Violaceous skin reaction of the hand.

Mr. C is a 74-year-old male with colon cancer who originally was treated with surgery and 5-fluorouracil-based chemotherapy. One year after Mr. C completed treatment, paramedics were called to transport him to the emergency room (ER) after he experienced a grand mal seizure in his home. An 18-gauge catheter was placed in his right hand in the ambulance for IV access. He was given 10 mg IV diazepam en route to the ER to control his seizures; then, an IV bolus dose of 750 mg of phenytoin was administered in the ER. Once his seizures were controlled, Mr. C was admitted to the inpatient medical/oncology unit with a diagnosis of metastatic colon cancer with new onset of seizures. He was placed on a medication regimen of daily oral phenytoin and oral diazepam as needed. On day two of Mr. C’s hospitalization, his IV line was discontinued because the nursing staff noted that his right hand had become violaceous and edematous (see Figure 1). By the end of day two, the patient had notable tenderness, discoloration, and edema of the right hand extending to his elbow (see Figure 2). During this time, Mr. C had palpable 2+ ulnar and radial pulses. The staff provided symptomatic care, including elevation of the affected extremity and application of a warm, dry compress to the hand. Possible drug reaction or IV infiltration versus cellulitis of the extremity was considered as the etiology for the patient’s soft-tissue injury.