Acute limb
ischemia induced by arterial vasospasm remains an exceptional situation, favoured by the use of arterial
vasoconstrictors. The risk of these substances is largely underestimated in the general population, especially with the co-administration of strong
cytochrome inhibitors like human immunodeficiency virus (
HIV) protease inhibitors. A 33-year-old woman, who used to take
dihydroergotamine for
orthostatic hypotension, was prescribed a post-exposure HIV prophylaxis including
lopinavir and ritonavir. One day later, she presented an acute bilateral limb
ischemia with a sudden
pain in both calves, initially while walking and then at rest with bilateral ischemic toes. Angiography confirmed diffuse arterial vasospasm of the lower limb arteries. A first-line
therapy with
isosorbide dinitrate and
amlodipine was ineffective, with rapid clinical worsening. A combination of
intra-arterial injections and intra-venous infusions of
vasodilators, transluminal balloon angioplasty and bilateral 4-Compartment fasciotomies permitted rapid improvement and finally resulted in both lower limbs rescue. This case and literature review illustrate
ergotism due to
ergotamine overdose after taking
HIV protease inhibitors. It also demonstrates the benefit of an interventional procedure besides medical
therapy with
vasodilators in severe arterial vasospasm. All along the lower limb arterial tree, transluminal balloon angioplasty restored the blood flow, without vasospasm recurrence. CONCLUSION: In case of
ergotism with acute lower limbs
ischemia, combining medical
vasodilator therapy with interventional procedure can restore the arterial blood flow, thus allowing to save lower limbs.