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A 39-year-old Polish man comes to the clinic for painful calves after walking long distances and for discoloration of the fingers with changes in temperature. He says his symptoms started two months ago, and he gets no relief from the ibuprofen. He has previously been healthy. He currently smokes a pack a day and drinks socially. He has no history of drug abuse. On physical examination, his blood pressure is 140/90 mm Hg, heart rate is 68/min, and he is afebrile. Examination of the hands reveals distal digital ischemia and trophic changes in the nails of both hands. Radial pulses are absent bilaterally, but all other pulses are present. His right calf shows evidence of a superficial thrombophlebitis. Laboratory studies show: white cell count 9,600/mm3, hematocrit 38.6%, MCV 89 μm3, ESR 40 mm/h, and C-ANCA as negative. The rheumatoid factor and ANA are negative. Which of the following should be done next for this patient?
(A) Heparin
(B) Prednisone
© Arterial bypass
(D) Cyclophosphamide
(E) Abstention from tobacco
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Abstention from tobacco...thromboangitis obleterans
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(E) Abstention from tobacco
Explanation:
This patient has thromboangiitis obliterans (Buerger's disease), which is an inflammatory occlusive disorder involving small and medium-sized arteries and veins in the distal and upper extremities. The prevalence is highest in men of Eastern European descent under the age of 40. Although the cause is unknown, there is a definite relationship to cigarette smoking and an increased incidence of HLA-B5 and -A9 antigens in patients with this disorder. Clinical features of thromboangiitis obliterans often include a triad of claudication of the affected extremity, Raynaud's phenomenon, and migratory superficial thrombophlebitis. Claudication is confined to the lower calves and feet or forearms and hands because this disorder primarily affects the distal vessels. Hand examination can reveal severe digital ischemia, trophic nail changes, ulceration, and gangrene at the tips of the fingers. Brachial and popliteal pulses are usually present, but radial, ulnar, and/or tibial pulses may be absent. Smooth, tapering, segmental lesions in the distal vessels are present on angiography. The diagnosis can be confirmed by excisional biopsy of an involved vessel. There is no specific treatment, except abstention from tobacco. The prognosis is worse in those who continue to smoke, but results are relatively good in those who stop. C-ANCA antibodies are usually found in Wegener's granulomatosis. Arterial bypass may be indicated in disease confined to larger vessels. The hand abnormalities effectively exclude peripheral vascular disease. If these measures fail, amputation may be required. Cyclophosphamide and prednisone do not help. Again, the management is to stop smoking.
