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Pain in the Foot: A 52 yo man in misery

Pain in the Foot: A 52 yo man in misery. Christie Seibert, MD September 21, 2005. No financial disclosures. The Patient. 52 yo man w/o sig PMH

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Pain in the Foot: A 52 yo man in misery

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  1. Pain in the Foot: A 52 yo man in misery Christie Seibert, MD September 21, 2005

  2. No financial disclosures.

  3. The Patient • 52 yo man w/o sig PMH • 2 mo ago: sudden onset of 8/10 pain in his R great toe and sole of foot, spreading toward his ankle. Occurs with rest and exertion. Worst when elevates R leg. • Treated with NSAIDS, which gave partial relief.

  4. The Patient • 3 wks ago: Same sxs in L foot. Also, R foot developing red-blue discoloration at toes, dorsum of foot. • Pain so severe that he is unable to work and has sig diff sleeping. Sleeps sitting in a chair. • Treated with NSAIDs again, ruled out for DVT.

  5. The Patient • PMH: Nephrolithiasis x 1. No meds. • SH: Works for a uniform rental company. Smokes 1ppd x 36 yrs. 3-4 beers/wk. “Occasional” marijuana. • FH: No FH of cancer, CAD, VTE. • ROS: Had URI about 2 wks prior to sxs.

  6. The Exam • VS: Afeb, BP 112/66, P 78 • General: Comfortable with feet on floor • CV, Lungs, Abd WNL • MSK: no synovitis, no limits in ROM • EXT: Non-pitting edema of both feet to mid calf. 2+ PT and DP pulses

  7. Skin Exam UptoDate.com Accessed 9/6/05

  8. Differential Diagnosis • Embolic Disease • Peripheral Vascular Disease (arterial insufficiency) • Vasculitis • Cryoglobulinemia • Buerger’s Disease

  9. Diagnostic Testing • CBC, LFT, Cr • ESR, CRP • ANA, RF, C-ANCA, P-ANCA • Hep B and C • Antiphospholipid antibodies • ECHO

  10. MRA of Lower Extremities: Iliac, femoral and popliteal circulations are widely patent. Several short segment moderate stenoses in posterior and anterior tibial arteries. Warfel, JH. The Extremities, 5th edition 1985

  11. Skin Biopsy • Multiple small, highly cellular, inflammatory thrombi • Relative sparing of the blood vessel wall • No vasculitis • No evidence of atherosclerosis

  12. Buerger’s Disease (Thromboangiitis Obliterans) • First described in 1879 • In 1908, Leo Buerger described pathologic findings in 11 amputated limbs • Worldwide distribution • Prevalence: Middles East/Far East > North America/Western Europe • 12.6 per 100,000 in Olmstead County

  13. Pathophysiology • Nonatherosclerotic segmental inflammatory disease of small and medium-sized arteries (skip lesions) • Distinguished from other vasculitis • Sparing of blood vessel wall • ESR, CRP normal • Autoantibodies negative

  14. Diagnostic Criteria • Typically age less than 45 years and male • Current or recent history of tobacco use • Distal extremity ischemia in the absence of proximal disease • Exclusion of autoimmune and hypercoaguable diseases

  15. Clinical Features • Usually presents as claudication, rest pain

  16. Skin Exam UptoDate.com Accessed 9/6/05

  17. Allen Test (+ in 65%) • Patient makes a fist • Examiner’s thumbs occlude radial and ulnar arteries • Patient opens hand into relaxed, partially flexed position • Pressure on ulnar artery is released while radial artery is compressed • Normally, hand should turn pink because of intact interconnecting arteries • Can be repeated releasing pressure of radial artery NEJM,2000;343(12):867.

  18. Treatment • Absolute abstinence of smoking • 40% who continue to smoke will require amputation, compared to 5% who quit • Not amenable to surgery • Negative studies regarding thrombolytic therapy

  19. Oh by the way, doc… • Cannabis arteritis first described in the 1960’s. • Mainly case reports and series. • Clinically and pathologically like Buerger’s disease, occurring rarely in young adults.

  20. Objectives • Recognize Buerger’s disease • Describe diagnostic criteria and clinical features of the disease • Describe the Allen Test • Know that complete smoking cessation is the only treatment

  21. References • Szuba a, Cooke JP. Thromboangiitis obliterans: An update on Buerger’s disease. West J of Med 1998;168(4):255-61. • Olin JW. Thromboangiitis Obliterans (Buerger’s Disease). NEJM 2000;343(12):864-9. • Mohler ER, Olin JW. Thromboangiitis Obliterans (Buerger’s Disease). Up to Date.com. Accessed 9/6/2005. Last updated 11/15/2004. • Combamale P, Consort T, Denis-Thelis L et al. Cannabis arteritis. Br J Dermatol 2005;152(1):166-9. • Disdier P, Granel B, Serratrice J et al. Cannabis arteritis revisited;ten new case reports. Angiology 2001;52(1):1-5.

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