Endgames Case Report

Ischaemia of the extremities in a smoker

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d8193 (Published 21 December 2011) Cite this as: BMJ 2011;343:d8193
  1. Rosanna Berryman, foundation doctor,
  2. Ian Currie, consultant vascular surgeon,
  3. Robert McCarthy, consultant vascular surgeon
  1. 1South Devon Healthcare NHS Foundation Trust, Torbay Hospital, Torquay TQ2 7AA, UK
  1. Correspondence to: R Berryman rberryman{at}nhs.net

A 51 year old man presented with a six week history of pain in his right hand, which was associated with blue discoloration and a discharge of pus from the tip of his index finger. He was a lifelong smoker but had no other cardiovascular risk factors. He had a history of Raynaud’s phenomenon affecting both hands and claudication of both feet.

His blood pressure was 120/80 mm Hg and his cardiovascular examination was normal. No carotid, subclavian, or femoral bruits were heard. Capillary refill was prolonged at six seconds. The right hand digits were cyanosed, with wet gangrene in the distal right index finger. Brachial pulses were palpable but radial and ulnar pulses were absent bilaterally. Femoral and popliteal pulses were palpable but all foot pulses were absent. Allen’s test was positive.

Laboratory investigations showed sodium 141 mmol/L (reference range 135-145), potassium 5.6 mmol/L (3.5-5.0), urea 6.5 mmol/L (2.5-6.7), creatinine 80 mmol/L (70-120), glucose 6 mmol/L (3-7.8), C reactive protein 16 mg/L (0-5), white blood cell count 12.4×109/L (4-10), and neutrophils 9.1×109/L (1.8-7.5). His autoimmune profile was negative and his hypercoagulability screen was normal. Electrocardiography showed a normal sinus rhythm. On angiographic assessment, he had normal proximal vessels but distal small vessel disease and medium vessel disease bilaterally; he also had segmental and distal occlusion of the radial and ulnar arteries and the posterior tibial arteries bilaterally. On ultrasound examination the vessels were dilated, with a halo of inflammatory tissue …

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