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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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Jain H, Mittal A, Didel S, Kumar P, Singh K. Use of prostaglandin and cyclophosphamide for pediatric lupus with digital gangrene: Back to safety before hitting the axe! Lupus 2023; 32:1572-1578. [PMID: 37876266 DOI: 10.1177/09612033231208850] [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] [Indexed: 10/26/2023]
Abstract
Digital gangrene is a rare presenting feature of childhood lupus and only a reported incidence of 1.3%. We describe two cases of pediatric onset systemic lupus erythematosus (SLE), both 16 years old, presenting with digital gangrene and the successful salvage of the digits after using intravenous cyclophosphamide for immunosuppression and use of intravenous prostaglandin E1 infusions for limb reperfusion. Both of the patients responded exceptionally to the infusions with resolution of gangrene and near-total preservation of the functionality of toes.
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Affiliation(s)
- Hritvik Jain
- Intern, Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, India
| | - Aliza Mittal
- Department of Pediatrics, All India Institute of Medical Sciences Jodhpur, Jodhpur, India
| | - Siyaram Didel
- Department of Pediatrics, All India Institute of Medical Sciences Jodhpur, Jodhpur, India
| | - Prawin Kumar
- Department of Pediatrics, All India Institute of Medical Sciences Jodhpur, Jodhpur, India
| | - Kuldeep Singh
- Department of Pediatrics, All India Institute of Medical Sciences Jodhpur, Jodhpur, India
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Boussaid S, Ben Majdouba M, Rekik S, Jemmali S, Zouaoui K, Rahmouni S, Sahli H, Elleuch M. Case Report: Extensive digital gangrene as a primary manifestation of late-onset systemic lupus erythematosus. F1000Res 2022; 11:922. [PMID: 38813136 PMCID: PMC11134139 DOI: 10.12688/f1000research.124225.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2022] [Indexed: 05/31/2024] Open
Abstract
Background: Digital gangrene is a rare but serious complication of systemic lupus erythematosus (SLE). It occurs usually in middle-aged patients with longer disease duration. Case: Herein we report the case of a 56-year-old man (with no history suggestive of Raynaud's phenomenon, diabetes mellitus, smoking, trauma, infection, or chemical exposure), who presented with SLE and digital gangrene was among the first signs. He presented with a one-month history of joint pain, hair loss, photosensitivity, mouth ulcers, malar rash, dyspnea, and digital pain. Physical examination revealed painful and diffuse erythematous skin lesions in the extremities and back, as well as cyanosis in the fingers. We noted lymphocytopenia (600 cells/mm 3), and an elevated C-reactive protein (15.1 mg/l) on laboratory tests. Immunological tests were positive for antinuclear antibodies (ANA) with Title 1:400. Pulmonary computed tomography revealed pulmonary fibrosis, and pulmonary function tests revealed the restrictive pulmonary disease. Diagnosis of SLE with lung involvement was retained. The immunological assessment in search of elements in favor of a vascular origin of the patient's skin lesions was negative. Treatment was initiated with 200 mg/day hydroxychloroquine. For dermal and pulmonary involvement, intravenous (IV) pulse therapy was used with methylprednisolone (1,000 mg/d for three consecutive days monthly) and cyclophosphamide (1 g/month). Calcium blocking agents were also prescribed. However, the lesions did not improve. The patient was given two infusions of rituximab (1 g) at a 14-day interval with a marked improvement ofthe majority of vasculitis lesions, and a partial improvement of dyspnea. Conclusions: Digital gangrene is a rare complication of late-onset SLE, especially as a primary manifestation.
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Affiliation(s)
- Soumaya Boussaid
- Rheumatology Department, La Rabta Hospital, La Rabta Jebbari, Tunis, 1007, Tunisia
- Faculty of Medicine of Tunis, University Tunis el Manar, La Rabta Jebbari, Tunis, 1007, Tunisia
- Research unit LR 05 SP 01, La Rabta Hospital, La Rabta Jebbari, Tunis, 1007, Tunisia
| | - Marouene Ben Majdouba
- Rheumatology Department, La Rabta Hospital, La Rabta Jebbari, Tunis, 1007, Tunisia
- Faculty of Medicine of Tunis, University Tunis el Manar, La Rabta Jebbari, Tunis, 1007, Tunisia
| | - Sonia Rekik
- Rheumatology Department, La Rabta Hospital, La Rabta Jebbari, Tunis, 1007, Tunisia
- Faculty of Medicine of Tunis, University Tunis el Manar, La Rabta Jebbari, Tunis, 1007, Tunisia
- Research unit LR 05 SP 01, La Rabta Hospital, La Rabta Jebbari, Tunis, 1007, Tunisia
| | - Samia Jemmali
- Rheumatology Department, La Rabta Hospital, La Rabta Jebbari, Tunis, 1007, Tunisia
- Faculty of Medicine of Tunis, University Tunis el Manar, La Rabta Jebbari, Tunis, 1007, Tunisia
- Research unit LR 05 SP 01, La Rabta Hospital, La Rabta Jebbari, Tunis, 1007, Tunisia
| | - Khaoula Zouaoui
- Rheumatology Department, La Rabta Hospital, La Rabta Jebbari, Tunis, 1007, Tunisia
- Faculty of Medicine of Tunis, University Tunis el Manar, La Rabta Jebbari, Tunis, 1007, Tunisia
- Research unit LR 05 SP 01, La Rabta Hospital, La Rabta Jebbari, Tunis, 1007, Tunisia
| | - Safa Rahmouni
- Rheumatology Department, La Rabta Hospital, La Rabta Jebbari, Tunis, 1007, Tunisia
- Faculty of Medicine of Tunis, University Tunis el Manar, La Rabta Jebbari, Tunis, 1007, Tunisia
- Research unit LR 05 SP 01, La Rabta Hospital, La Rabta Jebbari, Tunis, 1007, Tunisia
| | - Hela Sahli
- Rheumatology Department, La Rabta Hospital, La Rabta Jebbari, Tunis, 1007, Tunisia
- Faculty of Medicine of Tunis, University Tunis el Manar, La Rabta Jebbari, Tunis, 1007, Tunisia
- Research unit LR 05 SP 01, La Rabta Hospital, La Rabta Jebbari, Tunis, 1007, Tunisia
| | - Mohamed Elleuch
- Rheumatology Department, La Rabta Hospital, La Rabta Jebbari, Tunis, 1007, Tunisia
- Faculty of Medicine of Tunis, University Tunis el Manar, La Rabta Jebbari, Tunis, 1007, Tunisia
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