SHM Converge Scientific Abstract ePoster Gallery-Progressive Digital Ischemia Associated With Positive Antiphospholipid Antibodies

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A 61-year-old man with diabetes, hypertension, hyperlipidemia, tobacco use, Raynaud phenomenon, and a prior provoked DVT on apixaban presented with sudden purpuric rash of the legs and painful discoloration/ulceration of multiple fingers and toes. He was transferred for concern for catastrophic antiphospholipid syndrome or infective endocarditis because of previously positive anticardiolipin antibodies and exam findings that resembled embolic lesions.<br /><br />Workup showed elevated inflammatory markers and mildly positive anticardiolipin IgM and anti-beta-2-glycoprotein IgM antibodies, but the rest of the rheumatologic evaluation was negative. Blood cultures and echocardiography were negative for endocarditis, and neuroimaging showed no acute findings. Vascular imaging revealed a non-flow-limiting left popliteal artery dissection and superficial venous thrombosis, but ABIs were normal.<br /><br />Because the degree of ischemia was greater than expected for antiphospholipid syndrome alone, a skin biopsy of the right hallux was performed. Pathology showed leukocytoclastic vasculitis with vascular thrombosis and epidermal ulceration/necrosis, felt most consistent with thromboangiitis obliterans (TAO, Buerger’s disease). He was treated with prednisone, later hydroxychloroquine, and anticoagulation was changed from apixaban to warfarin.<br /><br />Despite treatment, he developed dry gangrene requiring wound care, later osteomyelitis, and ultimately right transmetatarsal amputation with partial left toe amputations. Three months later, antiphospholipid antibody titers became negative.<br /><br />This case highlights the diagnostic challenge of progressive digital ischemia, the overlap between TAO and antiphospholipid antibodies, and the importance of considering TAO even in patients older than the classic age range.

Asset Subtitle

Paige A. Cassidy

Meta Tag

Author List Jeremy J. Gentile, Paige A. Cassidy

Category Clinical Vignettes

Concept Digital Ischemia

Concept Gangrene

Concept Thromboangiitis Obliterans

Concept Tobacco Use

Concept Purpura

Distinguished Non-Finalist

Presenter Organization Corewell Health

Presenting Author Paige A. Cassidy

Track Adult

Keywords

thromboangiitis obliterans

Buerger disease

digital ischemia

antiphospholipid antibodies

leukocytoclastic vasculitis

dry gangrene

skin biopsy

warfarin

osteomyelitis

amputation

Digital Ischemia

Gangrene

Thromboangiitis Obliterans

Tobacco Use

Purpura