Normal Peripheral Pulses Research Articles

E030 Rheumatologists beware! Digital ischaemia as a presenting feature in metastatic ovarian cancer

Abstract Background/Aims Digital ischaemia is an umbrella term to describe the spectrum of acral vascular phenomena irrespective of aetiology, ranging from temporary (as in Raynaud’s phenomenon) to permanent (necrosis). It can be the presenting feature in multiple cancer types, and can be present with or without other features of connective tissue disease. Methods A 54-year-old woman was referred to Rheumatology with a four-day history of acute pain and ischaemic discolouration of all her fingertips bilaterally. There was no history of Raynaud’s phenomenon and no other clinical features of connective tissue disease. She had never smoked. There was a family history of breast cancer in her maternal aunt. She was admitted under vascular surgery for urgent review. All ten fingertips were ischaemic, with a capillary refill time of greater than five seconds. The history was otherwise significant for abdominal bloating, altered bowel habit and fatigue. Examination revealed normal peripheral pulses with no bruits, normal heart sounds and chest sounds. Her abdomen was soft with a mildly enlarged liver. Results FBC, U&E, and LFTs showed no abnormalities. CRP, ESR, ANA, serum protein electrophoresis and complement levels were all normal. Blood tests for ANCA, rheumatoid factor and anti-CCP were also negative. Lupus anticoagulant, anti-cardiolipin and anti-B2-glycoprotein were all negative. The tumour marker CA125 was markedly elevated at 837kU/L (0.0-35.0kU/L). A CT abdomen & pelvis showed a large right-sided adnexal mass with multiple enhancing peritoneal and omental nodules and moderate ascites. Biopsy of a metastatic deposit in the omentum revealed high grade serous ovarian adenocarcinoma. Partial improvement in digital ischaemia was achieved with iloprost and maintenance apixaban and sildenafil. Four cycles of carboplatin and paclitaxel chemotherapy produced near-complete resolution of digital ischaemia symptoms, corresponding to a fall in her CA125 level and reduction in the size of the ovarian mass and intra-abdominal metastases on CT. Ten cases of digital ischaemia associated with ovarian cancer have been described prior to this. The age of onset ranged from 45 to 71, with a median age of 56. Most patients had digital ischaemia without features of connective tissue disease. Four had no blood test abnormalities other than a raised tumour marker CA125. The time from onset of digital ischaemia to diagnosis of ovarian cancer ranged from less than one week to 2 years, with a median time of four months. Conclusion This case study supports previous findings that patients with digital ischaemia associated with ovarian cancer may have normal markers of inflammatory or rheumatological disease. Marked therapeutic responses can be achieved with systemic anti-cancer therapies. Therefore, underlying cancer should be suspected in patients with new-onset or worsening digital ischaemia over the age of 45. A high index of suspicion is required - rheumatologists beware! Disclosure J.H. Miller: None. P. Merry: None.

Pseudohypoglycemia: A Simple Approach to Complex Phenomenon

Background: Pseudohypoglycemia is a condition where the measured glucose level is falsely lower than the actual level. It can be due to impaired circulation or in vitro glycolysis. Clinical Case: Patient 1: A 58-year-old male with a past medical history of sickle cell trait was admitted for alcohol intoxication. Low blood glucose levels were found on finger stick point-of-care testing (POCT). Fasting and postprandial glucose levels were between 17 and 60 mg/dL. The patient was asymptomatic, alert with no tremor, palpitation, or sweating. Glucose POCT was repeated from the earlobe each time a low finger stick level was found, showing normal glucose levels ranging between 85 to 115 mg/dL, confirmed with venous blood glucose measurement. On examination, the patient had mild skin thickening of the hands, with no acrocyanosis, calcinosis, or finger ulceration—normal peripheral pulses with no signs of heart failure. Lab results showed macrocytic anemia, otherwise normal metabolic panel. ANA, anti-Scl-70, and anticentromere antibodies were negative. Patient 2: A 91-year-old female admitted for decompensated heart failure was incidentally found to have fasting glucose levels on finger stick POCT ranging between 30–50 mg/dL. Postprandial glucose on finger stick POCT was ranging between 55–120 mg/dL. Venous glucose levels were ranging between 90 and 180 mg/dL. The patient was alert and asymptomatic. Examination showed bilateral acrocyanosis, poor peripheral circulation with capillary refill > 5 seconds, pitting pedal edema, elevated JVP, and crackles on chest auscultation. Labs showed BNP levels of 1130 pg/mL (n < 100 pg/mL), with ejection fraction of about 35% on echocardiography. Heart failure management was optimized, and warming of the hands with blankets improved peripheral circulation, with capillary refill < 2 seconds, and resolution of cyanosis coinciding with matching of finger stick POCT glucose levels to that of venous blood. Both patients were asymptomatic at the time of low POCT glucose and thus did not fulfill Whipple’s triad (measured hypoglycemia, symptomatic, a reversal of symptoms on glucose administration). Furthermore, they had no history of diabetes or the use of any hypoglycemic agents. Thus, normal venous blood glucose levels documented at the time of low POCT glucose lead to a diagnosis of pseudohypoglycemia. The etiology in patient 1 was likely due to peripheral vascular disease. In patient 2, the cause was likely due to congestive heart failure, with poor peripheral perfusion. Clinical Lesson: Low glucose levels are frequently encountered in clinical practice. It is essential to check if the non-diabetic patient is symptomatic or not. It is worth checking glucose levels from other sites in asymptomatic patients who do not fulfill Whipple’s triad before preceding into an elaborate hypoglycemia work-up.

79-Year-Old Man With Shortness of Breath and Fevers

79-Year-Old Man With Shortness of Breath and Fevers

Term Neonate with Respiratory Distress.

A female infant is born at 39 weeks to a 21-year-old primigravida with an unremarkable antenatal history and good prenatal care. The Apgar scores are 6, 7, and 8 at 1, 5, and 10 minutes, respectively. Physical examination reveals an appropriate-for–gestational age 3.3-kg term infant with grunting, tachypnea, and intercostal retractions. Decreased air entry is noted over the right side of the chest. A grade 2/6 systolic murmur is heard over the left sternal border with normal heart sounds and good peripheral pulses. The rest of the physical examination findings are within normal limits except for a right-sided small ear tag. The neonate requires positive pressure ventilation initially in the delivery room and then is placed on continuous positive airway pressure (CPAP) at 30% fraction of inspired oxygen. Chest radiography shows near-complete opacification of the right thorax with mass effect and normal lung markings on the left (Fig 1). Due to worsening respiratory distress, she undergoes intubation and is transferred to the regional perinatal center for diagnosis and management. Figure 1. Anteroposterior view radiograph of chest and abdomen at birth showing near-complete opacification of the right thorax. Differential diagnoses considered at this point for unilateral lung field opacity with mass effect include right-sided diaphragmatic hernia, congenital pulmonary airway malformation, pulmonary sequestration, or a space-occupying lesion like a tumor. Ultrasonography of the chest shows a large, solid mass in the right thorax with an intact diaphragm, an abnormality consistent with consolidated lung or a tumor (Fig 2 …

Valve-Like and Protruding Calcified Intimal Flap Complicating Common Iliac Arteries Kissing Stenting.

Endovascular therapy for iliac artery chronic total occlusions is nowadays associated with low rates of procedure-related complications and improved clinical outcomes, and it is predominantly used as first-line therapy prior to aortobifemoral bypass grafting. Herein, we describe the case of a patient presenting with an ischemic left foot digit ulcer and suffering complex aortoiliac lesions, who received common iliac arteries kissing stents, illustrating at final antegrade and retrograde angiograms the early recognition of a blood flow obstructing valve-like calcified intimal flap protruding through the stent struts, which was obstructing antegrade but not retrograde unilateral iliac arterial axis blood flow. The problem was resolved by reconstructing the aortic bifurcation at a more proximal level. Completion angiogram verified normal patency of aorta and iliac vessels. Additionally, a severe left femoral bifurcation stenosis was also corrected by endarterectomy-arterioplasty with a bovine patch. Postintervention ankle brachial pressure indices were significantly improved. At the 6-month and 2-year follow-up, normal peripheral pulses were still reported without intermittent claudication suggesting the durability of the procedure. Through stent-protruding calcified intimal flap, is a very rare, but existing source of antegrade blood flow obstruction after common iliac arteries kissing stents.

Anterior Sacroiliac Dislocation: A Case Report and Review of the Literature.

Injuries to the sacroiliac joints are most commonly caused by high-energy trauma. Orthopaedic traumatologists frequently treat sacroiliac dislocations and fracture-dislocations as part of the spectrum of pelvic ring injuries. Typical sacroiliac joint dislocations are posterior; anterior dislocations are extremely rare. As with posterior dislocations, these are high-energy injuries with concomitant visceral, neurologic, and other osseous injuries. We describe a case of anterior sacroiliac dislocation that was treated with a closed reduction and percutaneous fixation in a trauma patient with multiple injuries. The patient was informed that data concerning the case would be submitted for publication, and she provided consent. A twenty-one-year-old unrestrained driver was involved in a head-on collision with a tree at an unknown speed after reportedly attempting to avoid pedestrians in the road. She was initially evaluated in Mexico and was transferred to our level-I trauma center twelve hours after the accident. On admission to the trauma bay, the initial vital signs were blood pressure of 122/70 mm Hg, heart rate of 94 bpm, respiration of 24 bpm, and oxygen saturation of 100% on 2 L per nasal cannula. The initial hemoglobin and hematocrit levels were 10.9 g/dL and 31.6%, respectively. On examination, the patient was alert and oriented with a Glasgow Coma Scale score of 15. The spine was nontender, but she did have tenderness to palpation in the left sacroiliac region with accompanying ecchymosis posteriorly. The pelvis was unstable with lateral and anteroposterior compression. The patient had complete loss of sensation and motor function of the left lower extremity, although she had normal peripheral pulses in all four extremities. Perineal examination revealed no open wounds; however, there was left labial swelling and ecchymosis. A Foley catheter had been placed prior to arrival, and gross blood was identified in the urine. The stool guaiac test was negative, …

Obscure Severe Infrarenal Aortoiliac Stenosis With Severe Transient Lactic Acidosis.

A 57-year-old man presented with sudden onset of leg pain, right-sided weakness, aphasia, confusion, drooling, and severe lactic acidosis (15 mmol/L). He had normal peripheral pulses and demonstrated no pain, pallor, poikilothermia, paresthesia, or paralysis. Empiric antibiotics, aspirin, full-dose enoxaparin, and intravenous fluid were initiated. Lactic acid level decreased to 2.5 mmol/L. The patient was subsequently extubated and was alert and oriented with no complaints of leg or abdominal pain. Unexpectedly, the patient developed cardiac arrest, rebound severe lactic acidosis (8.13 mmol/L), and signs of acute limb ischemia. Emergent computed tomography of the aorta confirmed infrarenal aortoiliac thrombosis. Transient leg pain and transient severe lactic acidosis can be unusual presentations of severe infrarenal aortoiliac stenosis. When in doubt, vascular studies should be implemented without delay to identify this catastrophic diagnosis.

The hypertension caused by stenosis of renal arterie

An otherwise healthy, 12.5-year-old malepresented with sudden onset chest pain, wasadmitted to hospital for elevated blood pres-Panel 1Panel 2Acta Medica Academica 2011;40(1):83DOI 10.5644/ama2006-124.12sure. Physical examination showed systolicheart murmur grade 2/6 in the aortic areawith abdominal vascular murmur and normalperipheral pulses. Blood pressure waselevated: (left arm) 170/110 mmHg, (left leg)185/115 mmHg. The plasma renin activity(6.5 nmol/l/h) was elevated. Renal functionwas normal. Doppler blood flow fromboth renal arteries showed a suspected mildobstruction.

Acute chest pain: Acute coronary syndrome versus lead perforation: A case report

BackgroundDiagnosing pacemaker lead perforation in the setting of chest pain and EKG changes is difficult and usually not considered unless we have awareness and high index of suspicion. This kind of clinical scenario represents one of the diagnostic challenges.Case presentationA 77 year-old Caucasian female came to emergency room with left sided non-exertional chest pain radiating to her back for the past two days. A week prior to this presentation, she had a stent supported angioplasty for in-stent re-stenosis and subsequently dual chamber pacemaker implantation for sick sinus syndrome. On physical exam she is very obese, had normal vital signs, peripheral pulses and cardio-respiratory exam. Electrocardiogram revealed new T- wave inversions in inferior and anterior leads. Initial chest X-ray, 2D-Echocardiogram and cardiac enzymes were normal. Acute coronary syndrome was considered as an initial probable diagnosis. She was anticoagulated with heparin and eptifibatide. Patient continued to have chest pain with negative cardiac biomarkers. She developed hypotension, oliguria, elevated white count, pyuria and renal failure. Because of a normal 2D-echocardiogram, cardiac etiology for shock was not suspected. After initial fluid challenge, empiric treatment for septic shock was initiated with antibiotics and vasopressors. Work up for pulmonary embolism and intra-abdominal hemorrhage was negative. Because of persistent chest pain, shock with cold & clammy extremities and elevated central venous pressure cardiogenic shock was considered and a repeat 2D-echocardiogram was done on third day of hospitalization which revealed pericardial effusion. Non-contrast CT-scan chest done to look for lead position confirmed that she had hemorrhagic pericardial effusion along with lead perforation. Patient underwent pericardial window placement along with over-sewing of atrial wall to seal the leakage point. The patient improved and was then discharged from the hospital.ConclusionLead perforation presenting with chest pain and EKG changes is often not appreciated resulting in significant delay in diagnosis and inappropriate treatment.

Case 2: An unusual cause of syncope

An 11-year-old girl presented to the emergency department with three brief episodes of syncope that day. Before each episode, the patient was standing and then felt weak and dizzy. Subsequently, she vomited once and experienced lower abdominal pain. She had no fever, diarrhea or dysuria. She denied visual or gait disturbances, weakness, paresthesia, chest pain or shortness of breath. There was a remote history of trauma one month previous when she fell approximately four feet off an unloading ski chairlift onto her abdomen. She was examined and medically cleared at the time. Her past medical history was unremarkable. Her menarche was one month earlier, and she denied being sexually active. She was on no medications. On physical examination in the emergency department, she appeared pale with slightly dry mucus membranes. She was alert with a supple neck. Her heart rate was 120 beats/min and her respiratory rate was 20 breaths/min. Her blood pressure was 110/60 mmHg and she was saturating 98% in room air. When she sat up, she felt dizzy and presyncopal. Her head and neck examination was normal. Her cardiorespiratory examination revealed a clear chest with no murmurs and normal peripheral pulses and perfusion. Her abdomen was soft with diffuse tenderness in the lower quadrants bilaterally. Her neurological examination was normal. Initial investigations revealed a white blood cell count of 14.3 × 109/L, hemoglobin of 101 g/L, and platelets of 274 × 109/L. The urine pregnancy test was negative. Liver function tests, renal function tests and amylase were normal. The chest x-ray and electrocardiogram were within normal limits. The patient was given a bolus of 20 mL/kg of normal saline and sent for an abdominal CT (computed tomography) scan where the diagnosis was made. When the hemoglobin was repeated 4 h later because of the CT scan findings, it had dropped to 81 g/L.

Cystic Adventitial Disease: A Trap for the Unwary

Cystic adventitial disease is an uncommon condition. A case of cystic adventitial disease of the popliteal artery is reported in a young man who has been followed up for 14 years after surgical treatment. Early recognition and treatment of the condition will prevent progression to popliteal thrombosis and critical ischaemia. However, diagnosis of the condition is difficult. Characteristic features in the presenting history, such as fluctuation in severity of symptoms, sudden onset after vigorous activity and delayed recovery time after cessation of exercise are identified, which should help the clinician avoid misdiagnosis and delayed diagnosis of the condition. The clinician is also warned of the associated misleading clinical features such as the presence of normal peripheral pulses and normal ankle pressures in some cases of CAD.

Non-surgical treatment of aneurysms of bilateral persistent sciatic artery

Case Report weeks her symptoms vanished. Considering the natural history of this pathology, 17 we decided to adopt an identical strategy on the left side. Under angiographic control (Fig. 4) the left sciatic artery was occluded from its origin. A small segment of this artery refilled because of a retrograde flow from a distal anastomotic arc. At follow-up 1 year later the patient did not have any symptoms and had normal peripheral pulses. The atrophy of the right gluteal region persisted.

Calcaneal necrosis secondary to distal embolisation: a rare complication of peripheral intraarterial thrombolysis

Embolisation of small fragments of lysing thrombus frequently accompanies peripheral thrombolysis and usually resolves with continued infusion of the thrombolytic agent) Rarely, urgent surgical intervention is required following massive distal embolisation or lack of improvement after further thrombolytic infusion. 2 There are seldom long term sequelae after successfully treated distal embolisation. complete the lysis of the popliteal occlusion and reestablish good run-off with normal peripheral pulses.

Radionuclide limb blood flow measurements to resolve diagnostic problems in vascular surgery.

This paper describes the application of radionuclide limb blood flow measurements in 60 patients presenting to the vascular surgeons with exercise-induced leg pain. All patients were considered to be diagnostic problems since either their symptoms were atypical for peripheral vascular disease, or they had normal peripheral pulses and/or a normal ankle/brachial pressure index. Thirty-one patients were ultimately shown to have peripheral vascular disease and underwent treatment. In all these cases the limb blood flow to one or both legs was below the normal range. Twenty-three patients were shown, by myelography, computed tomography or plain radiography, to have orthopaedic disease and in all cases their limb blood flow to both legs was within the normal range. In five patients, the limb blood flow was normal and the symptoms spontaneously resolved, no cause for the leg pain having been found (one patient refused angiography). Radionuclide limb blood flow is a simple and reliable diagnostic test which is superior to the assessment of peripheral pulses or their ankle to brachial pressure index in resolving diagnostic problems in vascular surgery.

Cystic myxomatous degeneration of the right common and external iliac artery

• Please address all correspondence to: W. E. Tuinebreijer, Vondellaan 13, Rode Kruis Ziekenhuis, 1942 LE Beverwijk, The Netherlands, tory of intermittent claudication affecting the right upper and lower leg. Her exercise tolerance, which was initially 100m, became normal with exercise therapy but two months before admission her complaints reappeared suddenly and worsened progressively. The patient had been a smoker until 12 months prior to admission (10-12 cigarettes a day), but otherwise there were no risk factors for atherosclerosis. On examination the pulse in the right groin was found to be diminished and no distal pulses were palpable. In the left leg normal peripheral pulses were palpable. The ankle systolic pressure index at rest was 0.55 in the right leg and 1.03 in the left leg. Arteriography showed a smooth walled stenosis of the right common iliac artery, and complete occlusion of the right external lilac and common femoral arteries (Fig. 1). At operation the right common and external iliac arteries and the common femoral artery were exposed and seen to contain a clear liquid and to be dilated. Through arteriotomies in the common femoral and common iliac arteries mucoid liquid under pressure escaped and the intima was found to be dissected by the fluid. An endarterectomy of the common femoral and iliac arteries was easily performed. At the distal end of the mucoid degeneration the intima was well attached. The arteriotomies were closed by direct suture. The patient remained symptom-free 20 months after the operation, with a normal arteriogram and a normal ankle systolic pressure index.

Radiation of anginal pain to the legs.

Pain radiated from the chest to one or both legs (17 cases), or from the legs to the chest (two cases) in 19 patients with angina or acute myocardial infarction. The leg pain was assumed to be related to the angina pectoris when both were of a similar character and occurred together, when the leg pain occurred at rest, and when there were normal peripheral pulses in the leg. Pain was felt in the left leg by 10 patients, the right leg by two patients, and in both legs by seven. Three patients experienced pain in the thigh(s), six in the shin(s), and 10 had pain in both. In six patients the pain extended down to the inner two to four toes. The pain was always felt in front of the legs. This distribution accords with the suggestion that some sensory cardiac nerve fibres occur in the lumbar sympathetic ganglia and that pain is projected into the corresponding dermatomes.

One way of coping with diabetes.

People sometimes ask me how I have coped with diabetes over the past 38 years. I hope it has been good sense as well as luck which has enabled me to keep a normal optic fundus, blood pressure, peripheral pulses, and renal function. I have had coronary problems but not much more than many contem poraries. Most important is that until the past few years I have worked, played, travelled, dined, and wined without serious limitation. It all started just before my 30th birthday when I had an acute onset of thirst and polyuria (at 4 pm one Monday). After three days I tested my urine. As the Fehling's solution turned bright orange I dropped the tube: patients got diabetes, not doctors, I thought. But acceptance came quickly and I resolved not to let it hinder me in any way.

Ultrasound measurements of pulse-wave velocity in the peripheral arteries of diabetic subjects.

1. Pulse-wave velocity in both upper and lower limbs has been measured in a series of diabetic and control subjects. Subjects were studied with a Doppler ultrasound system and a real-time frequency analyser. 2. The subjects comprised three groups: (a) diabetic subjects with peripheral neuropathy (43); (b) non-complicated diabetic subjects (8); (c) non-diabetic control subjects (11). Those diabetic subjects with peripheral neuropathy included 12 with non-infected foot ulcers, nine with healed foot ulcers and 22 who gave no history of foot ulceration. All of the diabetic and control subjects had clinically normal peripheral pulses. 3. In the upper limbs the pulse-wave velocity was similar for all groups. By contrast, in the lower limbs pulse-wave velocity was significantly increased (P less than 0.005) in patients with healed or ulcerated feet compared with controls, non-complicated diabetic subjects or diabetic subjects with peripheral neuropathy alone. 4. It is suggested that the increased pulse-wave velocity results from an underlying, diffuse, atherosclerosis. This is not detectable clinically and was found to predominantly affect the lower limb arteries rather than the upper limb vessels. This may be an important aetiological factor in the development of foot ulcers in these patients.

Gangrene of toes with normal peripheral pulses.

Ten patients with pregangrenous and gangrenous changes of the toes in the presence of normal peripheral pulses are described. In the absence of diabetes this is an uncommon condition and is only rarely reported upon in the literature. Four patients had non occlusive arteriosclerotic changes in large arteries; three suffered from thrombocytosis and one from polycythemia vera; one patient had a monoclonal gamopathy and one was exposed to cold three months before the onset of gangrene. None of these patients smoked regularly. Severe pain usually preceded the gangrene. The process did not progress proximally in any patients, and in those who underwent toe amputations the healing was uneventful. Vasodilators and low-molecular dextran were not effective. Lumbar sympathectomy was performed in three patients, also with no effect on the course of the disease. Treatment of hematological disorders gave relief in three patients. Proximal arteriosclerotic changes should be corrected if possible to eliminate a source of emboli. In two patients anti-platelet aggregation agents provided relief. Toe amputation should be conservative and performed when definite demarcation appears between necrotic and viable tissue. This condition has a benign prognosis.

Atheromatous Microembolism Simulating Polymyositis

A case of atheromatous microembolism to the lower extremities illustrated some typical findings: sudden onset of leg pain, cool legs with normal peripheral pulses, petechiae, livedo reticularis, and elevated, tender nodules which represented muscle necrosis. The dominant clinical picture was consistent with acute polymyositis. Diagnosis of atheromatous microembolism with muscle necrosis was confirmed by muscle biopsy.