.Mr.

Hemin Salih

19 years old , chicken shopper from Sulumani presented to me on th 26 Feb. 2003, complaining of severe pin and needle (numbness) sensation in the forehands.

The condition started one year ago when he was pealing chickens with hot & cold water, he felt mild prickling sensation in the fingers increasing gradually to moderate degree over few minutes,

specially with exposure to alternating hot & cold water, it became less on rest & drying up the hands.

pro paga tes pr ox ima lly to fo re hand s ass ocia ted with ch ange o f co lo ur in each episode from white to blue to red. With the redness, the pain abolished to replaced by burning sensation. He is mild smoker (3 cigarettes/ day) for 2 years, taking no any drug, underwent no any surgery.

Completely vaccinated, not allergic to any known drug, admitted on 9th Feb. for fainting attack (hypotension, diarrhea) for few hours in our surgical unite.

O/E;….. Locally the hands were mottled, with skin atrophy, loss of hair , unhealed scratches (3 weeks old or more), with atrophy of the thinner & hypo thinner eminences, iteossei muscles with weak skill movements, no obvious veins.

Nails were brittle with white areas, the nail beds were pale, capillary filling delayed, hands were cold, pulses were normal, Allen test was negative .

On exposure to cold we saw the sequence of the colour changes from white,

to blue

to red.

Lower limbs were also involved Beurgers test was negative BUT after exposure of the feet to cold water it became positive; Pale on elevation.

 Dusky

blue on hanging over the side of the bed ;DEPENDENCY (2-3m);

Investigations
 All

blood tests were within normal ranges  Cervical spine X-ray; NO cervical ribs

Doppler sonography
 Revealed

obstructed left axillary artery with opened up collaterals

Repeated examination
After this Doppler's result; I repeated the clinical examination after 5minutes exercise ;pulses were normal &allen test was negative. the patient did not felt any Pain in the hands

Proffesional Dx

DDX;
 1.Buergers

disease ;  Raynauds syndrom occurs in male patients with Buergers disease specially in young age group (usually under the age of 30 years).  Usually one or tow of the three manifestations are present & occasionally allthree.  OUR patient is-male;  -young(19 Y ).  -smoker.  - With arterial occlusive dis.  -lower limbs are also

DDx
 2.Erythema

pernio -Chilblains; Painful ,often localized swellings due to cold injury On exposure to heat >itch, pain, may weep fluid & ulcerate childhood, familial & in female.

DDx
 3.Acrocyanosis;

Persitent, cold cyanosis of the hands & occasionally the feet. initiated by cold and the hands are MOIST, no PAIN. young women >end > red,warm & swollen.

DDx
 

4.Erythromelalgia; painful rubor affecting the feet , more rarely ,the hands. the skin is flushed with VENOUS CONGestion . extreme hyperasthesia OLDER associated with Gout Polythycaemia There may be a history of Frostbite Injury.

DDx
 5.Livido

reticularis; is cyanotic blotching & mottling of the skin similar to normal cold response BUT associated with Autoimmune ( Anti phospholipid syn.) dis.

DDx
 6.Vibration

white finger dis ( VWF) ; occupational < vibrating tools Cold sensitivity & blanching.

DDx
 7.Drugs;

-Ergot. -Beta blockers. -inadvertent IA thiopentone. -nicotine. -heavy metals.

Rx in general
 Protection

from the cold  Avoidance of pulp & nail-bed infection  Total abstinence from smoking  Rx of the primary etiology ,if any found  Nifedipine  Steroids  Vasospastic antagonists  Sympathectomy in BUERGERS DIS.

Master your semester with Scribd & The New York Times

Special offer for students: Only $4.99/month.

Master your semester with Scribd & The New York Times

Cancel anytime.