Case Report: A Patient Presents with Digital Ischemia & Gangrene

The patient’s fevers resolved; however, his arthralgias persisted. In addition, he developed cyanotic changes in his fingertips and toes. In follow-up with his primary care physician a few days later, he was started on 40 mg of prednisone daily to treat his elevated ANA.

He returned to his dentist, who treated him with fluconazole for oral thrush, and his arthralgias improved after a few days.

He returned to the hospital one week later for acrocyanosis. He underwent vascular studies, including venous Doppler ultrasounds, which were negative for deep vein thrombosis (DVT), and spiral CT to rule out pulmonary embolism. Pulse volume recording (PVR) and anklebrachial index (ABI) tests showed normal triphasic Dopplers and wave forms, except in his toes. CT angiography with runoff showed patent major arteries from the aorta to the ankles, without stenosis.

He was evaluated by a vascular surgeon, who ruled out macrovascular disease. He was started on procardia and nitropaste for suspected thromboangiitis obliterans (TAO) and was advised to stop smoking.

Two weeks later, he was seen again by his primary care physician, who increased the prednisone to 60 mg daily, which gave him partial relief from the squeezing pains in his feet and hands. The patient was referred to a rheumatologist.

FIGURE A: Acrocyanosis, gangrene, and subungual splinter hemorrhage of the fingers before admission. FIGURE B: Acrocyanosis and gangrene of the toes before admission and prior to amputation. (Click to enlarge.)

He was seen by the rheumatologist two weeks later, who noted the patient had cyanosis with mild gangrene involving both index fingers (see Figure 1A), big toes, and his left second and third toes (see Figure 1B). Splinter hemorrhages were noted in his index fingers as well (see Figure 1A).

Despite the positive ANA, other symptoms and signs of connective tissue disease were absent, including rash, sun sensitivity, alopecia, mouth sores, pleurisy, Raynaud’s phenomenon, hemocytopenia and renal or neurologic disease. Ear, nose, throat, respiratory and renal abnormalities to suggest ANCA vasculitis were also absent. Aspirin was added to the patient’s medications, and he was continued on prednisone and nifedipine.

On follow-up with the rheumatologist a few days later, the ischemia in his toes had worsened, and he had developed dusky, purple patches on the soles of both feet and tissue breakdown in both index fingertips. He was in a significant amount of pain. Laboratory test results from his initial rheumatology visit included a positive aPL profile, noted in Table 2.