Click to enlarge.
Cryoglobulins, ANA, Scl-70, blood and fungal cultures were negative; complement levels were normal. His C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) had normalized.
He was admitted to our facility for possible APS and to rule out infective endocarditis in the setting of his recent dental work.
He had diminished dorsalis pedis and posterior tibial pulses, cyanotic changes in the distal tips of his toes, with blistering of toes one, two and three of his left foot. Capillary refill was extremely delayed in the affected toes, and he had ischemic changes with dark necrosis on the distal right hallux. The podiatric consultant opened the blister on the third toe, revealing clear serous fluid, which did not appear purulent. Intravenous (IV) vancomycin, IV ceftriaxone, heparin infusion, hydroxychloroquine and atorvastatin were started for limb-threatening distal ischemia in the context of his abnormal aPL profile. Blood cultures were negative, and a trans-esophageal echocardiogram was normal. The patient was discharged on warfarin, prednisone, hydroxychloroquine, nifedipine and atorvastatin.
FIGURES A–C: The patient’s left foot following first hospital discharge. FIGURE D: Digital ischemia, gangrene and cellulitis of the left foot one day prior to amputation. FIGURE E: The patient’s left foot three months post-amputation. (Click to enlarge.)
The patient was seen one week after discharge. He admitted to continued smoking, despite recommendations to quit. Prednisone tapering was started in view of the normal inflammatory markers. When seen by the podiatrist a week later, he was noted to have progressive gangrene of the left first and second toes, down to bone (see Figure 2 A–D), necessitating amputation of the first, second and third toes.
