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9 Κρητο-Κυπριακο Συμποσιο Ρευματολογιας 20 Οκτωμβριου 2017 Λεμεσος

9 Κρητο-Κυπριακο Συμποσιο Ρευματολογιας 20 Οκτωμβριου 2017 Λεμεσος. Dr Nedi Zannettou , Physician Rheumatologist . Apollonio Private Hospital , Nicosia Cyprus . 9 Κρητο-Κυπριακο Συμποσιο Ρευματολογιας 20 Οκτωμβριου 2017 Λεμεσος.

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9 Κρητο-Κυπριακο Συμποσιο Ρευματολογιας 20 Οκτωμβριου 2017 Λεμεσος

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  1. 9 Κρητο-Κυπριακο Συμποσιο Ρευματολογιας20 Οκτωμβριου 2017 Λεμεσος Dr Nedi Zannettou, Physician Rheumatologist. Apollonio Private Hospital, Nicosia Cyprus. 9 Κρητο-Κυπριακο Συμποσιο Ρευματολογιας 20 Οκτωμβριου 2017 Λεμεσος

  2. 9 Κρητο-Κυπριακο Συμποσιο Ρευματολογιας20 Οκτωβριου 2017 Λεμεσος

  3. 1st case • Middle age woman 45 • Wheeled in exam room • Severe pain left leg • Clinically, very tender over the trochanteric region • X-ray pelvis and hips- normal • Diagnosed as trochanteric bursitis and treated with local steroid injection, NSAID’s and topical anti inflammatory patches

  4. Follow up in 24 hours • Recurrence of the pain • Blood tests: WCC- 14,23 with normal differential count; ESR-31mm/hr. and CRP-11.3mg/L • MRI

  5. MRI • Tear of the left gluteus Medius tendon, extensive intramuscular edema of the left gluteus Medius muscle and fluid around the myotendinous junction; there is associated left trochanteric bursitis and fluid extending around the left vastus lateralis muscle

  6. Further management Arthroscopic debridement booked due to severity of the symptoms. Findings: • Inflammation of the bursa • Tear of the gluteus Medius tendon 3. Abscess- draining into the thigh 4. Massive tissue necrosis

  7. Brucella screening done • Farm worker • Cattle and sheep • Patient non toxic, afebrile • Suspected cold abscess

  8. Culture –MRSA!!!!!!! • Further questioning: several Voltaren injections buttock at her local clinic • 3 further surgical debridement’s, Vancomycin, linezolid for 8 weeks

  9. Novartis Global Safety Database (spontaneous and clinical trial reports) for diclofenac ampoules from 1978 -2003 revealed: • 115 reports of injection site necrosis, • 37 reports of injection site abscess • 11 reports of injection site reaction • 6 reports of necrotizing fasciitis (south Africa 1 case fatal-post haemorrhoidectomy) • 2 cases of necrotizing myositis. • Interestingly, pain was only reported in 9 of these cases • Number of treatments is in excess of 100,000,000 units over this 25 year period.

  10. Intramuscular diclofenac: 25 year worldwide safety • In summary, the use of intramuscular diclofenac is widespread, estimated, some 100 000 000 units • Voltarol have been used over 25 years and the number of cases of tissue damage are ‘tiny’!!!!!!!!

  11. Diclofenac and Muscle Damage There have been a number of worrying case reports in the literature concerning tissue damage occurring secondary to IM Diclofenac. References1. Pillans, O’ Connor N. Tissue necrosis and necrotizing fasciitis after intramuscular administration of Diclofenac. Annals of Pharmacotherapy 1995;29(3)264 – 266.2. Power I. Muscle damage with Diclofenac injections. Anaesthesia 1992; 47:451.

  12. Intramuscular diclofenac: 25 year worldwide safety perspective The defense unions have stated that IM injections of Diclofenac into the thigh are the least safe and the Committee on Safety for Medicines has received a significant number of reports concerning the above issue. None of the cases that were opened were defensible and one of the recommendations was that alternative routes of administration should be used where possible

  13. There is still undeniable evidence that Diclofenac administered in this way can result in devastating side effects. Such practice must therefore be able to withstand scrutiny in the event of a complaint or litigation

  14. Recommendations for imi diclofenac • In view of these uncommon but nevertheless devastating side effects, our Trust has withdrawn IM Diclofenac from the Trust formulary. We prefer to use rectal Diclofenac or one of the newer COX 2 inhibitors. We believe that the latter named agents are worthy of clinical use and further analysis.

  15. 2nd case • Young athlete, soccer player • Severe pain both legs following physical exertion • Pain predictable and reproducible after about the same time following activity. • Pain: cramp-like, numbness, tingling, feeling of fullness, • Relieve after sometime of rest

  16. Dynamic MRI- before and after activity • Findings: • STIR: post exercise: diffuse hyperintensity involving the posterior muscular compartment of the legs • 0.2cm increase in thickness of the gastrognemius medial and lateral head muscles at the same level

  17. Chronic exertional Compartment Syndrome Management: Completely to cease activities causing compartment Fasciotomy Other therapies have no effect.

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