SHM Converge Scientific Abstract ePoster Gallery-Woe to the Blue Toe

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This case describes a 55-year-old man with painful blue discoloration of the left third and fourth toes, consistent with blue toe syndrome. His history included coronary artery disease, a known left ventricular (LV) mural thrombus, tobacco use, and recent thalamic, splenic, and renal infarcts. He admitted nonadherence to outpatient aspirin and warfarin.<br /><br />On exam, he had toe duskiness, weak distal pulses, and delayed capillary refill, but intact strength and sensation. Labs showed leukocytosis, elevated hemoglobin and platelets, and subtherapeutic anticoagulation. Autoimmune testing was negative. A hypercoagulable evaluation revealed low erythropoietin and a positive JAK2 mutation, confirming polycythemia vera (PV). Echocardiography showed a large mobile LV thrombus that had enlarged to 4 cm. CT imaging also showed filling defects in the aortic arch and descending thoracic aorta, while lower-extremity vascular studies were normal.<br /><br />The authors concluded that the toe ischemia was most likely cardioembolic, driven by hypercoagulability from PV and the large LV thrombus, rather than peripheral arterial disease or autoimmune vasculitis. They emphasize that blue toe syndrome has a broad differential, including atheroembolism, thrombosis, autoimmune disease, malignancy, and hypercoagulable states, so thorough workup is essential.<br /><br />Treatment included aspirin, hydroxyurea, planned weekly outpatient phlebotomy for PV, and resumption of warfarin for the LV thrombus. The case highlights the importance of broad diagnostic evaluation, specialty follow-up, and patient counseling about medication adherence to prevent recurrent embolic and ischemic complications.

Asset Subtitle

Jennifer Franke

Meta Tag

Author List Andrew Kao, Hannah Wellington, Janan Leppo, Jennifer Franke, Maryann T. Ally

Category Clinical Vignettes

Concept Blue Toe Syndrome

Concept Polycythemia Vera

Concept Embolism

Concept Thrombosis

Concept Echocardiography

Distinguished Non-Finalist

Presenter Organization Ucsd

Presenting Author Jennifer Franke

Track Adult

Keywords

blue toe syndrome

polycythemia vera

left ventricular thrombus

cardioembolic ischemia

JAK2 mutation

toe ischemia

hypercoagulable state

warfarin nonadherence

hydroxyurea

embolism

Blue Toe Syndrome

Polycythemia Vera

Embolism

Thrombosis

Echocardiography