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 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.

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.

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.

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

Skin Exam

UptoDate.com Accessed 9/6/05

Differential Diagnosis

Embolic Disease Peripheral Vascular Disease (arterial

insufficiency) Vasculitis Cryoglobulinemia Buerger’s Disease

Diagnostic Testing

CBC, LFT, Cr ESR, CRP ANA, RF, C-ANCA, P-ANCA Hep B and C Antiphospholipid antibodies ECHO

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

Skin Biopsy

Multiple small, highly cellular, inflammatory thrombi

Relative sparing of the blood vessel wall No vasculitis No evidence of atherosclerosis

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

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

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

Clinical Features Usually presents as claudication, rest pain

Features Atherosclerosis Buerger’s Ds

Age > 40yo 20-45yo

Other risk factors +++ no

Upper extremity involvement

rare Up to 90%

Proximal vessel involvement

+++ rare

Pulse exam decreased preserved

Superficial Thrombophlebitis

no Up to 40%

Skin Exam

UptoDate.com Accessed 9/6/05

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.

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

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.

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

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.