Phenytoin-Induced Purple Glove Syndrome

 

Basis: Extravasation of the phenytoin infusate into soft tissue about the infusion site. This appears related to the presence of propylene glycol, sodium hydroxide and/or ethanol to enhance drug solubility. In more severe cases there may be venous thrombosis.

 

Features:

(1) discoloration around and distal to a site of intravenous infusion of phenytoin

(2) edema

(3) pain in the affected area

Stage	Timing after Infusion	Findings
1	2-12 hours	pale blue or purplish discoloration appears about the intravenous needle insertion site
2	next 12-16 hours	edema develops and discoloration continues to spreads distally to involve the hand and fingers; there may be a petechial rash
3	days to weeks	healing with receding of the discoloration, starting from periphery

 

Severe forms:

(1) venous thrombosis

(2) compartment syndrome with limb ischemia (and loss of peripheral pulses)

(3) skin blistering or necrosis with ulceration

(4) gangrene of fingers

 

Patients at increased risk:

(1) elderly (fragile blood vessels, other causes)

(2) patients receiving large amounts of phenytoin

(3) patients receiving the drug with multiple infusions (greater risk of infiltration)

(4) patients who are comatose or unable to report pain (delayed recognition)

(5) patients with multiple seizures or agitation and nonstabilized infusion sites (greater risk of infiltration)

 

Differential diagnosis:

(1) cellulitis (associated with fever, purulent discharge and more erythematous appearance)

(2) arterial or venous thrombosis from other causes

 

Prevention:

(1) Awareness of the risk following infiltration, with attention to infusion technique and prompt discontinuation of the infusion if problems arise. However, cases may occur with good technique and no clinical evidence of extravasation.

(2) Use of fosphenytoin, which is a water-soluble formulation that does not require the addition of solubilizing agents.