Rheumatology

PCP submission

This is a 63 y/o w/m incarcerated patient with no previous medical history who presents with sudden severe pain and mottling of left 5th toe and right lateral/dorsal aspect of right foot 3-4 weeks ago with no trauma. Bilateral foot X-ray normal. No edema/cellulitis. Describes severe burning pain that is not improved with NSAIDS. Has been treated initially with levofloxacin 500 mg qd x 7 days then Keflex 500 mg qid c 7 days.

Specialist response

Thank you for this consult. My initial thoughts are that he may have a blood clot in smaller blood vessels. Ideally we would get a CT angio of the lower extremities to further evaluate his circulation. Do you happen to have a picture that you could attach here? That would be helpful for me to see as it may help with my differential diagnosis. Does he have any drug use or is he is smoker? Does she have any systemic autoimmune symptoms? I would check labs for small-vessel vasculitis which would include ANCA, ANA, ds DNA, anti Smith, C3, C4, RF, CCP, SSA, SSB, hepatitis panel, and HIV. I would also check a urinalysis with urine protein/creatinine ratio. In terms of managing his pain right now you may consider starting him on gabapentin and then I would also consider increasing the enoxaparin to full anticoagulation dosing. The thrombocytosis is likely reactive, but I would also recommend getting the opinion of Hematology as well.

Thank you for the pictures. I would also add in the anti-phospholipid labs cardiolipin IgG and IgM, Beta 2 glycoprotein IgG and IgM, and lupus anticoagulant. I would also add in vasodilators such as amlodipine or nifedipine.