Painful, Discolored Toes With Sores in a 43-Year-Old Woman

Colin C. Edgerton, MD


April 02, 2021

Physical Examination and Workup

Upon physical examination, the patient's oral temperature is 98.8°F (37.1°C). Her pulse has a regular rhythm, with a rate of 79 beats/min. Her blood pressure is 112/66 mm Hg.

The head and neck examination, including auscultation of the carotid arteries and funduscopic visualization, is normal. Her lungs are clear to auscultation. The cardiac examination reveals normal S1 and S2 heart sounds, without murmurs, rubs, or gallops. Her abdomen is soft and nontender, with normal active bowel sounds on auscultation. No abdominal masses or organomegaly are noted. Vascular examination reveals 2+ pulses at the axillary, brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial regions, without bruits. The neurologic examination is nonfocal.

Dermatologic examination reveals nonblanching purpuric lesions overlying the pulp area of the right first, third, and fifth toes, as well as the left second and third toes, with superficial ulceration of the right third toe. The lesions are surrounded by poorly demarcated blanching erythema (Figures 1-3). The remainder of the dermatologic examination is normal, with normal upper-extremity nail-fold capillaroscopy.

Figure 1.

Figure 2.

Figure 3.

The laboratory findings, including a complete blood count and comprehensive metabolic panel, are normal. The prothrombin time and partial thromboplastin time are normal. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level, both inflammatory markers, are normal. Tests for antinuclear antibodies (ANA), antineutrophil cytoplasmic antibodies (ANCA), rheumatoid factor, lupus anticoagulant, anticardiolipin antibodies, antihistone antibodies, anticentromere antibodies, and cryoglobulins are all negative. Testing for acute and chronic viral hepatitis is negative. A lower-extremity arteriogram reveals patent vasculature with normal-appearing flow.

A punch biopsy of the left second toe reveals both superficial and deep perivascular inflammatory infiltrate that is predominantly lymphocytic, superficial dermal hemorrhage, and a lichenoid tissue reaction/interface dermatitis (Figures 4-6).

Figure 4.

Figure 5.

Figure 6.


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