Dry and blackened toes

Introduction Dry toe at the toe is one of the symptoms of occlusive thromboangiitis. Thrombosis angiitis obliterans (tao) is a kind of vascular inflammation that is different from arteriosclerosis and segmental distribution. The lesions mainly involve the middle and small arteries and veins of the distal extremities. The pathological features are mainly characterized. Inflammatory cells infiltrate thrombus, and less involved in the vessel wall. From a clinical point of view, any person who can make the peripheral blood vessels persistently paralyzed may be a causative factor, and the cause may be comprehensive. Long-lasting vasospasm affects the blood supply of the nourishing blood vessels in the wall, which can cause ischemic damage to the wall, leading to inflammatory reactions and thrombosis, which form the basis of the occurrence and development of this disease.

Cause

The etiology of thromboangiitis obliterans is still not fully understood and is generally believed to be caused by a combination of factors. mainly includes:

1. Smoking: refers to active and passive smokers, nicotine can cause blood vessels to contract. According to statistics, 80% to 95% of patients have a history of smoking. Quitting smoking can improve the condition, and then relapse after smoking. Smoking is closely related to this disease, but it is not the only cause of illness. Because women smokers, the incidence is not high, and a small number of patients never smoke.

2. Cold and infection: Cold damage can cause blood vessels to contract, so the incidence rate in the north is significantly higher than in the south. Because many patients have skin fungal infections, some scholars believe that it affects the human immune response, can increase the fibrinogen content in the blood, prone to thrombosis. However, some susceptible people are often exposed to cold environment due to work relationship, and although there are fungal infections, the incidence is not high, so it is not possible to confirm the main cause of cold and infection as the disease, but may be a Causes of aggravation of vasospasm.

3. Sex hormones: Most of the patients are male, and they are all young and young, which may be related to prostate dysfunction and vasomotor dysfunction.

4. Vascular neuromodulation disorders: The autonomic nervous system's dysregulation of endogenous or exogenous stimuli can cause the blood vessels to be paralyzed, which can lead to thickening of the wall and thrombosis.

5. Trauma: A small number of patients have a history of physical injury, such as crushing, strenuous exercise, long-distance walking, etc., the incidence may be related to vascular injury. However, some minor trauma is not enough to cause limb vascular injury, and sometimes mild trauma to one limb and vasculitis in other limbs. These conditions are difficult to explain with direct trauma violence. Some people think that after trauma, nerve receptors are stimulated, which causes central nervous system dysfunction, which gradually loses the regulation of peripheral blood vessels, causing vasospasm and long-term paralysis leading to thrombosis.

6. Immunology: Clinical studies have shown that patients with vasculitis have specific cellular and humoral immunity against human arterial antigens, and anti-arterial antibodies are present in serum. Various immunoglobulins (igm, igg, iga) and c3 complexes are found in the patient's blood vessels. Antinuclear antibodies are found in the serum, no anti-mitochondrial antibodies, human leukocyte antigen abnormalities and the presence of these autoantibodies suggest that the disease may be itself Immune disease. In recent years, it has been reported in the literature that the patient's arterial antigen is used as a complement-binding test, and the positive rate is 44.3%. The positive rate is higher in the acute active period.

In short, from a clinical point of view, any person who can make the peripheral blood vessels persistently paralyzed is likely to be a causative factor, and the cause may be comprehensive. Long-lasting vasospasm affects the blood supply of the nourishing blood vessels in the wall, which can cause ischemic damage to the wall, leading to inflammatory reactions and thrombosis, which form the basis of the occurrence and development of this disease.

an examination

Related inspection

Skin lesions

The onset of the disease is concealed, the disease progresses slowly, and it is often a periodic episode. After a long period of evolution, the condition gradually increases. Its clinical manifestations are mainly caused by blood flow reduction and limb ischemia after limb arterial occlusion. The severity of the condition is based on the location of the vascular occlusion. The extent and extent of the collateral circulation and the presence or absence of a continuous infection may vary.

Symptom

(1) cold and paresthesia: cold limbs and coldness are common early symptoms. The body surface temperature of the affected part is reduced, especially at the toe (finger) end. Due to the ischemic influence of the nerve endings, the affected limbs (toes, fingers) may have sensation abnormalities such as sputum, acupuncture, numbness or burning.

(2) Pain: It is also an early symptom, which originates from arterial spasm. It is caused by stimulation of nerve receptors in the blood vessel wall and surrounding tissues, and the pain is generally not severe.

(3) Intermittent claudication: is a special manifestation of ischemic pain caused by occlusion of endarteritis and thrombosis. That is, when the patient walks for a long distance, the calf or the foot muscles are painful or painful. If you continue walking, the pain is aggravated and you have to stop. After a short break, the pain is relieved quickly, and the pain reappears after walking. The symptoms are intermittent claudication. As the disease progresses, the walking distance is gradually shortened, and the time for stopping the rest increases.

(4) Resting pain: The condition continues to develop, the arterial ischemia is more serious, the pain is severe and sustained, and even if the limb is at rest, the pain is still more than that, which is called resting pain. Especially at night, when the limbs are raised, the pain is aggravated. After the drooping, the pain can be slightly relieved. The patient sat down on the knees day and night and stayed up all night. Sometimes the affected limb is drooping at the bedside to relieve the pain. If it is complicated, the pain is more severe.

(5) Changes in skin color: skin is pale due to arterial ischemia, accompanied by a decrease in superficial vascular tone and thinning of the skin, flushing or cyanosis may occur.

(6) Arterial pulsation weakened or disappeared: the pulsation of the dorsal or posterior tibial artery, the ulnar or radial artery, weakened or disappeared as the lesion progressed.

(7) Nutritional disorders: long-term chronic ischemia of the affected limbs, malnutrition in the tissues, manifested as dry skin, desquamation, chapped, hair loss, thickening of the toe (finger), slow deformation and growth, relaxation of the calf muscles, atrophy, The circumference is tapered. The disease progresses worse, the ischemic tissue of the extremities is severe, and eventually ulcers or gangrene are produced. Mostly dry gangrene, first appeared at the end of one or two toes or next to the toenail, and then involved the entire toe. At the beginning, the toe end is dry and black, and the necrotic tissue is detached to form a long-lasting ulcer. At this time, the pain in the extremities is more severe, the patient can not fall asleep day and night, the appetite is reduced, the weight is weak, the face is pale and even anemia. If the infection is concurrent, when it is wet and gangrene, symptoms such as hyperthermia, chills, irritability and other symptoms of toxemia appear.

(8) ambulatory thrombotic superficial phlebitis: about 1/2 of patients in the pre-onset or onset of the disease, in the calf or superficial veins of the foot, repeated migratory thrombophlebitis. The symptoms of the superficial veins are red, nodular, with mild pain. After 2 to 3 weeks of acute attack, the symptoms subsided and repeated over time. The condition was not affected by the patient for several months or years. note.

2. Physical examination

(1) Burger test: the patient was placed in a supine position, and the lower limbs were raised 45°. After 3 minutes, the skin of the positive person was pale, numbness or pain. When the patient sat up, the skin of the foot became flushed or appeared after the lower limbs drooped. Local purpura, this examination indicates that there is a serious lack of blood supply to the affected limb.

(2) allen test: The purpose of this test is to understand the occlusion of the hand artery in patients with thromboangiitis obliterans. That is, the patient's radial artery is pressed, and the fist is repeatedly punched and fisted. If the skin color of the original finger ischemic area is restored, it is proved that the lateral branch of the ulnar artery origin is sound, and the distal artery is occluded. Similarly, this test can also detect the soundness of the collateral artery of the radial artery.

(3) nerve block test: that is, through spinal anesthesia or epidural anesthesia, block the lumbar sympathetic nerve, if the skin temperature of the affected limb is significantly increased, suggesting that the distal limb ischemia is mainly caused by arterial spasm, otherwise it may have There is arterial occlusion. However, this test is an invasive procedure and is currently rarely used clinically.

3. Clinical staging

According to the severity of the disease, the clinical process is generally divided into three phases: the first phase, the ischemic phase; the second phase, the dystrophic phase; the third phase, the gangrene period. Mastering clinical staging is important for identifying the severity of the disease and choosing a reasonable treatment.

(1) Ischemic period: It is an early stage of the disease, and the affected limb is numb, cold, cold, and sore. Intermittent claudication followed, the examination showed that the skin temperature of the affected limb was slightly lower, the color was paler, the pulsation of the foot and/or the posterior tibial artery was weakened, and the migratory thrombotic superficial phlebitis could be repeated. This period causes ischemic causes, and the functional factor () is greater than the organic factor (occlusion).

(2) dystrophic period: for the progression of the disease, the pain turns into persistent rest pain, the pain at night is severe, and the patient can't fall asleep while sitting on the foot. The skin temperature dropped significantly, apparently pale or with flushing and purple spots. The skin is dry, sweat-free, toenail thickening, calf muscle atrophy, and the back of the foot and/or the posterior tibial artery disappear. Various arterial function tests were positive, and after the lumbar sympathetic block test, skin temperature rise could still occur, but it did not reach normal levels. This stage of the lesion is an arterial occlusion, and the collateral circulation can still maintain the survival of the affected limb.

(3) The gangrene period: it is the late stage of the disease. The toe (finger) end of the affected limb is black, dry, dry and gangrene, ulcer formation. The pain is severe, sitting on the knees and feet, day and night, can not fall asleep, weight loss, anemia. If it is a concurrent infection, it becomes wet and gangrene. In addition to the above position, the affected limb may be swollen, and in severe cases, the symptoms of systemic poisoning may be life-threatening. At this stage, the arteries are completely occluded, and the collaterals are insufficient to compensate for the blood supply necessary. The necrotic limbs cannot survive.

Differential diagnosis

Differential diagnosis of dry toe at the toe:

1, gangrene of the foot: diabetic foot lesions refers to: diabetic patients due to vascular disease caused by insufficient blood supply, due to neuropathy caused by sensory loss and infection with foot changes. Patients who have amputated for diabetic foot disease are 5 to 10 times more likely than non-diabetics. In fact, similar pathological changes can occur in other parts of the body, except that the incidence of foot lesions is significantly higher than in other areas. The main manifestations of diabetic foot are lower extremity pain and skin ulcers. From light to heavy, it can be intermittent claudication, lower limb rest pain and foot gangrene. In the early stage of the disease, the physical examination can detect the lack of blood supply to the lower limbs. For example, when the lower limbs are raised, the skin of the feet is pale, and when the lower limbs sag, it is purple-red. The feet are cold, and the dorsal artery pulsation weakens and disappears. Intermittent claudication is when the patient sometimes walks and suddenly feels pain in the lower extremities, and has to walk limping. Rest pain is the result of further development of lower extremity vascular disease. Not only does the lower limbs supply insufficient blood when walking, but also the lower limbs are painful because of blood. In severe cases, patients can sleep at night. The disease develops further, and the lower limbs, especially the feet, can be necrotic, and the wounds are unhealed for a long time. In severe cases, they have to amputated to the disabled.

2, foot ulcers: leprosy ulcers generally occur in the vicinity of the foot and the limbs joints.

Diagnosis of dry toe at the toe:

In clinical practice, the diagnosis of thromboangiitis obliterans is generally easier, but early diagnosis sometimes becomes difficult.

1. Diagnostic criteria

In 1995, the diagnostic criteria for thromboangiitis obliterans revised by the Committee on Peripheral Vascular Diseases of the Chinese Association of Integrative Medicine was:

(1) Almost all men, the age of onset is 20 to 45 years old.

(2) Chronic limb arterial ischemia, such as numbness, cold, intermittent claudication, congestion, changes in nutritional disorders, etc., often involving the lower extremities, fewer upper limbs.

(3) 40% to 60% have a history and signs of migratory thrombophlebitis.

(4) Various examinations have shown that the location of limb arterial occlusion and stenosis is mostly in the arteries and their distal arteries (often involving the small and medium arteries of the limbs).

(5) Almost all have a history of smoking, or have a history of cold.

(6) Excluding limb arteriosclerotic occlusive disease, diabetic gangrene, arteritis, limb arterial embolism, Raynaud's disease, traumatic arterial occlusive disease, connective tissue disease vascular disease, cold injury vascular disease and allergic vasculitis .

(7) During the active period of the disease, the positive rate of igg, iga, igm, anti-arterial antibody and immune complex in the patient's blood increased, and the t cell function index decreased.

(8) Arteriography:

1 lesions are more. The femoral artery and its distal end are more common;

2 Arteries are segmental occlusion and stenosis, and the arteries and proximal cardiac arteries between the occlusion segments are mostly normal;

3 The proximal end of the arterial occlusion has a "root" collateral artery;

4 Arteries have no distortion, stiffness and plaque imaging.

The previous five items of clinical diagnosis are the main basis. If there are conditions, other indicators can be more accurate.

2. Special manifestations of thromboangiitis obliterans

In clinical diagnosis, attention should also be paid to some special clinical manifestations of thromboangiitis obliterans, which is conducive to early diagnosis.

(1) Beginning with thrombotic superficial phlebitis: some patients often start with migratory thrombophlebitis, first invading the limb vein, and intermittently occurring for several months, years or more than 10 years before the limb arteries are involved. Limb ischemic manifestations. If clinically do not pay attention to the "recurrent migratory" feature, it is often misdiagnosed as general thrombotic superficial phlebitis and delayed treatment.

(2) First joint pain: Some patients first suffered from lower extremity joint pain, followed by limb ischemia and foot artery pulsation disappeared. Therefore, in the early stage of the disease can be misdiagnosed as rheumatoid arthritis, according to anti-rheumatic treatment is invalid.

(3) Single toe ischemic manifestations: Some patients first have a single toe or two toes. The toes are cold and cold, and they are pale or purple, sometimes intermittent, and the dorsal artery of the foot. The posterior tibial artery is pulsating well. This is the first violation of the toe artery, resulting in simple toe artery spasm or occlusion.

(4) First intermittent claudication: Patients often have initial symptoms of intermittent deafness. When walking, the calves and soles are tired and painful. After a little rest, they can be relieved or disappeared. After a period of time, when the limbs are cold, cold, and color changes, the patient's attention is taken. Therefore, all young males, who have long-term smoking hobbies, and intermittent claudication of lower extremities, should consider thromboangiitis obliterans, should be further examined to confirm the diagnosis, timely early treatment.

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