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CPC #3: The Mummified Finger. Bridging the Gap. Where Clinical and Basic Sciences Meet. Louisa Balazs, MD, PhD Associate Professor of Pathology. Faiz Rehman, MD Fellow, Cardiovascular Diseases. Karl T. Weber, MD Professor of Medicine.
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CPC #3: The Mummified Finger Bridging the Gap. Where Clinical and Basic Sciences Meet Louisa Balazs, MD, PhD Associate Professor of Pathology Faiz Rehman, MD Fellow, Cardiovascular Diseases Karl T. Weber, MD Professor of Medicine
October 1, 1951, and hamlets throughout the south of France were still in the throes of economic recovery; the struggle in Vietnam further drained French resources. Despite postwar scarcities, fall’s harvest had provided a good yield—an outcome in doubt given Spring’s heavy rainfall and June’s hot sun.
October 1, 1951, and hamlets throughout the south of France were still in the throes of economic recovery; the struggle in Vietnam further drained French resources. Despite postwar scarcities, fall’s harvest had provided a good yield—an outcome in doubt given Spring’s heavy rainfall and June’s hot sun.
October 1, 1951, and hamlets throughout the south of France were still in the throes of economic recovery; the struggle in Vietnam further drained French resources. Despite postwar scarcities, fall’s harvest had provided a good yield—an outcome in doubt given Spring’s heavy rainfall and June’s hot sun.
Sustenance for destitute Mr. H., his wife and two children, depended on pickled pork, cheese, honey and well water. Spirits soared when they learned baker J. would provide them with flour. Though mottled gray and having a sticky texture that made working batter difficult, H. beamed when bread tasted just fine.
Within days all were brought to clinic, where Nicole Monier, resident in internal medicine, was working. In wife and children, throbbing calves gave way to burning pains and discolored toes.
For H., painful fingers turned black. As Nicole examined his right index finger, it fell off! What caused this affliction in previously healthy people? None had fever and others in their village had not taken ill. This vivid experience remained with Nicole for years. Comparisons were inevitable. For example,
Mr. G., a 25-year-old Polish immigrant whose religious preference made him a target of the Nazi regime of terror. His family had fled to the French countryside, where they followed their religious customs and diet. An office clerk, G., complained of a painful right index finger and left thumb worsened by cooler weather.
Weeks ago, his right hand became swollen and painful. No trauma, fever or chills. Months earlier, he had a painful right calf on whose medial aspect was a several-centimeter-long red cord. The left calf was involved weeks later. A gangrenous digit of the right hand had been lost last winter while stacking firewood. Dupuytren’s contractures were present bilaterally. Only in Poland had he smoked cigarettes.
Blood pressure normal; heart and abdomen unremarkable. Normal renal function. After Nicole had compressed his right radial and ulnar arteries, she instructed him to open and close his hand until it blanched; restoration of color was rapid upon release of the radial artery, but delayed when this maneuver was repeated for the ulnar artery.
Occlusions of digital arteries and ulnar artery were found on arteriography. Buy why? Vasospasm due to a circulating substance?
And then there was Mr. S., a 45-year-old service station worker. For one month he noted pain and numbness of distal digits of his hands with blanching, followed by bluish discoloration and then throbbing redness; cooler temperatures were provocative. In changing tires or fixing dented fenders, he used a hammer or his left hand as a hammer.
And then there was Mr. S., a 45-year-old service station worker. For one month he noted pain and numbness of distal digits of his hands with blanching, followed by bluish discoloration and then throbbing redness; cooler temperatures were provocative. In changing tires or fixing dented fenders, he used a hammer or his left hand as a hammer.
Normal examination except cool 4th and 5th digits of the left hand with Dupuytren’s contraction. A cord-like mass was felt radial to hypothenar muscles; ulnar pulse was diminished and Allen’s test positive.
Normal examination except cool 4th and 5th digits of the left hand with Dupuytren’s contraction. A cord-like mass was felt radial to hypothenar muscles; ulnar pulse was diminished and Allen’s test positive.
Arteriography revealed sparse vascularity of digits with aneurysm of the ulnar artery adjacent to the hamate bone. Was a local substance responsible for vasospasm, perhaps released from injured tissue?
The Mummified Finger Faiz Rehman MD And K.T Weber MD
Mr H(symptoms) • History of ingestion of flour having a”sticky texture and being mottled gray” • Within dayswife and children develop throbbing calves with burning pains and discolored toes. • Mr H.’s fingers are painful and then turn black
Mr H(exam) • Mr H.’s finger falls off
Mr G(symptoms) • Painful right index finger and left thumb, worsened by cooler weather. • Swollen right hand for weeks (in the absence of trauma, fever or chills) • Months earlier, painful left calf with along red cord medially /duration several weeks • Gangrenous digit of right hand lost last winter • Smoker
Mr G(exam) • BP normal • Heart normal • Abdomen normal • Dupuytren’s contracture bilaterally • Compression of right ulnar and radial arteries followed by opening and closure of hand until blanching seen ,resulted in restoration of color upon release of radial artery but delayed for the ulnar artery
Exam • The Allen test is abnormal in two-thirds of patient. To perform this test, both the radial and ulnar arteries are compressed while the hand is clenched and then opened. This activity causes palmar blanching. Release of compression from either pulse should normally produce palmar erythema if the palmar arches are patent. • If they are occluded, pallor persists on the side where compression is maintained. • Discrete, tender, erythematous subcutaneous cords, indicating a superficial thrombophlebitis, may be present on the distal aspects of the extremities
Arteriography showed occlusion of right ulnar artery and digital arteries
Angiogram of the Hand Showing Multiple Occlusions of the Digital Arteries, with Collateralization ("Corkscrew Collaterals") around the Areas of Occlusion (Arrows).
Mr S(symptoms) • Pain and numbness in 4th and 5th digits with blanching. • Followed by bluish discoloration and then throbbing rednesss. (Cooler temperatures were provacative) • Occupation: Changing tires/fixing dented fenders
Mr S(exam) • Cool 4th and 5 th digits • Dupuytrens’s contracture • Cord-like mass radial to hypothenar muscles. • Ulnar pulse diminished • Allen’s test positive
Mr S(arteriography) • Sparse vascularity of digits • Aneurysm of ulnar artery next to hamate bone
Differential diagnosis • Ergotism • Buerger’s disease • Hammer-hypothenar syndromePolyarteritis Nodosa Raynaud Phenomenon Reflex Sympathetic Dystrophy Scleroderma Takayasu Arteritis
Ergotism • The drygangreneis a result ofvasoconstrictioninduced by the ergotamine-ergocristine alkaloids of the fungus. • It effects the more poorly vascularized distal structures, such as the fingers and toes. Symptoms include desquamation, weak peripheral pulse, loss of peripheral sensation, edema and ultimately the death and loss of affected tissues
CLINICAL FINDINGS. • Patients may have claudication of the hands, forearms, feet, or calves. The majority of patients with TAO have pain at rest and digital ulcerations. Often, more than one extremity is affected. • Raynaud phenomenon occurs in approximately 45 percent of patients, and superficial thrombophlebitis, which may be migratory, occurs in approximately 40 percent of patients.
CLINICAL FINDINGS. • Patients may have claudication of the hands, forearms, feet, or calves. The majority of patients with TAO have pain at rest and digital ulcerations. Often, more than one extremity is affected. • Raynaud phenomenon occurs in approximately 45 percent of patients, and superficial thrombophlebitis, which may be migratory, occurs in approximately 40 percent of patients.
Hypothenar hammer syndrome • Thrombosis of the ulnar artery in the hand is the most common type of upper extremity vascular occlusion. • It is commonly known as hypothenar hammer syndrome because it is often the result of a constant pounding on the ulnar side of the palm of the hand such as might be associated with roofing workers. • Multiple symptoms can result, including and not limited to pain, numbness and tingling, weakness of grip, discoloration of the fingers and even ulcers of the finger tips
ERGOTISM Ergotamine induced arterial constriction
Buerger’s disease Thrombangiitis obliterans Gangrenes of extremities
Dupuytren’s contracture Benign fibroblast proliferation, Palmar/plantar
In the Middle Ages, gangrenous ergotism appeared west of the Rhine River; the convulsive form to the east. An outbreak of ergotism appeared in the south of France some 40 years ago. With the gangrenous form, limbs and/or digits become swollen; excruciating pain follows. Numbness occurs suddenly and affected parts turn black; mummified, they are lost without pain or hemorrhage.
A moist spring and dry June favor contamination of rye by the fungus Claviceps purpurea, whose hard, purple body, or sclerotium, gives infected plant ovaries a cockspur (ergot in French) appearance. Midwives had long given ergot to hasten childbirth; the alkaloid ergotamine was used for migraine headache and pruritus of hepatic origin. Toxic effects, due to intense arterial constriction, resembled those seen in H. and family.
A moist spring and dry June favor contamination of rye by the fungus Claviceps purpurea, whose hard, purple body, or sclerotium, gives infected plant ovaries a cockspur (ergot in French) appearance. Midwives had long given ergot to hasten childbirth; the alkaloid ergotamine was used for migraine headache and pruritus of hepatic origin. Toxic effects, due to intense arterial constriction, resembled those seen in H. and family.
