A 61-year-old with heavy tobacco use.

Abstract

A 61-year-old female with a past medial history of type II diabetes controlled with metformin, peripheral upper and lower extremity neuropathy, right below knee amputation, and a 62-pack year smoking history presented to the emergency department complaining of a non-related chief complaint. However, on physical examination, her upper extremities were significant for nine previously amputated digits to the proximal interphalangeal joints and dry gangrene of the 2nd and 3rd digits of the left hand with necrotic eschars scattered over both hands. The patient endorsed multiple burns by cigarettes of unknown time frames in between the 2nd and 3rd digits (Figures 1 and 2). Thromboangiitis obliterans (Buerger's disease) is a nonatherosclerotic inflammatory disease of small and medium blood vessels strongly associated with tobacco use.1 Historically, this disease disproportionately affected men, but current trends show a rise in female diagnosis.2 Patients will often present with resting pain of the extremities and chronic necrotic eschars due to digital ischemia. Many patients have concurrent Raynaud's phenomenon.3 Diagnosis is based on either the Shionoya or Olin criteria.4, 5 Each of these criteria share features such as, but not limited to, onset before 45 (Shionoya) or 50 (Olin), history of or actively smoking, absence of other atherosclerotic risk factors, absence of connective tissue or autoimmune disease (Olin), and the absence of diabetes mellitus.6 Arteriographic findings are supportive but not diagnostic, such as collateral vessel corkscrewing without known atherosclerotic obstruction.7 Current treatment is smoking cessation.1 This patient had a previous diagnosis of thromboangiitis obliterans. She was found to be non-compliant with smoking cessation, smoking now 2 packs per day, up from the previously documented 1.5 packs per day. Smoking cessation education was provided. She is currently receiving treatment for cigarette burns of the 2nd and 3rd digit. A special thank you to our patient.