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Interferon-β is the first approved treatment for relapsing multiple sclerosis. Although generally well tolerated, it is sometimes associated with cutaneous reactions at the injection site. To decrease local side effects, it has been suggested that injection sites in the belly, the thigh, and the arms are regularly changed. These cutaneous reactions range from slight erythema to necrosis. We report the first mononeuropathy associated with local adverse reaction after interferon-β injection.
A 39 year old woman had a 15 year history of multiple sclerosis, and a 3 year history of secondary progressive phase (EDSS=6). She had been treated for 3 years with subcutaneous interferon-β 1b (Betaferon®) every other day, when a painful violaceous, livedoid pattern on the skin of the posterior aspect of the right upper arm appeared, at a site of injection at the mid-portion of the humerus. Two days later, a necrotic ulcer (diameter 10 mm, depth 2 mm) occurred. Concomitantly, she experienced tingling on the dorsal aspect of the thumb without motor or reflex abnormalities. The livedo lasted a month, and the spontaneous ulcer healed in the same time. The sensory dysfunction recovered 10 months after onset. The following laboratory tests were negative or normal: glycaemic tests, antinuclear antibodies, rheumatoid factor, complement fractions, cryoglobulin, thyroid tests, and anticardiolipin antibodies.
Radial neuropathy was confirmed by neurophysiological testing performed 3 months after the onset. A motor conduction block (80% reduction of the compound muscle action potential amplitude) was found on the right radial nerve at the level of the injection site related necrosis. In addition, cutaneous thermal thresholds (TSA-2001, Medoc, Ramat, Israel) in the right radial nerve territory were significantly higher than the contralateral ones, whereas radial sensory nerve action potential amplitudes were normal and symmetric (right 82 μV; left 92 μV). Ten months after onset, the conduction block had disappeared and thermal thresholds were normal.
Cutaneous necrosis occurred in 1% to 3% of patients treated by interferon-β1b.1 Necrosis may be favoured by an inadequate injection technique, not rotating the injection sites, or absence of heating of the diluent before the injection. Cutaneous necrosis associated with interferon-β injection is thought to potentially combine inflammatory and ischaemic local damage.2 The pathophysiological mechanism of the focal neuropathies can only be hypothetical, but several features of our case suggest an ichaemic mechanism. Conduction block in motor nerve fibres is a feature of ischaemic nerve injury.3 The discrepancy between thermal sensory impairment and normal sensory nerve action potential amplitude is consistent with the higher susceptibility to ischaemia of smaller nerve fibres4; Raynaud's phenomenon has been recently reported as the first evidence of ischaemic lesion induced by interferon-β injection for multiple sclerosis.5
This led us to avoid some recommended sites of injection, which correspond to the anatomical course of peripheral nerves. These include the posterior aspect of the arm to preserve the radial nerve, the lateral abdominal wall, and close to the anterior superior iliac spine, to preserve the lateral femoral cutaneous nerve, and the upper aspect of the buttock to preserve the sciatic nerve.
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