A 43-year-old woman presents to the rheumatology clinic with a 1-month history of painful, discolored toes. She first noted an onset of redness and itching at the tips of her toes about 2 months before presentation. The itching progressed to tenderness, followed by the formation of "sores" over the affected areas. She notes that the toes have been sensitive to cold, particularly when she leaves the house and is exposed to winter weather. She denies any trauma to her feet, recent illnesses, or surgical interventions. She has never suffered similar symptoms in the past and has received no specific therapy. She feels otherwise well and denies any fevers, joint pains, gastrointestinal complaints, or weight changes. Her current medications include over-the-counter fish-oil tablets and a daily multivitamin. She does not smoke tobacco and drinks 3 glasses of wine weekly.
On physical examination, her oral temperature is 98.8ºF (37.1ºC). Her pulse has a regular rhythm, with a rate of 79 bpm. Her blood pressure is 112/66 mm Hg. The examination of her head and neck, including auscultation of the carotid arteries and funduscopic visualization, is normal. Her lungs are clear to auscultation. The cardiac examination reveals normal S1 and S2 heart sounds, without murmurs, rubs, or gallops. Her abdomen is soft and nontender, with normal active bowel sounds on auscultation. No abdominal masses or organomegaly are noted. Her vascular examination reveals 2+ pulses at the axillary, brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial regions, without bruits. The neurologic examination is nonfocal. Nonblanching purpuric lesions overlying the pulp area of the right 1st, 3rd, and 5th toes, as well as the left 2nd and 3rd toes, with superficial ulceration of the right 3rd toe, are noted on the dermatologic examination. The lesions are surrounded by poorly demarcated blanching erythema The remainder of the dermatologic examination is normal, with normal upper extremity nailfold capillaroscopy.
The laboratory analysis, including a complete blood count (CBC) and comprehensive ****bolic panel, are normal. The prothrombin time (PT) and partial thromboplastin time (PTT) are each normal. The findings of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), both inflammatory markers, are normal. Testing for antinuclear antibodies (ANA), antineutrophil cytosplasmic antibodies (ANCA), rheumatoid factor (RF), lupus anticoagulant, anticardiolipin antibodies, antihistone antibodies, anticentromere antibodies, and cryoglobulins, all have negative results. Testing for acute and chronic viral hepatitis is negative. A lower extremity arteriogram reveals patent vasculature with normal-appearing flow. A punch biopsy of the left 2nd toe reveals both superficial and deep perivascular predominantly lymphocytic inflammatory infiltrate and superficial dermal hemorrhage, in addition to an interface/lichenoid dermatitis.
Immersion foot, or trench foot, is a medical condition caused by prolonged exposure of the feet to damp, unsanitary and cold conditions above freezing point.
i do not think it is Purple toe syndrome
because she is not taking warfarin
Purple toe syndrome
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i am confused between
Raynaud phenomenon and Chilblains
Chilblains, also called perniosis or blain, when occurring on the feet, is a medical condition that is often confused with frostbite and trench foot. Chilblains are acral ulcers that occur when a predisposed individual is exposed to cold and humidity. Acral refers to the extremities (e.g. fingers and toes). Chilblains are often idiopathic in origin but can be manifestations of serious medical conditions that need to be investigated. Chilblains can be prevented by keeping the feet and hands warm in cold weather. Smoking cessation and consultation with a dermatologist is advised
Chilblains (also called perniosis) is a localized cutaneous inflammatory lesion associated with cold exposure. The diagnosis in this case was suggested by the characteristic ******** and appearance of the lesions, as well as their association with cold exposure.
The lesions are either single or multiple, are erythematous to violaceous in color, and are characterized by pruritic or burning pain. Chilblains lesions usually resolve within a few days; however, a more prolonged course, with blistering and ulceration, may occur with repeated cold exposure (as was seen in this case).
Chilblains are categorized as primary or secondary, based on the absence or presence of an associated underlying condition. Primary chilblains (also called banal chilblains) occurs in the absence of an underlying disorder. Primary chilblains is milder than secondary disease, with complete resolution typically occurring within 3 weeks; however, chronic cases have been described with repeated exposure to cold. Secondary chilblains occurs in association with several systemic conditions, including systemic lupus erythematosus (chilblain lupus), cryoproteins, antiphospholipid antibodies, myelomonocytic leukemia, and as a reaction to certain medications (such as infliximab, sulindac, terbinafine).
The treatment of primary chilblains includes both conservative and pharmacologic measures. Conservative measures include avoidance of cold temperatures, use of warm clothing, and avoidance of vasoconstrictive agents, including nicotine, caffeine and ephedra-containing substances (such as decongestants and diet aids). Nifedipine has demonstrated efficacy in the treatment of chilblains, a benefit thought related to its vasodilatory properties. At doses of 20-60mg daily, nifedipine reduced existing lesions and prevented new lesions from developing.
The patient in this case was counseled regarding conservative treatment measures, such as avoidance of cold and the wearing of warm clothing. She was initiated on low-dose, extended-release nifedipine (30mg once daily.) The lesions resolved completely within 1 month of therapy, and the nifedipine was discontinued after 3 months of disease-free therapy. The lesions did not recur, which was in keeping with the generally excellent prognosis for properly treated primary chilblains.
Dr.Shadows
Outstanding Member
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