Case 113: Purple Toe - Tobacco - Hypertension and Treatment with Mini-Boot

At age 51, this white female smoker ( 1.5 packs per day for 30 years) was hospitalized at Bryn Mawr with a one week history of having a purple painful big toe. She had had nocturnal leg cramps for 1.5 years and enjoyed a 3/day cocktail habit. A vascular surgery consultant found pseudohypertension at the ankle and diagnosed inoperable severe peripheral ischemia. Calcium was seen in her aorta in her chest x-ray. Variable levels of hypertension were found in her brachial artery. A boot consultation was requested.

Doppler waveforms were thin, tall and biphasic in the anterior and posterior tibial at the ankle attesting to their patency while again pseudohypertension suggested medial calcinosis of the vessel walls. Reduced pressure and low rounded waveforms in the peroneal artery suggested it had significant obstructive disease. The dorsalis pedis could not be traced to the big toe, which was presumed to receive what arterial flow it had through collaterals from the plantar circulation and the posterior tibial as the faint Doppler sounds at the base of the toe could be obliterated by digital pressure on the posterior tibial at the ankle. She received treatments with the Mini-Boot and on occasion the Long-Boot 3-4 times a day from 11/10 to 11/17 when she was discharged. Her pain lessened and her toe slowly pinked up.

Even with the foot elevated over the side of the bed, the toe remained slightly discolored beyond a line of demarcation a centimeter proximal to the interphalangeal joint on November 14th, her fifth day of boot treatment.

Her family doctor noted blisters on the plantar surface of her toe on 11/26 and again admitted her to the hospital. Again the vascular surgery consultant found no surgical options. The boot service was again consulted and again Mini-Boot treatments were administered until 12/5 when she was discharged. Subsequently, she came to the outpatient boot clinic to receive treatments biweekly until her toe was obviously normal. During the course of two hospitalizations, her vascular tests changed from 11/10 to 12/4 as follows: height of the Doppler waveform: 52 to 45 mm in the anterior tibial, 94 to 108 mm in the posterior tibial, 10 to 42 in the peroneal and 13 to 25 in the dorsalis pedis, while the pulse volume at the ankle increased from 1.2 to 1.6 units.


Small blisters and persistent discoloration led to re-hospitalization

At the time of discharge, her toe was close to normal

Discharged from the outpatient clinic, her distal foot was generally healthier, even to the texture of her toenails

Comments: She gave up smoking and over the last 16 years has continued to do volunteer work around the hospital. She has had no further foot problems. The family doctor had a referral habit to the vascular surgeon of many years duration. As the "new kid on the block", the boot service gets his patients only after invasive procedures have been ruled out. This lady could have been handled solely in the outpatient boot clinic and would have done well equally well in the long term... if she stopped smoking. Her freedom from vascular disease in the feet and her change in facial complexion after stopping smoking suggest smoking was responsible for her problems. Buerger's disease?

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