- Email: [email protected]
Carpal tunnel syndrome associated with danazol therapy
COMMUNICATIONS IN BRIEF
This section is suitable for reporting results of therapeutic trials, descriptions of new procedures or instruments, and case reports which illustrate a principle. Reports should be limited to seven hundred words and two references. Use of an illustration or table requires a proportionate reduction in total words.
Carpal tunnel syndrome danazol therapy
associated
A. Sikka, M.D., E. Kemmann, M.D., R. M. Vrablik, M.D., and L. Grossman,
with
M.D.
Rutgers Community Health Plan and Department ?f Obstetrics and Gynecology, Cnrzlerslty of Medicine and Dentistry qf Near JerseyR,utgrrs Medical School, Srub Rruwuick, Ne’pw Jersq
The carpal tunnel syndrome is a condition characterired by symptoms and signs of median nerve compression at the wrist. As a result there may be paresthesia, sensory impairment, and eventually muscular atrophy in the hand area supplied by the median nerve. Positive Tinel’s sign (distal tingling on percussion of the wrist) may be noted; also, on flexion of the hand paresthesia may be described (Phalen’s sign). Causes include occupational hazard, amyloidosis, or thickening of connective tissue as a result of a number of conditions including rheumatoid arthritis, hypothyroidism, and acromegaly. The gynecologist-obstetrician may see apparently transient carpal tunnel syndrome in association with pregnancy, estrogen-progestin medication, or highdose progestin medication.’ We recently encountered a patient with endometriosis who developed transient carpal tunnel syndrome which started while she received danazol therapy (Danocrine, Winthrop Laboratories, New York). I). S.. a 29-vear-old, para O-O-O-O,white woman complained ot infertility of 3 years’ duration. The patient’s menarche was at age I?: subsequently she had had regular menstrual cycles every 28 + 2 days without significant pain. In contraceptives had been used for contraception. c-al/surgical history was unremarkable. ‘l-he initial infertility investigation showed no an(l included biphasic basal body temperature h~sterosalpingogram, an endometrial biopsy, an.llysis of her husband.
&print requests: E. Clbktetrics and Gynecology, list! v of New Jersey-Rutgers ‘\ t-w Jersey 08903.
Kernmann, University Medical
the past, oral Her mediabnormalities recordings, a and a semen
M.D., Department of of Medicine and DenSchool, New Brunswick,
Physical examination revealed a woman 160 cm tall and weighing 54.5 kg with normal general and pelvic examination. On June 2, 1982, the patient underwent a diagnostic laparoscopy which showed Stage II (American Fertility Society Classification) endometriosis; both fallopian tubes were patent and not affected by the endometriosis or any adhesions. Prior to operation normal preadmission laboratory studies (complete blood count, urinalysis, biochemical screen, and sodium. potassium, and chlorine electrolytes) had been obtained. The patient was started on a regimen of danazol therapy (Danocrine, 200 mg four times a day, po) with the onset of her next menstrual period (July 9, 1982). After 2 months of therapy, the patient complained of pain in the right wrist, with some tingling and numbness of the fingers. The symptoms were more severe at night. The patient was seen in the Rheumatology Clinic for further evaluation; on examination, she exhibited positive Tinel’s and Phalen’s signs, but there was no evidence of hand atrophy or loss of strength. The diagnosis of carpal tunnel syndrome was made, and a wrist splint was ordered. One month later, danazol was discontinued. On follow-up a week later, the carpal tunnel syndrome was markedly improved. The patient still had positive Tinel’s sign, but Phalen’s sign was negative. One month later she was asymptomatic.
The patient presented with carpal tunnel syndrome that developed during danazol therapy and resolved once such therapy was discontinued. Danazol is a synthetic steroidal medication primarily for the treatment of endometriosis. One previous report has indicated a similar association of carpal tunnel syndrome and danazol therapy.’ Although carpal tunnel syndrome may be of idiopathic origin or due to underlying disease processes, which may not manifest themselves at this point (i.e., amyloidosis), the close temporal association may suggest a causal relationship. This is further supported by the observation of development of carpal tunnel syndrome in pregnancy or during intake of other steroids. In all these conditions, fluid retention has been invoked as the mechanism by which the nerve is compressed. It is well known that danazol therapy may cause fluid retention: thus, it is quite possible that this is the mechanism in the development of danazol-associated carpal tunnel syndrome. If so, the condition would be expected to be limited and to improve after danazol ther-
Volume Number
apy
Communications
147 1
is discontinued.
Physicians
using
danazol
should
be
aware of this possible association. REFERENCES
1. DiSaia, megestrol
P. J., and Morrow, acetate,
AM.
C. P.: Unusual j.
OBSTET.
side effect
GYNECOL.
of
129~460,
1977.
2. Gray,
R. G.: Bilateral carpal tunnel syndrome and arthritis associated with danazol administration, Arthritis Rheum. 21:493, 1978.
Pregnancy complicated by periarteritis nodosa: Induced abortion as an alternative David A. Nagey, M.D., Ph.D., Kenneth J. Fortier, M.D., and James Linder,
M.D.
Departments of Obstetrics and Gynecology and Patholog?, University of MaTland Hospital, Baltimore, Maryland, and Duke Univeuzq Medical Center, Durham, North Carolina
Periarteritis
nodosa
is a rare
vasculitis
that
is appar-
ently immune complex-mediated and involves medium-sized and smaller arteries in a tibrinoid necrosis that, with healing, yields partial to complete vascular occlusion with resultant end-organ ischemia. The organs usually most affected are the skin, the central nervous
system,
Reprint Obstetrics 22 South
the kidneys,
and
the
heart,
but
this
condi-
requests: Dr. David A. Nagey, Department of and Gynecology, University of Maryland Hospital, Greene St., Baltimore, Maryland 21201.
Fig. 1. Photomicrograph
of placenta
in brief
103
tion characteristically may involve essentially any organ system. The disease is most common in men in their fifth and sixth decades of life and so is an even more rare complication of pregnancy. Nine cases of classical periarteritis nodosa in pregnancl have been reported.‘. ’ A single black woman was in good health until the age of 23 (in 1975) when she developed polyarthralgias, low-grade fever, and abdominal pain. E\:aluation resulted in an exploratory Iaparotomy with cholecytitectomy and a wedge resection of the liver. Pathologic examination of the surgical specimen resulted in the diagnosis of periarteriris nodosa. Her postoperative course was complicatc*d by cerebritis that was unresponsive to glucocorticoids, remitting only with the use of cyclophosphamide. Additional postoperative complications included hypertension and myocarditis. However, the patient was finally discharged on a regimen of propranolol, hydrochlorothiazide. and prednisonc; these medications were continued to the present. The patient underwent a suction therapeutic abortion while under paracervical anesthesia at the age of 26, without sequelae. She presented again in October, 1980, at the age of 28 at 16 weeks’ gestation, desirous of carrying her pregnancy ro term. Initial evaluation included a normal physical examination and normal blood counts -and chemistry tests. Urinalysis showed proteinurla (2+), and creatinine clearance was 30 ml/min. In view of poor renal function, the previous documentation of poor maternal outcomes in term pregnancies with periarteritis nodosa, and the patient’s previous survival of an abortion, it was recommended that she undergo abortion and sterilization. The patient agreed and underwent a suction abortion with laparosc epic total cauterization while under general anesthesia with ,
with
normal
microanatomy.
(X 100.)
This section is suitable for reporting results of therapeutic trials, descriptions of new procedures or instruments, and case reports which illustrate a principle. Reports should be limited to seven hundred words and two references. Use of an illustration or table requires a proportionate reduction in total words.
Carpal tunnel syndrome danazol therapy
associated
A. Sikka, M.D., E. Kemmann, M.D., R. M. Vrablik, M.D., and L. Grossman,
with
M.D.
Rutgers Community Health Plan and Department ?f Obstetrics and Gynecology, Cnrzlerslty of Medicine and Dentistry qf Near JerseyR,utgrrs Medical School, Srub Rruwuick, Ne’pw Jersq
The carpal tunnel syndrome is a condition characterired by symptoms and signs of median nerve compression at the wrist. As a result there may be paresthesia, sensory impairment, and eventually muscular atrophy in the hand area supplied by the median nerve. Positive Tinel’s sign (distal tingling on percussion of the wrist) may be noted; also, on flexion of the hand paresthesia may be described (Phalen’s sign). Causes include occupational hazard, amyloidosis, or thickening of connective tissue as a result of a number of conditions including rheumatoid arthritis, hypothyroidism, and acromegaly. The gynecologist-obstetrician may see apparently transient carpal tunnel syndrome in association with pregnancy, estrogen-progestin medication, or highdose progestin medication.’ We recently encountered a patient with endometriosis who developed transient carpal tunnel syndrome which started while she received danazol therapy (Danocrine, Winthrop Laboratories, New York). I). S.. a 29-vear-old, para O-O-O-O,white woman complained ot infertility of 3 years’ duration. The patient’s menarche was at age I?: subsequently she had had regular menstrual cycles every 28 + 2 days without significant pain. In contraceptives had been used for contraception. c-al/surgical history was unremarkable. ‘l-he initial infertility investigation showed no an(l included biphasic basal body temperature h~sterosalpingogram, an endometrial biopsy, an.llysis of her husband.
&print requests: E. Clbktetrics and Gynecology, list! v of New Jersey-Rutgers ‘\ t-w Jersey 08903.
Kernmann, University Medical
the past, oral Her mediabnormalities recordings, a and a semen
M.D., Department of of Medicine and DenSchool, New Brunswick,
Physical examination revealed a woman 160 cm tall and weighing 54.5 kg with normal general and pelvic examination. On June 2, 1982, the patient underwent a diagnostic laparoscopy which showed Stage II (American Fertility Society Classification) endometriosis; both fallopian tubes were patent and not affected by the endometriosis or any adhesions. Prior to operation normal preadmission laboratory studies (complete blood count, urinalysis, biochemical screen, and sodium. potassium, and chlorine electrolytes) had been obtained. The patient was started on a regimen of danazol therapy (Danocrine, 200 mg four times a day, po) with the onset of her next menstrual period (July 9, 1982). After 2 months of therapy, the patient complained of pain in the right wrist, with some tingling and numbness of the fingers. The symptoms were more severe at night. The patient was seen in the Rheumatology Clinic for further evaluation; on examination, she exhibited positive Tinel’s and Phalen’s signs, but there was no evidence of hand atrophy or loss of strength. The diagnosis of carpal tunnel syndrome was made, and a wrist splint was ordered. One month later, danazol was discontinued. On follow-up a week later, the carpal tunnel syndrome was markedly improved. The patient still had positive Tinel’s sign, but Phalen’s sign was negative. One month later she was asymptomatic.
The patient presented with carpal tunnel syndrome that developed during danazol therapy and resolved once such therapy was discontinued. Danazol is a synthetic steroidal medication primarily for the treatment of endometriosis. One previous report has indicated a similar association of carpal tunnel syndrome and danazol therapy.’ Although carpal tunnel syndrome may be of idiopathic origin or due to underlying disease processes, which may not manifest themselves at this point (i.e., amyloidosis), the close temporal association may suggest a causal relationship. This is further supported by the observation of development of carpal tunnel syndrome in pregnancy or during intake of other steroids. In all these conditions, fluid retention has been invoked as the mechanism by which the nerve is compressed. It is well known that danazol therapy may cause fluid retention: thus, it is quite possible that this is the mechanism in the development of danazol-associated carpal tunnel syndrome. If so, the condition would be expected to be limited and to improve after danazol ther-
Volume Number
apy
Communications
147 1
is discontinued.
Physicians
using
danazol
should
be
aware of this possible association. REFERENCES
1. DiSaia, megestrol
P. J., and Morrow, acetate,
AM.
C. P.: Unusual j.
OBSTET.
side effect
GYNECOL.
of
129~460,
1977.
2. Gray,
R. G.: Bilateral carpal tunnel syndrome and arthritis associated with danazol administration, Arthritis Rheum. 21:493, 1978.
Pregnancy complicated by periarteritis nodosa: Induced abortion as an alternative David A. Nagey, M.D., Ph.D., Kenneth J. Fortier, M.D., and James Linder,
M.D.
Departments of Obstetrics and Gynecology and Patholog?, University of MaTland Hospital, Baltimore, Maryland, and Duke Univeuzq Medical Center, Durham, North Carolina
Periarteritis
nodosa
is a rare
vasculitis
that
is appar-
ently immune complex-mediated and involves medium-sized and smaller arteries in a tibrinoid necrosis that, with healing, yields partial to complete vascular occlusion with resultant end-organ ischemia. The organs usually most affected are the skin, the central nervous
system,
Reprint Obstetrics 22 South
the kidneys,
and
the
heart,
but
this
condi-
requests: Dr. David A. Nagey, Department of and Gynecology, University of Maryland Hospital, Greene St., Baltimore, Maryland 21201.
Fig. 1. Photomicrograph
of placenta
in brief
103
tion characteristically may involve essentially any organ system. The disease is most common in men in their fifth and sixth decades of life and so is an even more rare complication of pregnancy. Nine cases of classical periarteritis nodosa in pregnancl have been reported.‘. ’ A single black woman was in good health until the age of 23 (in 1975) when she developed polyarthralgias, low-grade fever, and abdominal pain. E\:aluation resulted in an exploratory Iaparotomy with cholecytitectomy and a wedge resection of the liver. Pathologic examination of the surgical specimen resulted in the diagnosis of periarteriris nodosa. Her postoperative course was complicatc*d by cerebritis that was unresponsive to glucocorticoids, remitting only with the use of cyclophosphamide. Additional postoperative complications included hypertension and myocarditis. However, the patient was finally discharged on a regimen of propranolol, hydrochlorothiazide. and prednisonc; these medications were continued to the present. The patient underwent a suction therapeutic abortion while under paracervical anesthesia at the age of 26, without sequelae. She presented again in October, 1980, at the age of 28 at 16 weeks’ gestation, desirous of carrying her pregnancy ro term. Initial evaluation included a normal physical examination and normal blood counts -and chemistry tests. Urinalysis showed proteinurla (2+), and creatinine clearance was 30 ml/min. In view of poor renal function, the previous documentation of poor maternal outcomes in term pregnancies with periarteritis nodosa, and the patient’s previous survival of an abortion, it was recommended that she undergo abortion and sterilization. The patient agreed and underwent a suction abortion with laparosc epic total cauterization while under general anesthesia with ,
with
normal
microanatomy.
(X 100.)