Complex Regional Pain Syndrome Type 1 Produced by Hematoma Formation after Blood Donation: A Case Report

The occurrence of hematoma and bruise formation, accounting for the majority of donation-related complications in the arm, rarely results in Complex Regional Pain Syndrome (CRPS). We report a 24-year-old man who presented with CRPS on his right upper limb two months later due to hematoma and bruising formation just after a blood donation following with immediate performance of strenuous exercise in the upper limbs. Triple phase bone scan, one of the bone scintigraphic studies, revealed positive fi ndings and was compatible with the symptoms of CRPS, e.g. hyperalgesia, swelling and discoloration. The potentially disabling condition, however, ended up with a thankfully benign outcome because of our early fi nding and proper treatment that included three-day oral prednisolone and two-week physiotherapy and occupational rehabilitation. To our knowledge, CRPS produced by donation-related complications with subsequent hematoma and bruise due to vigorous exercise is rare. CRPS should be taken into consideration in a blood donor who demonstrated allodynia because of performing heavy exercise immediately after blood donation. Case Report Complex Regional Pain Syndrome Type 1 Produced by Hematoma Formation after Blood Donation: A Case Report Cheng-Chiang Chang1 and Shin-Tsu Chang1,2* 1Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan 2Department of Physical Medicine and Rehabilitation, Taichung Veterans General Hospital, Taichung, Taiwan Received: 11 January, 2021 Accepted: 01 February, 2021 Published: 02 February, 2021 *Corresponding author: Dr. Shin-Tsu Chang, Department of Physical Medicine and Rehabilitation, TriService General Hospital, School of Medicine, National Defense Medical Center, No.161, Sec. 6, Minquan East Road, Neihu District, Taipei 11490, Taiwan, Tel: 886935-605578; E-mail:


Introduction
Approximately one third of whole-blood donors have an adverse physical event during or after whole-blood donation.
Most of the common adverse effects associated with arm fi ndings after blood donation are bruise (22.7%), soreness (10.0%), and hematoma (1.7%) [1]. The reasons of the upper limbs adverse events due to blood donation are multifactorial, including genetic factors, infl ammatory process, peripheral/ central dyssensitization, sympathetic malregulation, somatosensory cortex reorganization, and psychophysiologic interactions, and all symptoms are likely a result of different combinations following with time elapse [2]. Complex Regional Pain Syndrome (CRPS) induced by hematoma might be another severe complication of blood donation.
Anatomically speaking, sensory branches of the musculocutaneous nerve locate below the antecubital veins, as is classically taught, although they are also above the antecubital veins or intertwine with them. Local nerve injuries are unavoidable after phlebotomy because nerve branches are situated so close to the vessels and are impalpable. The frequency of nerve irritation is relatively high. Newman reported an occurrence of 40% of the nerve injuries after a straightforward phlebotomy [3]. Another study based on a donor interview reported that sensory changes in the forearm and hand occur in approximately 1% of whole-blood donors [1].
The nerve distribution in the donor's arm might play an important role on the possibility of occurrence of CRPS, which has been shown to be developed due to abnormalities in the central and peripheral nervous systems after a nociceptive painful event. The characteristic of CRPS develops unproportionately with the painful event and is not limited to a single nerve course. Pathophysiological aspects including neurogenic infl ammation, impairment of sympathetic function, and coupling between sympathetic efferents and nociceptive afferents should all be taken into consideration  [4,5]. The diagnosis is ordinarily made on a clinical basis.
There is no pathognomonic laboratory fi nding for CRPS. An alternative way in bone scintigraphy, the Triple Phase Bone Scan (TPBS), can show increased uptake in the involved limb earlier in the process. Multidisciplinary treatment combining

Transcutaneous
Electrical Nerve Stimulation (TENS), physical therapy, psychotherapy using behavior modifi cation techniques, and oral medications are sometimes helpful [6].
CRPS induced by formation of hematoma followed blood donation has never been described in the literature before.
We present a 24-year-old patient, which developed CRPS two months after blood donation. It was considered that hematoma with bruise on the antecubital fossa or antecubital cutaneous nerve injury could probably have led to the development of CRPS.

Case report
A 24-year-old man experienced progressive painful swelling of the right upper extremity two months after blood donation. He had an unremarkable past medical history, and is enthusiastic about donating blood. Voluntarily, he had already donated blood two times during his service in the army. Two months prior to this admission, he donated blood for the third time via the right antecubital vein as usual in the morning. An amount of 250 ml whole blood was collected from the vein with a 16-gauge needle using aseptic technique. Eight hours later in the early evening, he was ordered to join routine military training that consisted of chin-ups, push-ups and running and he practiced them vigorously. Unknowingly, he found bruising and hematoma appearing on his forearm, which spread from the site of venipuncture with slight pain during the resting period. From that day on, he began to suffer intermittent painful swelling and discoloration in the right upper extremity after every training course, which became more severe when he performed grenade-throwing. Two days before the admission, he developed a burning pain on the right hand with obvious cyanosis, swelling, weakness and limited active Range of Motion (ROM) after the strenuous exercise. According to his statement these problems were not related to any trauma.
On admission, the patient had a pain Visual Analogue Scales (VAS) of 8/10, and the pain in the forearm progressively worsened and was unrelieved by rest, with a hematoma on the antecubital fossa combined with a large area of bruise by 15x7 cm 2 . Together with were extensive swelling, mild hyperpigmentation, allodynia, coldness, cyanosis and limited ROM of the right upper limb, especially on the right wrist.
The hyperalgesia on the affected muscle-guarding limb was so intense that to undergo even a slight touch could induce a burning and tingling pain out of proportion to the injury and extend beyond the confi nes of dermatomal distribution. All of the following studies were within normal limits, including C-reactive protein, hemoglobin, white blood cell count, blood chemistry, rheumatoid factor and nerve conduction studies. The TPBS showed the increased uptakes in the right forearm, wrist and hand, and is consistent with the fi nding of CRPS type 1. He was undergone physiotherapy with whirl-pool hydrotherapy and silver spike point stimulation, as well as occupational therapy such as daily living training, hand function training, and motor-sensory training. A signifi cant improvement was noted followed by three-day prednisolone administration with 15 mg four times a day on the fi rst day of admission, and was weaned by 20 mg a day over three-day period.
All symptoms gradually disappeared in two weeks. The patient had a VAS of 1/10 before being discharged from our ward.
Three months since outpatient follow-up, he has made fairly good recovery with regards to his overall general condition. images of in the affected limb [13]. The imaging of TPBS in our case demonstrated increased uptake in the right forearm, wrist and hand that was consistent with the fi nding of CRPS type 1.

Discussion
The early fi nding of CRPS can also be seen in brain image as increased uptake in the contralateral thalamus [14,15], but our case did not have the perfusion scan at the time.
Diagnosing a CRPS at an early stage is important because treatment in the early stage may lead to a good outcome.
The best treatment for CRPS is not known yet. For the relief of symptoms, many kinds of treatment, such as TENS, corticosteroids, adrenergic blocking agents, calcium channel blockers, anti-depressants, hyperbaric oxygen therapy and so on, have been used with varying effects. Two small randomized controlled trials have reported that a 4-to 12-week course of high-dose glucocorticoids administered orally 3 or 4 times daily, can alleviate pain, edema and hyperalgesia in CRPS patients [16,17]. In summary, we present a case of CRPS type 1 due to blood donation complications which was exacerbated with hematoma and bruising. Early intervention plays an important role in reducing the long-term sequelae. Whenever performing a blood collection, donors must be informed to be aware of the possibility of the formation of hematoma if inadequate resting period, which may also be noxious for the emergence of CRPS.
In order to shorten the clinical course, to reduce the possibility of disability, and to prevent long-term morbidity medical personnel should make an early fi nding and provide proper treatment as soon as possible. can occur after venipuncture due to nerve injury.

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2. Blood donation with subsequent vigorous exercise induced extensive hematoma and bruise triggering CRPS type 1 has never been reported in the literature.
3. Whenever performing a blood collection, donors must be informed to be aware of the possibility of the formation of hematoma if inadequate resting period, which might also be noxious for the emergence of CRPS.