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Agrawal A, Bhagawati J, Kumar S, Acharya S. Black Digits Matter: A Multispecialty Enigma. Cureus 2024; 16:e55133. [PMID: 38558690 PMCID: PMC10979651 DOI: 10.7759/cureus.55133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 02/28/2024] [Indexed: 04/04/2024] Open
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.
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Affiliation(s)
- Abhijeet Agrawal
- Department of Medicine, Jawaharlal Nehru Medical College, Wardha, IND
| | - Jahnabi Bhagawati
- Department of Medicine, Jawaharlal Nehru Medical College, Wardha, IND
| | - Sunil Kumar
- Department of Medicine, Jawaharlal Nehru Medical College, Wardha, IND
| | - Sourya Acharya
- Department of Medicine, Jawaharlal Nehru Medical College, Wardha, IND
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Misra DP, Jain N, Ora M, Singh K, Agarwal V, Sharma A. Outcome Measures and Biomarkers for Disease Assessment in Takayasu Arteritis. Diagnostics (Basel) 2022; 12:diagnostics12102565. [PMID: 36292253 PMCID: PMC9601573 DOI: 10.3390/diagnostics12102565] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 10/16/2022] [Accepted: 10/18/2022] [Indexed: 12/05/2022] Open
Abstract
Takayasu arteritis (TAK) is a less common large vessel vasculitis where histopathology of involved arteries is difficult to access except during open surgical procedures. Assessment of disease activity in TAK, therefore, relies on surrogate measures. Clinical disease activity measures such as the National Institutes of Health (NIH) score, the Disease Extent Index in TAK (DEI.TAK) and the Indian TAK Clinical Activity Score (ITAS2010) inconsistently associate with acute phase reactants (APRs). Computerized tomographic angiography (CTA), magnetic resonance angiography (MRA), or color Doppler Ultrasound (CDUS) enables anatomical characterization of stenosis, dilatation, and vessel wall characteristics. Vascular wall uptake of 18-fluorodeoxyglucose or other ligands using positron emission tomography computerized tomography (PET-CT) helps assess metabolic activity, which reflects disease activity well in a subset of TAK with normal APRs. Angiographic scoring systems to quantitate the extent of vascular involvement in TAK have been developed recently. Erythrocyte sedimentation rate and C-reactive protein have a moderate performance in distinguishing active TAK. Numerous novel biomarkers are under evaluation in TAK. Limited literature suggests a better assessment of active disease by combining APRs, PET-CT, and circulating biomarkers. Validated damage indices and patient-reported outcome measures specific to TAK are lacking. Few biomarkers have been evaluated to reflect vascular damage in TAK and constitute important research agenda.
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Affiliation(s)
- Durga Prasanna Misra
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow 226014, India
- Correspondence: (D.P.M.); (A.S.)
| | - Neeraj Jain
- Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow 226014, India
| | - Manish Ora
- Department of Nuclear Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow 226014, India
| | - Kritika Singh
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow 226014, India
| | - Vikas Agarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow 226014, India
| | - Aman Sharma
- Clinical Immunology and Rheumatology Services, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
- Correspondence: (D.P.M.); (A.S.)
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Bhatt K, Jindal P, Gupta S, Suri S. Digital gangrene and pulmonary consolidation in a young girl with Takayasu arteritis. Mod Rheumatol Case Rep 2022; 6:230-233. [PMID: 34904154 DOI: 10.1093/mrcr/rxab038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/06/2021] [Accepted: 10/01/2021] [Indexed: 06/14/2023]
Abstract
Takayasu arteritis (TA) is a large-vessel vasculitis most commonly affecting women of childbearing age. The disease process is usually slow and smoldering, presenting over months to years. Digital gangrene is an uncommon manifestation of TA because of the formation of good collateral circulation. Similarly, although pulmonary artery involvement is well described, pulmonary parenchymal involvement is very rare. We are reporting a case of a young girl with TA presenting with digital gangrene and pulmonary consolidation, which was treated successfully with a combination of aggressive systemic immunosuppression and anti-coagulants. The possible mechanism for gangrene along with the confounding diagnostic possibility of co-existing tuberculosis have been discussed.
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Affiliation(s)
| | | | - Sudesh Gupta
- Satyam Medical Center, Dehradun, Uttarakhand, India
| | - Shalini Suri
- Suri Diagnostic Center, Dehradun, Uttarakhand, India
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Singla S, Kalani K, Ban A. Co-existing ulcerative colitis and takayasu arteritis: A case-based review. INDIAN JOURNAL OF RHEUMATOLOGY 2022. [DOI: 10.4103/injr.injr_290_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
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Gururani S, Sreesailam SK, Narayanan R, Devarasetti PK, Rajasekhar L. Winslow Pathway Collaterals: An Unusual Arterial Network in Takayasu Arteritis. J R Coll Physicians Edinb 2020; 50:295-298. [DOI: 10.4997/jrcpe.2020.317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Takayasu arteritis which is reported more commonly from Asia and in females can present as middle aortic syndrome with lower limb claudication. We present a case of a young male with Takayasu arteritis with middle aortic syndrome and Winslow pathway collaterals with lower limb ischaemia, hypertension, coronary occlusion and stroke. The extensive collateral formation was visible as a clinical finding over the abdominal wall. The identification of these collateral pathways is essential in understanding the extent of haemodynamically significant disease and it alerts to the possibility of surgical injury during procedures like laparotomy or harvesting of internal thoracic artery for coronary artery bypass graft.
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Affiliation(s)
- Subodh Gururani
- Senior residents, Department of Clinical Immunology and Rheumatology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Sreejitha K Sreesailam
- Senior residents, Department of Clinical Immunology and Rheumatology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Ramakrishna Narayanan
- Assistant professors, Department of Radiology and Imageology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Phani K Devarasetti
- Assistant professors, Department of Radiology and Imageology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Liza Rajasekhar
- Professor and Head, Department of Clinical Immunology and Rheumatology, Nizam's Institute of Medical Sciences, Hyderabad, India
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Strunk D, Schulte-Mecklenbeck A, Golombeck KS, Meyer zu Hörste G, Melzer N, Beuker C, Schmidt A, Wiendl H, Meuth SG, Gross CC, Minnerup J. Immune cell profiling in the cerebrospinal fluid of patients with primary angiitis of the central nervous system reflects the heterogeneity of the disease. J Neuroimmunol 2018; 321:109-116. [DOI: 10.1016/j.jneuroim.2018.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 06/05/2018] [Accepted: 06/05/2018] [Indexed: 10/14/2022]
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Jain A, Misra DP, Ramesh A, Basu D, Jain VK, Negi VS. Tuberculosis mimicking primary systemic vasculitis: not to be missed! Trop Doct 2017; 47:158-164. [PMID: 28092221 DOI: 10.1177/0049475516687432] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Infections are an important differential diagnosis in patients presenting with features of systemic vasculitis. We report a young lady with constitutional features, leg ulcers, digital gangrene and absent peripheral pulses with cervical adenopathy. Chest imaging revealed multiple necrotic lung lesions and involvement of left subclavian artery at its origin from the aorta, Histopathology from cervical lymph nodes showed multiple caseated lymph nodes, which in the context of a positive Mantoux test led us to diagnose tuberculosis and institute appropriate therapy. This is only the second report of tuberculosis presenting as peripheral gangrene, cutaneous ulcers and absent pulses, and serves to educate rheumatologists regarding the need to consider infections as mimics of vasculitis, especially in the developing countries.
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Affiliation(s)
- Ankit Jain
- 1 Senior Resident, Department of Clinical Immunology, JIPMER, Puducherry, India
| | - Durga Prasanna Misra
- 2 Assistant Professor, Department of Clinical Immunology, JIPMER, Puducherry, India
| | - A Ramesh
- 3 Associate Professor, Department of Radiodiagnosis, JIPMER, Puducherry, India
| | - Debdatta Basu
- 4 Professor, Department of Pathology, JIPMER, Puducherry, India
| | - Vikramraj K Jain
- 2 Assistant Professor, Department of Clinical Immunology, JIPMER, Puducherry, India
| | - Vir Singh Negi
- 5 Professor and Head, Department of Clinical Immunology, JIPMER, Puducherry, India
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Takayasu arteritis (TA) first presenting with intestinal ischemia: a case report and review of gastrointestinal tract involvement (ischemic and non-ischemic) associated with TA. Rheumatol Int 2016; 37:169-175. [PMID: 27832292 DOI: 10.1007/s00296-016-3600-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 11/04/2016] [Indexed: 10/20/2022]
Abstract
Takayasu arteritis (TA) is a large vessel vasculitis involving the aorta and its major branches. Insidious inflammation usually results in gradual arterial narrowing; however, critical organ ischemia is rare. We describe a young male with TA who presented with acute mesenteric ischemia requiring intestinal resection, followed by critical limb ischemia. In our literature review, we identified intestinal gangrene as a rare manifestation of TA. However, intestinal ischemia as the first manifestation of TA has been scarcely reported in the literature. Also, ischemia of the intestine occurring together with critical limb ischemia is extremely unusual. Rheumatologists should be aware of TA as a rare cause of gastrointestinal vasculitis in young adults, which can be easily suspected by routinely examining all the peripheral pulses.
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