Question of the Week # 241

241) A 44 year old man is evaluated in the clinic for moderately severe pain in his bilateral lower extremities for the past 6 months. He describes pain that occurs at rest and is increased on walking. The pain is worse in winters. His history is significant for chronic smoking about 2 packs per day for the past 25 years. He denies any history of thrombosis. On examination, he is afebrile and heart sounds are regular. Distal lower extremities are tender to touch. An ulcer measuring 2cm is noted on the left great toe. Posterior tibial and dorsalis pedis artery pulses are diminished. There is erythema and tenderness along the course of great saphenous vein. Laboratory investigations including complete blood count, chemistry panel and anti-nuclear antibodies are with in normal limits. Which of the following is most helpful in distinguishing this disorder from other vaso-occlusive diseases?

A)     Raynaud phenomenon

B)     Superficial Phlebitis

C)      Digital ulcers

D)     Young age

E)     Diminished arterial pulses

9 Responses

  1. c

  2. ccccccccc

  3. E

  4. Dr Red can you please explain
    This looks like Buergers disease,more common in young smoker,
    is it raynauds or sup phlebitis more suggestive of the disease?

  5. C…….Skin ulcerations and gangrene of the digits (fingers and toes) are common in Buerger’s disease, and less common in others conditions. This is a desease of arteries and veins.

    Buerger’s disease (thromboangiitis obliterans) is a rare disease of the……. arteries and veins……….. in the arms and legs. In Buerger’s disease, your blood vessels become inflamed, swell and can become blocked with blood clots (thrombi). This eventually damages or destroys skin tissues and may lead to infection and gangrene. Buerger’s disease usually first shows in the hands and feet and may eventually affect larger areas of your arms and legs.

    The classic Buerger’s Disease patient is a young male (e.g., 20–40 years old) who is a heavy cigarette smoker. More recently, however, a higher percentage of women and people over the age of 50 have been recognized to have this disease. Buerger’s disease is most common in the Orient, Southeast Asia, India and the Middle East, but appears to be rare among African–Americans.

    Buerger’s disease can be mimicked by a wide variety of other diseases that cause diminished blood flow to the extremities. These other disorders must be ruled out with an aggressive evaluation, because their treatments differ substantially from that of Buerger’s Disease (for Buerger’s, there is only one treatment known to be effective: complete smoking cessation.

    Diseases with which Buerger’s Disease may be confused include atherosclerosis (build–up of cholesterol plaques in the arteries), endocarditis (an infection of the lining of the heart), other types of vasculitis, severe Raynaud’s phenomenon associated with connective tissue disorders (e.g., lupus or scleroderma), clotting disorders of the blood, and others.

    Angiograms of the upper and lower extremities can be helpful in making the diagnosis of Buerger’s disease. In the proper clinical setting, certain angiographic findings are diagnostic of Buerger’s. These findings include a “corkscrew” appearance of arteries that result from vascular damage, particularly the arteries in the region of the wrists and ankles. Angiograms may also show occlusions (blockages) or stenoses (narrowings) in multiple areas of both the arms and legs.
    In order to rule out other forms of vasculitis (by excluding involvement of vascular regions atypical for Buerger’s), it is sometimes necessary to perform angiograms of other body regions (e.g., a mesenteric angiogram).

    Skin biopsies of affected extremities are rarely performed because of the frequent concern that a biopsy site near an area poorly perfused with blood will not heal well

    • Thromboangiitis obliterans or Buerger’s disease is a segmental occlusive inflammatory condition of arteries and veins, with thrombosis and recanalization of the affected vessels. It is a nonatherosclerotic inflammatory disease affecting small and medium sized arteries and veins of upper and lower extremities.

      The disease is found worldwide, the prevalence among all patients with peripheral arterial disease ranges from values as low as 0.5 to 5.6% in Western Europe to values as high as 45 to 63% in India, 16 to 66% in Korea and Japan, and 80% among Ashkenazi Jews.

      The prevalence of the disease in the general population in Japan was estimated at 5/100,000 persons in 1985. The clinical criteria edited by Olin in 2000 include: age under 45 years; current or recent history of tobacco use; presence of distal-extremity ischemia, indicated by claudication, pain at rest, ischemic ulcers or gangrenes, and documented by non-invasive vascular testing; exclusion of autoimmune diseases, hypercoagulable states and diabetes mellitus; exclusion of a proximal source of emboli by echocardiography or arteriography; consistent arteriographic findings in the clinically involved and non-involved limbs.

      The etiology of thromboangiitis obliterans is unknown, but use or exposure to tobacco is central to the initiation and progression of the disease. If the patient smokes, stopping completely is an essential first step of treatment. The role of other treatments including vasodilating or anti-clotting drugs, surgical revascularization or sympathectomy in preventing amputation or treating pain, remains unclear

      Because a firm diagnosis of Buerger disease is difficult to establish, a number of different diagnostic criteria have been proposed.[6] Olin asserts that the following criteria must be met for the diagnosis to be made with reasonable certainty:[7] •Age younger than 45 years
      •Current (or recent) history of tobacco use
      •Presence of distal extremity ischemia (indicated by claudication, pain at rest, ischemic ulcers, or gangrene) documented by noninvasive vascular testing
      •Exclusion of autoimmune diseases, hypercoagulable states, and diabetes mellitus by laboratory tests
      •Exclusion of a proximal source of emboli by echocardiography and arteriography
      •Consistent arteriographic findings in the clinically involved and noninvolved limbs

      Most patients (70-80%) with Buerger disease present with distal ischemic rest pain and/or ischemic ulcerations on the toes, feet, or fingers

  6. D

  7. C)

  8. D) Question says “Which of the following is most helpful in distinguishing this disorder from other vaso-occlusive diseases?” if pt has young age (<45), male and a smoker and you exclude other causes of vaso-occlusion its likely Buerger's disease. I dont think digital ulcer is most helpful for differentiating. Does that mean any pt with digital ulcer is ikely Buergers?? Anything can cause digital ulcer – actually I think diabetes is likely to cause more digital ulcers in the gen population than Bueger's

    My 2 cents

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