.Mr.

Hemin Salih
 19 years old , chicken shopper
from Sulumani presented to me on
26 Feb. 2003, complaining of severe
th

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.
 Duskyblue on hanging over the side of the
bed ;DEPENDENCY (2-3m);
 Investigations
 Allblood 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.Lividoreticularis;
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.