Dermatology Online Journal

Focal iatrogenic peticheae: An unusual post electroconvulsive therapy skin finding
Mary S McCallister MD¹, Ahmad Athar MD², Rashid M Rashid MD³
Dermatology Online Journal 14 (12): 7

1. Medical education, Indiana University School of Medicine, Indianapolis, Indiana
2. Department of Internal Medicine, St. Vincent Hospital, Indianapolis, Indiana
3. Department of Dermatology, MD Anderson Cancer Center, UT-Houston, Texas. RashidRashid.MDPhD@yahoo.com

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Abstract

Electroconvulsive therapy (ECT) is an established treatment for refractory cases of major depression for over 60 years. There are many widely known and reported side effects of ECT. However, cutaneous changes post-ECT are rarely reported in the peer-reviewed literature. This report illustrates a case of post-ECT changes that consisted of petichiae. This manuscript also discusses the potential pathogenesis behind this presentation.

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Case report

Our patient is a 53-year-old Caucasian female with a history of recurrent and severe major depressive disorder who was admitted to the hospital for pre- Electroconvulsive therapy (ECT) work-up. The patient had never had ECT in the past. She had a past medical history notable for microcytic anemia, type II diabetes mellitus, gastroparesis, chronic cholecystitis, and viral encephalitis. She did not have any personal or family history of any bleeding disorders or skin disorders. The patient's medications prior to and during the time period in which she received ECT were: ascorbic acid, citalopram, clonazepam, enoxaparin, erythromycin, furosemide, ibuprofen, insulin aspart, insulin glargine, metoclopramide, multivitamin, modafinil, naproxen, niacin, nystatin, pantoprazole, pentoxifylline, simvastatin, tramadol, venlafaxine, and zinc.

The patient received her first ECT treatment without complication. Anesthesia was induced with glycopyrolate 0.2 mg, methohexinol 70 mg, and succinylcholine 70 mg. After adequate anesthesia and paralysis was achieved, a bifrontal stimulus was delivered (DE 15.4, pulse width 1.0 milliseconds, frequency 40 Hz, duration 0.75 seconds, current 0.8 amperes). The electroencephalogram recorded 77 seconds of seizure activity.

A second ECT treatment was administered three days later without complication. Anesthesia was identical to that used in the first treatment. A bifrontal stimulus was delivered (DE 26.5, pulse width 1.0 milliseconds, frequency 40 Hz, duration 1.25 seconds) that resulted in 68 seconds of seizure activity according to electroencephalogram recordings.

Figure 1
Figure 1. Unilateral petechiae ends in a clear and demarcated area on the distal forearm. This photograph was taken 5 days after ECT therapy.

A third ECT treatment was delivered two days after the second ECT treatment. The anesthesia administered for the third ECT treatment was identical to that of the first two ECT treatments. The stimulus delivered (DE 25.9, pulse width 1.0 milliseconds, frequency 40 Hz, duration 1.25 seconds) that resulted in 47 seconds of seizure activity as recorded on the electroencephalogram. One day after the administration of this ECT treatment, the patient was noted on physical exam to have skin changes present only on the dorsal right hand and forearm. These consisted of pinpoint, nonblanching, 1mm red macules most consistent with petechiae. There was a noticeable absence of petechiae about the right dorsal wrist in a 6mm wide circumferential band-shaped area. There were no vesicles, pustules, or abrasions noted on the skin. Petechiae were not seen anywhere else on the body. The patient had no other complications from this third ECT treatment. Of note regarding her ECT treatments was the usage of upper extremity restraints on the wrists of the patient during all three treatments. The petechiae started to resolve soon after appearance. The patient refused biopsy. Basic metabolic panel and complete blood count was normal before and after ECT.

Discussion

Electroconvulsive therapy (ECT) has been used as treatment for refractory cases of major depression for over 60 years [1]. It is considered to be a transiently effective treatment option and may result in an earlier onset of symptom improvement compared to drug therapy. There are no absolute contraindications to ECT [2]. There are, however, many widely known and reported side effects of ECT. These include adverse outcomes related to administration of anesthesia such as post-ictal confusion, nausea, headache, muscle pain, short-term cognitive side effects, anterograde and retrograde amnesia. Also reported as resultant from ECT are cardiac events including hypertension, tachycardia, arrhythmias, and asystole [2].

Although a thorough search of Medline was performed, we are unaware of other reports of ECT leading to the development of petechiae on any area of the body. In an article by Sienaert et al., a case of ECT being used on a patient that also had Ehlers-Danlos Syndrome is discussed [3]. Even in this patient, whose skin was abnormally hyperextensible and fragile, ECT did not result in any damage to the patient's skin. The article, however, does not mention any use of wrist or ankle restraints during the treatment sessions. The article does mention that the Hamilton cuff technique was not used to avoid damage to the skin and vessels in the foot, so it is likely restraints were also not used for the same reasons.

We believe that the petechiae present on our patient's right hand and forearm were due to the presence of a wrist restraint on the patient's right wrist during the procedure. Supportive evidence of this theory is the absence of petechiae in a circumferential band-shaped area on the patient's dorsal right wrist. Unfortunately, The pathogenesis of the petechiae is less clear. However, it is interesting to note that such cases of focal petechiae are especially well known in forensic medicine, as noted in victims of strangulation [4].

Our literature search did provide some possible suggestions as to the pathoetiology, and we hope an increased awareness of this and other similar cases would eventually provide more clues. Amongst our findings, we noted a phenomenon described in the literature whereby a period of hypoxia followed by reestablished blood flow can induce petechiae on the skin [1]. It is possible that a re-establishment in blood flow and increased pressure in small vessels that have already been damaged by a preceding period of ischemia cause the damaged vessels to break and petechiae to form. Other theories have also been proposed and include vasocongestion as a central pathologic process [4]. These theories are illustrated in cases in the literature involving cardiopulmonary resuscitation [1], victims of strangulation [4], and victims of crush asphyxia [5].

Finally, in victims of crush asphyxia, this diagnosis hinges on the history of chest or abdominal compression along with the presence of skin petechiae on the chest and abdomen [5]. More importantly, it has been reported in the literature that the pattern of petechiae seen on crush victims' chests can be influenced by tight-fitting clothing. For example, beneath the area of a victim's brassiere, few to no petechiae would be seen, known as the "brassiere sign" [5]. This phenomenon was hypothesized to be due to reduced vascular congestion in this area where the tight-fitting brassiere was compressing the underlying vessels. This same hypothesis can be applied to our patient developing petechiae due to a tight-fitting wrist restraint. The wrist restraint was fitted tightly enough around the patient's right wrist such that the underlying vessels were compressed. Consequently, there developed vascular congestion and a setting of ischemia in the vessels of the hand while the wrist restraint was in place. Vascular damage may also have occurred as the edges of the restraint stretched and strained the skin during the convulsions.

It is also important to consider the possibility that the petechiae and purpura are similar to those noted after valsalva, seizure episodes, or severe emesis. This is believed to be due to sudden high venous pressure with resultant vascular congestion and rupture of vessels. The actual mechanism and pathoetiology is not known although theories raised include transient extreme hypertension and/or release of vasoactive substances that induce vessel dilation, leak, and even rupture [6, 7].

Another possible theory involves the fact that convulsive forces in a wrist-restrained patient can be sufficient to break osteoporotic bone, and could easily damage vessels [8]. Once the restraint was removed, blood flow was re-established in the vessels that were damaged during the ischemic convulsive period. These fragile vessels then break due to the increased blood flow and pressure when the restraint is removed and skin petechiae manifest. Thus, the petechiae seen in our patient was likely due to the presence of this wrist restraint rather than due to the actual ECT treatment. The possible damage is further emphasized by broken bones noted in similar ECT wrist restraint scenarios [8].

In conclusion, the use of wrist restraints in patients receiving ECT can result in the formation of skin petechiae. In patients receiving ECT, practioners should be aware of the possible complications due to the usage of wrist restraints. Care should be taken to ensure that if wrist restraints are used, they are adjusted properly and are not too tightly fitted on the patient. Finally, in patients that do exhibit physical side effects, physicians should also be aware of the limited short-term efficacy and lack of long-term safety testing of ECT [2].

References

1. Holtzmann J, Polosan M, Baro P, Bougerol T. ECT: from neuronal plasticity to mechanisms underlying antidepressant medication effect. Encephale. 2007;33:572-8. [PubMed]

2. Datto CJ. Side effects of electroconvulsive therapy. Depression and Anxiety. 2000;12:130-4. [PubMed]

3. Sienaert P, De Hert M, Houben M, et al. Safe ECT in a patient with the Ehlers-Danlos Syndrome. The Journal of ECT. 2003;19:230-3. [PubMed]

4. Plattner T, Bollinger S, Zollinger U. Forensic assessment of survived strangulation. Forensic Science International. 2005; 153:202-7. [PubMed]

5. Byard RW. The brassiere 'sign' - a distinctive marker in crush asphyxia. Journal of Clinic Forensic Medicine. 2005; 12:316-9. [PubMed]

6. Pierson JC, Suh PS. Powerlifter's purpura: a valsalva-associated phenomenon. Cutis. 2002 Aug;70(2):93-4. [PubMed]

7. Reis JJ, Kaplan PW. Postictal hemifacial purpura. Seizure. 1998 Aug;7(4):337-9. [PubMed]

8. Baethge C, Bschor T. Wrist fracture in a patient undergoing electroconvulsive treatment monitored using the "cuff" method. Eur Arch Psychiatry Clin Neurosci. 2003; 253:160-2. [PubMed]

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