Two-Toned Toes
Match the diagnosis to the photo by letter
a. Blue toe syndrome
b. Pernio (chilblains)
c. Subungual hematoma
d. Antiphospholipid syndrome
For answers, see next issue; for discussion, go to www.mdedge.com/clinicianreviews/picture
Answers to January “Picture This” (Clinician Reviews. 2018;28[1]:29): 1d, 2c, 3a, 4b
Photos and text for case 1 courtesy of Richard P. Usatine, MD; from Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:551-556.
To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/
You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.
Case presentation and photograph for Cases 2, 3, and 4 courtesy of Cutis. Copyright 2017 Frontline Medical Communications Inc.
4. For three days, a 63-year-old man has had severe, sudden-onset pain in the right hallux and fifth toe. The patient has hypertension and hyperlipidemia and has not undergone any vascular procedures. Physical exam reveals cyanotic change with remarkable coldness on the affected toes and livedo reticularis on the underside of the toes. Pulses are palpable. A biopsy of the fifth toe reveals thrombotic arterioles with cholesterol clefts.
Diagnosis: There are a variety of causes for blue toe syndrome, including embolism, thrombosis, vasoconstrictive disorders, infectious and noninfectious inflammation, extensive venous thrombosis, and abnormal blood circulation. Among them, only emboli from atherosclerotic plaques give rise to cholesterol clefts on biopsy. Such atheroemboli are often an iatrogenic complication, especially those caused by invasive percutaneous procedures or damage to the arterial walls from vascular surgery. However, spontaneous plaque hemorrhage or shearing forces of the circulating blood can disrupt atheromatous plaques and cause embolization of cholesterol crystals—which was likely the case with this patient, since no preceding events were noted.
,For more information, see “Painful Purple Toes.” Cutis. 2016;98(3):E8-E10.
