenient diagnostic tool due to its precision, lack of observer bias and reproducibility. (1) However, ambulatory blood pressure monitoring can be inconvenient, uncomfortable and sometimes harmful for the patient. (2) A 62-year-old man was placed on ambulatory blood pressure monitoring in the emergency department. Measurements were set at 20-minute intervals while the patient was in the acute care examination room. He had a history of coronary artery disease coronary artery disease, condition that results when the coronary arteries are narrowed or occluded, most commonly by atherosclerotic deposits of fibrous and fatty tissue. , hypertension, atrial fibrillation, diabetes and gout. After 4 hours on the monitor, the patient complained of some arm pain and new onset rash. On physical examination, a nonpalpable petechial rash was noted on the dorsal surface of the left hand and fingers (Fig.). The rash did not progress beyond 2 inches proximal to the left wrist. The palms, contralateral hand and feet were clear. The patient denied any pruritus. Blood pressure at the time the rash was detected was 185/100 (range, 181-206 mm Hg systolic Systolic The phase of blood circulation in which the heart's pumping chambers (ventricles) are actively pumping blood. The ventricles are squeezing (contracting) forcefully, and the pressure against the walls of the arteries is at its highest. and 96-108 mm Hg diastolic Diastolic The phase of blood circulation in which the heart's pumping chambers (ventricles) are being filled with blood. During this phase, the ventricles are at their most relaxed, and the pressure against the walls of the arteries is at its lowest. ). At the time of admission, the INR was 3.2. At 20 hours, the rash was still present but had not progressed. A Rumpel-Leede test for capillary fragility on the contralateral hand was positive. [FIGURE OMITTED] We believe this to be a complication of ambulatory blood pressure monitoring in a patient with increased capillary fragility due to hypertension, diabetes and vitamin K deficiency Vitamin K Deficiency Definition Vitamin K deficiency exists when chronic failure to eat sufficient amounts of vitamin K results in a tendency for spontaneous bleeding or in prolonged and excessive bleeding with trauma or injury. secondary to warfarin therapy. Other risk factors for increased capillary fragility include chronic renal failure chronic renal failure Chronic kidney failure Nephrology A slow decline in renal function, which may be 2º to chronic HTN, DM, CHF, SLE, or sickle cell anemia and, if extreme, leads to ESRD, mandating kidney dialysis; an abrupt decline in renal function may be , thrombocytopenia, coagulopathy (eg, von Willebrand disease Von Willebrand Disease Definition Von Willebrand disease is caused by a deficiency or an abnormality in a protein called von Willebrand factor and is characterized by prolonged bleeding. , disseminated intravascular coagulation disseminated intravascular coagulation n. Abbr. DIC A hemorrhagic disorder that occurs following the uncontrolled activation of clotting factors and fibrinolytic enzymes throughout small blood vessels, resulting in tissue necrosis and , etc.), and scurvy. In addition, the acutely elevated blood pressure with frequent cuff inflations on the same arm likely precipitated the rash. The inability of the cuff to exceed the systolic pressure may produce a faulty reading which signals the monitor to reinflate the cuff. This can lead to a prolonged inflation period of up to 3-5 min causing petechial hemorrhages in the ipsilateral hand. Clinicians should be aware of this potential complication of ambulatory blood pressure monitoring and avoid misinterpreting iatrogenic clinical findings for pathologic conditions. Brad Sapp, MD Internal Medicine Department Medical University of South Carolina “MUSC” redirects here. For Abel Santa María airport in Santa Clara, Cuba (ICAO code MUSC), see Abel Santa María Airport. The Medical University of South Carolina Charleston, SC Aaron Brown, MD Semaan Georges Kosseifi, MD III Internal Medicine Department East Tennessee State University Johnson City, TN References 1. White WB, Mansoor GA. Ambulatory blood pressure monitoring. Curr Opin Nephrol Hypertens 1993;2:928-934. 2. Appel LJ, Stason WB. Ambulatory blood pressure monitoring and blood pressure self-measurement in the diagnosis and management of hypertension. Ann Intern Med 1993;118:867-882. May the Warm Winds of Heaven blow softly upon your house. May the Great Spirit bless all who enter there. May your Mocassins make happy tracks in many snows, and may the Rainbow always touch your shoulder. --Cherokee prayer |
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