SHM Converge Scientific Abstract ePoster Gallery-Blueprints of Blue Toe: A Tale of Thrombocytosis, Pathophysiology, and the Importance of a Detailed History

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This case describes a 42-year-old woman with type 1 diabetes, recurrent DKA, coronary artery disease, peripheral arterial disease, and prior toe amputations from blue toe syndrome (BTS), who presented to an outside hospital with DKA, MSSA bacteremia, and worsening pain and discoloration of her right third toe. An initial transesophageal echocardiogram raised concern for endocarditis and septic emboli, but transfer to Thomas Jefferson University Hospital and subsequent cardiac MRI did not confirm a cardiac source. Imaging instead supported BTS.<br /><br />During the hospitalization, her platelet count rose as toe pain worsened, prompting evaluation for thrombocytosis-related causes. Hypercoagulable testing was negative, essential thrombocythemia was ruled out genetically, and cephalosporin-induced thrombocytosis was considered unlikely. A deeper history revealed progressive menorrhagia over the prior decade, severe microcytic anemia, and markedly low ferritin, consistent with iron deficiency. Review of prior admissions showed similar episodes of thrombocytosis, often around menstrual periods, including one before earlier toe amputations.<br /><br />The team concluded that severe iron-deficiency anemia from chronic blood loss was causing reactive thrombocytosis, which likely worsened microvascular thrombosis and contributed to BTS in the setting of underlying PAD. After intravenous iron repletion, the platelet count began to fall and toe pain improved significantly. The authors note that BTS is typically an embolic phenomenon but can have multiple causes, and that identifying and treating the underlying driver is essential to prevent progression to gangrene and amputation.<br /><br />The case emphasizes the importance of careful history-taking, reviewing prior data, and avoiding diagnostic anchoring. By recognizing reactive thrombocytosis from iron deficiency, the team may have prevented a third toe amputation.

Asset Subtitle

Karlie E. Brasch

Meta Tag

Author List Alan A. Kubey, Karlie E. Brasch

Category Clinical Vignettes

Concept Blue Toe Syndrome

Concept Toe Ischemia

Concept Septic Emboli

Concept Reactive Thrombocytosis

Concept Microvascular Thrombosis

Distinguished Non-Finalist

Presenter Organization Thomas Jefferson University Hospital, Philadelphia PA

Presenting Author Karlie E. Brasch

Track Adult

Keywords

blue toe syndrome

reactive thrombocytosis

iron deficiency anemia

menorrhagia

type 1 diabetes

peripheral arterial disease

microvascular thrombosis

toe amputation

MSSA bacteremia

intravenous iron

Blue Toe Syndrome

Toe Ischemia

Septic Emboli

Reactive Thrombocytosis

Microvascular Thrombosis