Black Digits Matter: A Multispecialty Enigma

Abstract

Introduction Digital ischemia is alike any other visceral ischemic event leading to severe tissue damage ultimately causing necrosis of the involved extremity. It's like a preview of the upcoming systemic disorder and can present itself in any specialty and hence everyone, be it a physician or a surgeon must be primed toward how to proceed with a case of digital ischemia. In this case series, we present six such cases that presented with digital ischemic events either as a sole presentation or were followed by other systemic manifestations that led to their evaluation and ultimately the etiology behind it. Material and method Patients visiting Rheumatology OPD with complaints suggestive of digital ischemia were included in this study. All patients underwent thorough history taking and clinical examination to establish the cause of digital ischemia. Patients with probable infective, trauma, cardiac, and drug-induced causes and malignancies were excluded. As per probable autoimmune causes, patients underwent evaluation via antinuclear antibodies by immunofluorescence (ANA by IF), antiphospholipid antibodies like lupus anticoagulant (LAC), anticardiolipin antibodies (AcL) and anti Beta2GP1 antibodies, extractable nuclear antigens (ENA) and in cases of suspected vasculitis doppler ultrasound and angiography. Results Six patients were identified as cases primarily presenting with digital ischemia or with a prior history of digital ischemia. Two patients were of the pediatric age group, one 16-year-old male presenting with acute arthritis and a history of digital ischemia one year back, and the other was a 12-year-old female with blackening of the second toe in her left foot with a history of similar complaints in the left great toe for which she underwent amputation of that toe. Other four cases were of the adult age group, with two cases of scleroderma, one with systemic lupus erythematosus, and one with Takayasu arteritis. All of these patients primarily presented to departments other than rheumatology. Conclusion Digital ischemia is a pan-specialty problem with the etiologies spreading across a vast spectrum of rheumatological disorders, many of which may present to different specialties initially, later discovered to be part of the systemic manifestation of autoimmune diseases. Hence, it becomes imperative to have a rheumatological perspective in these cases of digital ischemia which all specialities should be aware of, and timely referral may prevent permanent loss of the digits and in some cases the entire limb.

Keywords: antiphospholipid antibody; autoimmune; connective tissue disease; digital ischemia; digital ulcer; raynaud's phenomenon; scleroderma; systemic lupus erythematosus.

Figure 1. (A) Left Great Toe Showing Ischemic Discoloration. (B) Post-intravenous Thrombolysis Image

Figure 2. CT Angiogram Showing Long Segment Obstruction in the Left Superficial Femoral Artery with Collateral Formation (Arrow Showing No Contrast between Proximal and Distal Superficial Femoral Artery)

CT: Computerized Tomography

Figure 3. Left Second Toe Showing Ischemic Changes

Figure 4. Angiography Showing Blood Flow in the Lower Limb Above the Knee

Figure 5. Angiogram Showing No Blood Flow in the Right Leg Below the Knee

Figure 6. Post-balloon Angioplasty Restoration of Blood Flow in the Right Leg Below the Knee

Figure 7. Right Third Toe Showing Ischemic Changes

Figure 8. Nail Fold Capillaroscopy Showing Giant Capillaries

Figure 9. Right Middle Finger Distal Phalanx Showing Necrotic Changes

Figure 10. Multiple Digits Showing Ischemic Discoloration With Left 2nd to 5th Terminal Phalanx Showing Necrotic Changes