SIR 2004 Film Panel Case: Gangrene Caused by Homocystinuria

Abstract

A 19-year-old man presented with gangrene of the right great toe that progressed to cyanosis of the distal half of the right foot within 2 weeks. Risk factors noted initially included minimal smoking history, no diabetes mellitus, no hypertension, and no trauma, although the patient was an avid soccer player. Subsequent questioning during the following year revealed a history of trauma to the right knee with a baseball bat 6 months before presentation and use of cocaine. Physical examination revealed a well-developed, well-nourished, athletic-appearing man with dry gangrene at the tip of the right great toe and wet gangrene at the base of the right great, second and third toes. He was entirely nondysmorphic. All pulses were 4 , with the exception of the right popliteal, dorsalis pedis, and posterior tibial pulses, which were absent. An ankle-brachial index of 0.47 was measured in the right lower extremity and a noninvasive diagnosis of right superficial femoral artery occlusion was made. Treatment was started immediately with 325 mg/d aspirin and 75 mg/d clopidogrel bisulfate (Plavix; Bristol-Myers Squibb, New York, NY) and the patient was advised to quit smoking. An angiogram was obtained the next day. Our institution does not require institutional review board approval for retrospective reports such as this.