Finger and Toe Necrosis: Is It Raynaud's?
Finger and Toe Necrosis: Is It Raynaud's?
Given the relative weakness and nonspecific nature of the laboratory and clinical data, how do you arrive at a clinical diagnosis that drives the initiation of treatment with heparin, powerful vasodilators, and high-dose steroids?
Here's how. Ask yourself these questions:
1. Does this woman have a systemic disorder? Answer: Of course she does.
2. Is this woman's digital ischemic disease progressing before your eyes despite high-dose pain medications, vasodilators, and aspirin? Answer: Yes.
3. What is the best (not perfect) diagnostic fit? Answer: This is not mainstream Raynaud disease. Endothelial cells are profoundly perturbed by some process that includes an activated immune system that is obstructing small blood vessels in the fingers and toes. I use the term "endothelopathy" as a general descriptor for this patient's vasculopathic disorder.
4. Having developed a pathophysiologic construct that involves damaged/activated endothelial cells, what therapeutic options could counteract the proinflammatory, prothrombotic, and prospasm capacities of endothelial cells? Answer: A combination of vasodilators, steroids, and heparin.
Because her physicians followed this thought process, the patient is now back to normal and will remain on long-term therapy with warfarin, aspirin, and vasodilators. The patient demanded to be taken off of steroids, and we are discussing whether to begin azathioprine therapy for long-term disease control.
Arriving at a Diagnosis
Given the relative weakness and nonspecific nature of the laboratory and clinical data, how do you arrive at a clinical diagnosis that drives the initiation of treatment with heparin, powerful vasodilators, and high-dose steroids?
Here's how. Ask yourself these questions:
1. Does this woman have a systemic disorder? Answer: Of course she does.
2. Is this woman's digital ischemic disease progressing before your eyes despite high-dose pain medications, vasodilators, and aspirin? Answer: Yes.
3. What is the best (not perfect) diagnostic fit? Answer: This is not mainstream Raynaud disease. Endothelial cells are profoundly perturbed by some process that includes an activated immune system that is obstructing small blood vessels in the fingers and toes. I use the term "endothelopathy" as a general descriptor for this patient's vasculopathic disorder.
4. Having developed a pathophysiologic construct that involves damaged/activated endothelial cells, what therapeutic options could counteract the proinflammatory, prothrombotic, and prospasm capacities of endothelial cells? Answer: A combination of vasodilators, steroids, and heparin.
Because her physicians followed this thought process, the patient is now back to normal and will remain on long-term therapy with warfarin, aspirin, and vasodilators. The patient demanded to be taken off of steroids, and we are discussing whether to begin azathioprine therapy for long-term disease control.
Source...