Livedo reticularis

Laboratory tests for hypercoagulable states should be done only when the cause of the stroke cannot be determined based on the presence of well-known risk factors. Protein C, protein S, and antithrombin III are best measured in steady state rather than in the acute stage. Antiphospholipid antibodies are of higher yield but should be reserved for patients aged less than 50 years and those who have had multiple venous or arterial thrombotic events or livedo reticularis. 

Adverse effects include sedation, vivid dreams, dry mouth, depression, hallucinations, anxiety, dizziness, psychosis, and confusion. Livedo reticularis (a diffuse mottling of the skin in upper or lower extremities) is a common but reversible side effect. 

Adverse reactions occurring in 3% of patients include nausea dizziness lightheadedness insomnia depression anxiety irritability hallucinations confusion anorexia dry mouth constipation ataxia livedo reticularis peripheral edema orthostatic hypotension headache. 

Type B effects are rare but should be recognized. They include oedema of the lower limbs (bromocriptine, amantadine), livedo reticularis (amantadine), diarrhoea (tolcapone, entacapone), paroxysmal hypertension and dysregulation of blood pressure control (selegiline), narcoleptic phenomena (pramipex-ole), and insomnia (all dopaminergic agonists). 

Amantadine was originally introduced as an antiviral compound (see Chapter 50), but it is modestly effective in treating symptoms of parkinsonism. It is useful in the early stages of parkinsonism or as an adjunct to levodopa therapy. Its mechanism of action in parkinsonism is not clear, but amantadine may affect dopamine release and reuptake. Additional sites of action may include antagonism at muscarinic and A-methyl-D-aspartate (NMDA) receptors. Adverse effects include nausea, dizziness, insomnia, confusion, hallucinations, ankle edema, and livedo reticularis. Amantadine and the anticholinergics may exert additive effects on mental functioning. 

D. Although not widely used, amantadine may be useful in the early stages of Parkinson s disease or as an adjunct to other agents. Livedo reticularis is a characteristic purple mottling of the skin associated with amantadine. 

Orthostatic hypotension, anorexia, headache, livedo reticularis (reddish blue, netlike... 

Livedo reticularis sometimes occurs in patients taking amantadine and usually clears within 1 month after the drug is withdrawn. Other dermatologic reactions have also been described. Peripheral edema, another well-recognized complication, is not accompanied by signs of cardiac, hepatic, or renal disease and responds to diuretics. Other adverse reactions to amantadine include headache, heart failure, postural hypotension, urinary retention, and gastrointestinal disturbances (eg, anorexia, nausea, constipation, and dry mouth). 

Rhabdomyolysis, acute renal insufficiency, pancreatitis, ileus, livedo reticularis, and raised transaminase activities developed in a patient who had taken lovastatin for 7 years and took erythromycin before a dental procedure. 

The primary adverse effects associated with amantadine are orthostatic hypotension, CNS disturbance (e.g., depression, confusion, hallucinations), and patches of skin discoloration on the lower extremities (livedo reticularis). However, these side effects are relatively mild compared to those of other anti-Parkinson drugs and are usually reversed by altering the drug dosage. 

Young (<50 years) and no other cause found past history or family history of venous thrombosis, especially if unusual site (cerebral, mesenteric, hepatic veins) recurrent miscarriage thrombocytopenia cardiac valve vegetations livedo reticularis raised ESR malaise positive syphilis serology... 

A 48-year-old woman with a 17-year history of Parkinson s disease developed a sensorimotor peripheral neuropathy after taking amantadine 300 mg/day for 8 years (12). She had livedo reticularis after only 1 year of treatment and this had become increasingly extensive. Attempts to withdraw the drug resulted in worsening Parkinsonian symptoms. However, after the neuropathy had been diagnosed, amantadine was withdrawn, with improvement of the neurological symptoms within 6 weeks and complete resolution after 6 months. However, the livedo reticularis was still present 18 months after withdrawal. 

This is the first description of peripheral neuropathy in these circumstances, but it suggests that chronic livedo reticularis may be a forerunner of more severe problems. 

Livedo reticularis has been stated to occur in as many as 90% of patients it is very common in female patients especially those with antiphosphohpid antibodies (19). 

Silver DE, Sahs AL. Livedo reticularis in Parkinson s disease patients treated with amantadine hydrochloride. Neurology 1972 22(7) 665-9. 

Paulson GW, Brandt JT. Amantadine, livedo reticularis, and antiphospholipid antibodies. Clin Neuropharmacol 1995 18(5) 466-7. 

Fluorouracil Topical antimitotic drug Telangiectasia bilateral cicatricial ectropion exacerbation of Herpes labialis pain, edema, livedo reticularis erosions (SEDA-7, 166) (SEDA-7, 166) (SEDA-5, 155)... 

Cholesterol embolization is thought to occur after removal of mural thrombi covering atherosclerotic plaques leading to direct exposure of the soft lipid-laden core of these plaques to the arterial circulation. The contents of the soft lipid core, including crystallized cholesterol, shower the downstream circulation. Cholesterol crystals are impervious to dissolution or lysis and they lodge in small arterioles, causing obstruction. Cholesterol embolization shortly after thrombolytic treatment is characterized by livedo reticularis or multiple necrotic lesions of the skin of both legs (7) but can also be associated with... 

Occasional Orthostatic hypotension, anorexia, headache, livedo reticularis (reddish blue, netlike blotching of skin), blurred vision, urinary retention, dry mouth/nose... 

Note Fifty to 90% of patients receiving amantadine for Parkinsonism develop a more or less livedo reticularis ... 

Nakasu Y+, Neurol Med Chir (Tokyo) 38(10), 669 Exanthems Livedo reticularis... 

Michel B +, Schweiz Med Wochenschr (German) I 15, 418 Exanthems Livedo reticularis... 

Dwyer C M +, / Am Acad Dermatol 29, 496 Hypersensitivity Livedo reticularis... 

Idiosyncratic drug reactions (2002) Dieckhaus CM +, Chem Biol Interact 142(1), 99 Lichen planus Livedo reticularis Lupus erythematosus Photosensitivity (<0.01 %)... 

Chia-Yu C +, Acta Dermato-Venereol 81(6), 426 Livedo reticularis... 

Au S+, Vancouver, Canada, March AAD Poster Livedo reticularis... 

Linear IgA dermatosis (1993) Parodi A+, Dermatology 187, 155 (1990) Guillaume JC +, Ann Dermatol Venereol (French) I 17, 899 Livedo reticularis... 

LittJZ, Beachwood, OH (personal case) (observation) Livedo reticularis... 

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