Extensive Ecchymoses After a Fall: Aspirin- and Ginkgo-Related and Arm Pain Caused by Tip of a Broken Needle in Patient With a History of Injection Drug Use

1. Extensive ecchymoses following a fall
A 72-year-old man slipped and fell backward in the bathroom, hitting hishead on the toilet seat; he suffered only minimal discomfort. The followingday, he presented with mild back pain and extensive bruising.

Impressive ecchymoses extended from his left flank to his right flank,across the midline, where a tender mass was palpated. Swelling was visiblefrom a distance at the L4 level; the 17 X 10-cm lesion was raised approximately1.5 cm, with overlying black-blue ecchymoses. The patient was takingself-prescribed baby aspirin, 81 mg/d; vitamins C, E, and B12; and Ginkgobiloba, 400 mg/d.

Could the fall alone have caused this extensive bruise-or is somethingelse involved?

1. Extensive ecchymoses following afall: Because of the severity of thebruising, a noncontrast CT scan of theabdomen was obtained. The scan revealeda soft tissue mass (a hematoma)within the subcutaneous fat that extendedto the adjacent muscle plane of thelower back; no intra-abdominal orretroperitoneal bleeding was noted. Thepatient was advised to discontinue boththe aspirin and the ginkgo.

Ginkgo, or Ginkgo biloba, isknown by several names, includingginkgo leaf, maidenhair tree, kewtree, fossil tree, ginkyo, yinhsing,Japanese silver apricot, Ginkgo folium,Salisburia adiantifolia, and bai guo ye.Ginkgo has long been used in folkand Chinese medicines for its purportedpsychotropic and neurotropic propertiesand as a sexual performanceenhancer, premature aging preventative,antacid, antihypertensive and heart disease treatment, and liver functionaid.^1,2 Ginkgolide B, one of a group of terpenes contained in Ginkgo biloba and aknown inhibitor of platelet-activating factor, is thought to cause some of the beneficialas well as some of the detrimental effects of ginkgo.³

Many adverse effects and interactions have been attributed to ginkgo,including bleeding dyscrasias, which have resulted in subdural hematoma⁴and subarachnoid hemorrhage⁵; skin allergy; phlebitis; mild GI complaints;headaches; dizziness; palpitations; diarrhea; nausea and vomiting; loss ofmuscle tone; weakness; perioral erythema; rectal burning; and painful analsphincter spasms.^1,2 Generalized convulsions after consumption of a largenumber of ginkgo nuts, coma in a patient with Alzheimer disease who wastaking low-dose trazodone and Ginkgo biloba, and postoperative bleedingafter laparoscopic cholecystectomy in a patient who consumed ginkgo havebeen reported.^6,8

After 3 weeks, this patient's ecchymoses had resolved, but a 20 X 18-cmhematoma was still palpable. In time, the hematoma cleared without treatment;the patient has had no further episodes of bleeding.

REFERENCES:1. Jellin JM, Batz F, Hitchens K. Natural Medicines Comprehensive Database: Pharmacist's Letter/Prescriber'sLetter. Stockton, Calif: Therapeutic Research Faculty; 1999.
2. DerMarderosian A, ed. Guide to Popular Natural Products. St Louis: Wolters Kluwer Company; 1999.
3. Chung KF, Dent G, McCusker M, et al. Effect of a ginkgolide mixture (BN 52063) in antagonising skinand platelet responses to platelet activating factor in man. Lancet. 1987;1(8527):248-251.
4. Rowin J, Lewis SL. Spontaneous bilateral subdural hematomas associated with chronic Ginkgo biloba ingestion.Neurology. 1996;46:1775-1776.
5. Vale S. Subarachnoid haemorrhage associated with Ginkgo biloba. Lancet. 1998;352:36.
6. Miwa H, Iijima M, Tanaka S, Mizuno Y. Generalized convulsions after consuming a large amount ofgingko nuts. Epilepsia. 2001;42:280-281.
7. Galluzzi S, Zanetti O, Binetti G, et al. Coma in a patient with Alzheimer's disease taking low-dose trazodoneand gingko biloba. J Neurol Neurosurg Psychiatry. 2000;68:679-680.
8. Fessenden JM, Wittenborn W, Clarke L. Gingko biloba: a case report of herbal medicine and bleedingpostoperatively from a laparoscopic cholecystectomy. Am Surg. 2001;67:33-35.

2. Discomfort and occasional pain of the upper arm

A 59-year-old woman with a history of extensivepsoriasis, hypertension, and obesity had experienced discomfortand occasional pain in her left upper arm forseveral months. She denied recent trauma. The physicalexamination revealed variable, nonspecific, mild tendernessalong the left upper arm.

What do you suspect is responsible for the discomfort?

2. Discomfort and occasional pain of the upper arm:On further questioning, the patient reluctantly told of havingused intravenous drugs many years earlier. Subcutaneousinfection and migration of the tip of a broken needlewere considered in the differential. Radiographs of the affectedarm demonstrated a needle tip in the soft tissue (A andB, arrows); no signs of active infection were noted.

The patient refused surgery to remove the needle tip.A complete blood cell count was normal; NSAIDs wereprescribed to manage the pain. The patient was advised toseek medical care if the pain increased or if local swellingor induration, fever, or general malaise developed.

In patients with a history of injection drug use, maintaina high index of suspicion for other potential healthrisks, such as:

• HIV disease.
• Hepatitis B and C.
• Bacteremia, with or without endocarditis.
• Local infections.

3. Multiple papules and scars

A 43-year-old woman presents withexcoriated papules and scarring on thearms and back. All of the lesions arevery similar in size and shape, and theyare located on areas that the patient caneasily reach.

What are your thoughts aboutthe cause of these lesions?

3. Multiple papules and scars: Lesions confined to areasthat the patient can easily reach strongly suggest neurotic excoriations.The presence of multiple old scars is a clue to thechronicity of this condition (A). Because neurotic excoriationsare caused by the patient's fingernails, they have a uniformdisciform size and shape (B); this helps distinguishthe wounds from factitial excoriations,which are made with foreign objects,such as fingernail files, forks, or othersharp implements.

A factitial disorder was diagnosedin another patient, a 30-year-old womanwho used amphetamines and had anextensive psychiatric history (C). Generally,these patients have fewer lesions,which vary in size and shape.

The severity of the patient'smental disturbance is another featurethat can differentiate neurotic and factitialdisease. Neurotic excoriation isusually associated with anxiety, depression,or obsessive-compulsive disorder,whereas factitial excoriationgenerally occurs in the setting ofmore serious mental illness, such aspsychoses or personality disorders.

The differential diagnosis ofthese self-induced conditions includesscarring dermatoses such as lupus,particularly discoid lupus. Treatment options for neuroticexcoriation are anxiolytic drugs (eg, a benzodiazepine)or antidepressants, such as doxepin. Usually, more potentpsychotropic agents are given to patients with factitialdisease.

4. Hyperpigmented areas of the palms

During a routine annual physical examination, a prominent area of hyperpigmentationwas noted on the palms of a 7-year-old African American boy.

What steps will you take to determine the cause of this discoloration?

4. Hyperpigmented areas of thepalms: Before undertaking an extensiveworkup to discover a perhaps exoticcause of this puzzling condition, amore in-depth history taking was warranted.In response to questioning,the child's mother reported that thepatient had suffered third-degreeburns on both palms at age 2 years;skin from the thigh, which is naturallydarker in color, had been used forgrafts on the injured hands.