Minerva
BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7275.1540 (Published 16 December 2000) Cite this as: BMJ 2000;321:1540All rapid responses
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Sir - We read with interest the case in Minerva (BMJ 2000 ; 321:
1540) entitled "purple toe syndrome" 1.
Classically this condition occurs
bilaterally and the discolouration blanches with pressure2. The
differential diagnosis includes warfarin necrosis and acral purpura, as
illustrated in this case, can be the initial manifestation of warfarin
induced necrosis3. This is an important point as warfarin necrosis can
result in significant morbidity and even mortality. Early diagnosis and
discontinuation of warfarin may prevent more serious sequelae although
where deemed absolutely necessary it may be continued4.
Secondly although mentioned by the authors that "purple toe syndrome" may
be due to cholesterol microemboli, when this occurs in patients on
warfarin it suggests bleeding into an atheromatous plaque which results in
microembolisation2. This would suggest the need for further investigation
in this gentleman to rule out aneurysmal disease of the abdominal aorta or
iliac, femoral or popliteal arteries as a source of cholesterol
microemboli. It is also important to state that classical cholesterol
embolisation usually affects the thighs or buttocks and results in
extensive skin necrosis quite unlike this case. We feel these points merit
consideration in the management of patients who develop purple
discolouration of the feet while on warfarin and were not highlighted by
the authors.
Dr Brian Kirby
Dermatology Research Fellow
Professor CEM Griffiths
Professor of Dermatology
Dermatology Centre,
University of Manchester
Hope Hospital,
Salford
Manchester
M6 8HD
References
1. Shrivastava V, Spencer C. Minerva 2000 ; 321 : 1540
2. Akle CA, Joiner CL. Purple toe syndrome. J R Soc Med 1981 ; 74 :
219
3. Stone MS, Rosen T. Acral purpura: an unusual sign of coumarin
necrosis. J Am Acad Dermatol 1986 ; 14 : 797-802.
4. Stewart AJ, Penamn ID, Cook MK, Ludlam CA. Warfarin-induced skin
necrosis. Post Grad Med J 1999 ; 75 : 233-255.
Competing interests: No competing interests
Discrepancy between work presented and published in paediatrics
Dear Sirs - Minerva (16th December 2000) notes the discrepancy
between work presented and that published in paediatrics. A paediatrician
suggests that help is required for the authors.
Recognition and assistance is also required from specialist journals, not
the least those published by the BMJ. There seems to be a belief on the
part of some journal editors that clinical observation and retrospective
analysis comes a very poor second to meta-analysis, double blind
controlled studies and laboratory effort.
The majority of practicing clinicians do not have the time or opportunity
to be involved in much prospective analysis, our administrative masters
(in the UK or elsewhere) see this as unproductive effort. All the more
reason to consider their efforts and encourage the submission of clinical
work.
The importance of evidence based studies is apparent to all, but without
clinical observations and reviews our clinical evidence will become more
detailed and involved looking at a decreasing area of medicine and we
shall finally involute completely.
d & d bossingham
Competing interests: No competing interests