Vaskulärer Ergotismus durch Getreidestaubinhalation

HISTORY AND CLINICAL FINDINGS: For 6 months a 42-year-old farmer without cardiovascular risk factors had been suffering from increasing pain in both feet and calves. Angiography two months apart had demonstrated progressive narrowing of all lower-leg arteries. Pain-free walking had become restricted to 50 m, there were no palpable pulses in the right foot and those in the left foot were markedly reduced. INVESTIGATIONS: Occlusion pressure of the right foot was 55 mm Hg. Repeat angiography showed proximal occlusion of all three lower-leg arteries. Biopsy and biochemical tests excluded degenerative and inflammatory causes of the vascular disease. DIAGNOSIS, TREATMENT AND COURSE: Enquiry of the patient discovered that he had been exposed to ergotamine-containing milling dust in the preparation of rye flour. Inhalational intake of ergotamine was proven by a high plasma ergotamine level. Attempted treatment with prostaglandin E1 (intraarterially for 16 days), doxazosin (2 mg/d) and acetylsalicylic acid 300 mg/d) had only little effect on symptoms. But complete avoidance of exposure to flour dust slowly decreased the plasma level of ergotamine within 4 months, after which all lower-leg arteries had almost completely re-opened. CONCLUSIONS: This is the first reported case proving that chronic ergotamine inhalation can cause ergotism affecting peripheral arteries. As the plasma ergotamine level fell only slowly it must be assumed that ergotamine had accumulated in a, so far unknown, body depot with slow release into the blood.