Cold Intolerance Following Collagenase Clostridium histolyticum Treatment for Dupuytren Contracture

Abstract

We have observed the development of cold intolerance in the hands of 2 patients after the use of collagenase Clostridium histolyticum (CCH) for the treatment of Dupuytren contracture.1Xiapex 0.9 mg powder and solvent for solution for injection. Medicines.org.uk. Available at: http://www.medicines.org.uk/emc/medicine/24411. Accessed October 4, 2013.Google Scholar, 2Badalamente M.A. Hurst L.C. Efficacy and safety of injectable mixed collagenase subtypes in the treatment of Dupuytren's contracture.J Hand Surg Am. 2007; 32: 767-774Abstract Full Text Full Text PDF PubMed Scopus (148) Google Scholar Cold intolerance is a poorly understood but well-recognized phenomenon associated with upper limb trauma.3Irwin M.S. Gilbert S.E. Terenghi G. Smith R.W. Green C.J. Cold intolerance following peripheral nerve injury: natural history and factors predicting severity of symptoms.J Hand Surg Br. 1997; 22: 308-316Crossref PubMed Scopus (158) Google Scholar Little is known about the factors involved with predicting symptom development or severity. Symptoms are pain, altered sensation, and color changes4Campbell D.A. Kay S.P. What is cold intolerance?.J Hand Surg Br. 1998; 23: 3-5Crossref PubMed Scopus (58) Google Scholar and can cause debilitating morbidity affecting patients' lives. Cold intolerance as a consequence of elective hand surgery has been described. McKirdy et al5McKirdy S.W. Jacobs N. Nassab R. Starley I.F. A retrospective review of cold intolerance following corrective surgery for Dupuytren's disease.Hand Ther. 2007; 12: 55-59Google Scholar reported that 44% of their cohort developed symptoms after corrective open surgery for Dupuytren disease, using the Blond McIndoe Cold Intolerance Symptom Severity scoring system.3Irwin M.S. Gilbert S.E. Terenghi G. Smith R.W. Green C.J. Cold intolerance following peripheral nerve injury: natural history and factors predicting severity of symptoms.J Hand Surg Br. 1997; 22: 308-316Crossref PubMed Scopus (158) Google Scholar The following patients reported new-onset cold intolerance after treatment with CCH for elective closed correction of Dupuytren contractures. A 67-year-old, nonsmoking, asthmatic man developed new and isolated symptoms of cold intolerance in the left index finger 7 months after CCH treatment in cords in the first web. The disease had limited extension and abduction of the thumb and extension of the index finger. The patient denied pre-existing trauma and cold intolerance or related conditions anywhere in the body. The procedure involved injection of reconstituted CCH into the densest area of contracture palpated on clinical examination followed by manipulation the following day under local anesthetic. This case was complicated by a small skin tear, which healed with conservative treatment within 2 weeks. Functional improvement immediately postmanipulation and after 2 weeks was excellent with recovery of full motion. The patient's Cold Intolerance Symptom Severity score was 27 (moderate discomfort)3Irwin M.S. Gilbert S.E. Terenghi G. Smith R.W. Green C.J. Cold intolerance following peripheral nerve injury: natural history and factors predicting severity of symptoms.J Hand Surg Br. 1997; 22: 308-316Crossref PubMed Scopus (158) Google Scholar at 7 months postmanipulation when the patient presented with cold intolerance and a recurrent but less severe contracture in the area treated with CCH. Cold intolerance was limited to intermittent pain with no triggers except cold weather. An open fasciectomy followed by hand therapy addressed the contracture, but cold intolerance symptoms did not improve. A 75-year-old woman underwent CCH treatment for palmar and digital involvement causing a 70° contracture of the right ring finger metacarpophalangeal joint. She had Stevens–Johnson syndrome, bronchiectasis, and polymyalgia rheumatica. She denied trauma and pre-existing cold intolerance in the hand. Postmanipulation review immediately and at 1 week showed no evidence of vascular compromise. Within 3 months, the patient reported symptoms of cold intolerance: namely, intermittent painless blue discoloration, without other associations, affecting only the treated finger (Fig. 1). All other digits showed normal coloration. She declined a Cold Intolerance Symptom Severity questionnaire and was managed with hand therapy and behavior modification. She continues to be under review. Our experience of CCH use has been extremely positive. Recognition of this complication has directed us toward including cold intolerance as a potential risk when consenting patients for CCH treatment. Further work is essential to identify how commonly cold intolerance arises after CCH treatment; accordingly, we urge clinicians to be vigilant of similar findings. Cold Intolerance Following Collagenase Clostridium histolyticum Treatment for Dupuytren Contracture: A Molecular MechanismJournal of Hand SurgeryVol. 39Issue 9PreviewWe read with great interest the letter by King and Belcher entitled “Cold Intolerance Following Collagenase Clostridium histolyticum Treatment for Dupuytren Contracture.”1 The authors had no explanation for collagenase C histolyticum–induced cold intolerance. We would like to expand on the discussion by introducing the route through which collagenase C histolyticum can cause cold intolerance. Full-Text PDF