80 y/o female with history of DM, HTN and CABG presents with acute onset of painless blue finger. ROS negative. Vitals normal. Exam pictured above. EKG sinus. Labs notable for eosinophilia, new onset renal failure and eosinophiluria (eosinophils in urine). A test was done and a diagnosis made. What is it?
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Video of thoracic echo of aorta
Diagnosis: Embolism from mobile aortic plaque.
Atheroemboli are a potential serious cause of a blue finger. Clues to diagnosis include atherosclerotic disease risk factors, evidence of acute organ failure secondary to decreased perfusion (ie renal failure, mesenteric ischemia, or stroke), eosinophilia and eosinophiluria. Transesophageal echo is the diagnostic study of choice because it can detect plaque mobility which cannot be seen on CT or MRI. Treatment includes secondary prevention of cardiovascular disease (aspirin, statins, BP control, smoking cessation, glycemic control), +/- warfarin/surgery both of which are controversial.
Source
Hirschmann, J. and Raugi, G. "Blue (or purple) toe syndrome" J Am Acad Dermatol. Jan 2009.
Manning, W. and Tunick, P. "Embolism from aortic plaque: Thromboembolism" Up to Date. Feb 2010.
Tunick, P. "Embolism from aortic plaque: Atheroembolism (cholesterol crystal embolism)" Up to Date. Sept 2010.
Hirschmann, J. and Raugi, G. "Blue (or purple) toe syndrome" J Am Acad Dermatol. Jan 2009.
Manning, W. and Tunick, P. "Embolism from aortic plaque: Thromboembolism" Up to Date. Feb 2010.
Tunick, P. "Embolism from aortic plaque: Atheroembolism (cholesterol crystal embolism)" Up to Date. Sept 2010.
Image source, blue finger: http://clinicalposters.com/news/2010/20100326_acrocyanosis-raynauds.html
Video source, thoracic echo: http://www.youtube.com/watch?v=1T1Azp0Zk14
Video source, thoracic echo: http://www.youtube.com/watch?v=1T1Azp0Zk14