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Case 339

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Male, 72-years-old, smoker, hypertensive, alcohol consumer for 52 years. Hospitalized due to severe ischemia on the left 2 through 5 digits, with 30 days of evolution, associated with pain at rest on the proximal area of the left hand. On the physical examination, the blood pressure on the right arm was 134/78mmHg and on the left arm was 126/62mmHg. Troponin I = 0,012ng/mL (normal range < 0,034).

Considering the clinical history and the presented image, the most likely diagnosis is?

a) Peripheral obstructive arterial disease

25%

b) Peripheral arterial embolism

25%

c) Raynaud's phenomenon

25%

d) Thromboangiitis obliterans

25%
   

Image Analysis 

Image 1: Left hand photograph enhancing extensive dry gangrene, affecting the 2nd through 5th digits. Presence of dry and black skin, restricted to the distal phalanges of the 2nd and 3rd digits and extending through the proximal phalanges of the 4th and 5th digits. Presence of pain at rest and on movement. It’s noticeable an area of increased redness on the borders of the necrotic lesion.

Highlights 

        The presence of advanced age, hypertension and smoking are important risk factors for peripheral obstructive arterial disease, beyond the finding of a difference greater than 15mmHg on the arterial blood pressure of the two upper limbs. The disease can present itself with acute ischemia of the limb, pain on movement or at rest and, on extreme cases, with ulceration and gangrene.

        Peripheral arterial embolism is an important cause of ischemia of the extremities, however, it has a faster evolution, varying between hours to days. The diagnosis includes electrocardiographic alterations, elevation of the troponin levels and signs of an embolus on the arterial duplex-scan.

        The Raynaud phenomenon consists on the abrupt and well delimited change of the color of the digits, in general with pallor followed by cyanosis due to vasospasm in response to low temperatures and emotional distress. It’s a frequent and self-limited phenomenon, with a higher prevalence in women between 20 and 40 years and it may be associated with an underlying disease.

         Thromboangiitis obliterans (Buerger Disease) is a non-atherosclerotic inflammatory endarteritis, with higher prevalence on the upper limbs than the peripheral obstructive arterial disease. There’s a strong association with the tobacco use and with being male. However, most patients are aged 20-45 years and, in this cases, two or more distal extremities tend to be affected. 

References

- BMJ Best Practice. Peripheral arterial disease: diagnosis and management. Disponível em: https://bestpractice.bmj.com/topics/pt-br/431/guidelines. Acesso em 25/09/18.
- Chung KC, Yoneda H. Upper extremity amputation. In: UpToDate. Disponível em: https://www.uptodate.com/contents/upper-extremity-amputation?search=upper%20extremity%20 amputation&source=search_result&selectedTitle=1~24&usage_type=default&display_rank=1. Acesso em 25/09/18.
- Doença arterial obstrutiva periférica: que atenção temos dispensado à abordagem clínica dos pacientes? Disponível em: http://www.scielo.br/pdf/jvb/v4n3/v4n3a07.
- Olin JW. Thromboangiitis obliterans (Buerger's disease). In: UpToDate. Disponível em: https://www.uptodate.com/contents/thromboangiitis-obliterans-buergers-disease?search=doen% C3%A7a%20de%20buerger&source=search_result&selectedTitle=1~35&usage_type=default&display_rank=1. Acesso em 25/09/18.

Authors

Elaine Kimie Iwayama Ikematu, 5th year medical student at Universidade de Minas Gerais
Email: elaineiwayama[at]gmail.com

Gabriel Sousa Santos, 5th year medical student at Universidade de Minas Gerais.
Email: gabrielssantos86[at]gmail.com

Supervisors

Carolina Coimbra Marinho MD. Specialist in intensive care. Adjunct Professor of the Department of Clínica Médica at Medical School of Universidade de Minas Gerais
Email: carolinacmarinho[at]gmail.com

Reviewers

Gabriella Yuka Shiomatsu, Guilherme Carvalho, William Alves, Daniela Manso, Izabella Costa, professor José Nelson Mendes Vieira and professor Viviane Santuari Parisotto Marino.

Translated by

Letícia de Melo Elias, 4th year medical student at Universidade Federal de Minas Gerais

E-mail: letimelo02[at]gmail.com

Test question

ACM – Are recomendations for the control of the risk of developing peripheral obstructive arterial disease, EXCEPT: 

a) Statin use

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b) Hiking programs

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c) Restriction of alcohol consumption

25%

d) Blood pressure control

25%

e) Tobacco abstinence

25%
   

Commentics

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