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Answers on p 794.
A 65 year old man presented to the accident and emergency (A&E) department with complaint of patchy mottling of both his feet. The following day this progressed to painful blisters and then to ulcers and gangrene (see fig 1).
Three weeks before this event, he had presented to the A&E department with bilateral painful thighs after routine and uneventful cardiac angiography. He was admitted on that occasion and treated with anticoagulant therapy. He was discharged home on the 10th day with warfarin.
His was known to have unstable angina, chronic obstructive airway disease, aortic aneurysm, and borderline hypercholesterolaemia, and he was a known ex-smoker. He was not known to be diabetic nor was his family history significant.
Physical examination revealed tender distal toes with intact distal pulses. Both his feet were warm and well perfused other than the gangrenous patches. Other neurovascular examinations of the lower limb yielded no abnormalities.
Laboratory investigation on admission revealed an eosinophilic count of 1.03 × 109/l, erythrocyte sedimentation rate 34 mm/hour, urea 8.4 mmol/l, and creatinine 138 μmol/l. A dipstick test of his urine showed it to be positive for red blood cells. His creatine kinase was 1363 U/l. His dorsalis pedis resting pressure indices were 0.99 and 0.97 for the left and right foot respectively.
- What is the clinical diagnosis? What could be the cause of the ulceration and gangrene in the feet?
- How can we confirm the diagnosis?
- What is the treatment and prognosis?