Durvalumab-associated vasculitis presenting as 'the blue toe syndrome'.

Durvalumab is a selective, high-affinity human immunoglobulin monoclonal antibody in a class called check point inhibitors, that blocks PD-L1 on tumour cells. Despite clinical success in increasing progression-free survival rates in patients with stage III non-small-cell lung cancer, durvalumab has been associated with immune-related side effects such as pneumonitis and colitis. We present a case of an 84-year-old woman with acral vasculitis presenting as blue toe syndrome, associated with prolonged use of durvalumab. After 1 year of fortnightly durvalumab therapy postchemoradiation therapy, the patient came in with a left blue big toe, and later developed bilateral livedo racemosa. The diagnosis of durvalumab-associated vasculitis was made and treatment with prednisolone was started with clinical improvement.

[A POEMS syndrome revealed by a blue toe syndrome]. / Un syndrome POEMS révélé par un syndrome des orteils bleus.

INTRODUCTION: Arterial and venous thromboses occur in almost one in five patients with POEMS syndrome and usually in macrocirculation. CASE REPORT: We report a 67-year-old male with a POEMS syndrome who presented initially with a blue toe syndrome. He complained of Raynaud's syndrome and left foot paresthesia. Physical examination showed gynecomastia, lymphadenopathies and skin lesions. Cardiovascular investigations excluded atrial fibrillation, unstable atherosclerotic lesions and vascular calcifications. Imaging studies showed diffuse osteosclerotic lesions. Monoclonal protein with lambda light chain was discovered and serum level of VEGF was increased at 2900pg/ml. CONCLUSION: This is to our knowledge the first case of thrombotic microangiopathy in POEMS syndrome without embolic cause or calciphylaxis.

Axillo-femoral bypass steal due to subclavian artery stenosis.

Subclavian artery stenosis can cause a flow reversal-so-called steal-not only in the ipsilateral vertebral artery, but also in the internal mammary artery in patients with a history of coronary-artery bypass grafting. Subclavian artery stenosis is also associated with peripheral artery disease elsewhere. We report a novel finding of axillo-femoral bypass steal due to subclavian artery stenosis identified by vascular ultrasonography.

A Controlled Study of Alprostadil Liposomal Preparation in the Treatment of Blue Toe Syndrome.

The aim of this study is to examine the efficacy of alprostadil liposomal preparation in the treatment of blue toe syndrome. As many as 32 patients with blue toe syndrome were randomized into the test group and a control group. Patients out of the test group were treated with alprostadil liposomal preparation, while those out of the control group received placebo administration. Inter-group comparisons were conducted for the post-therapeutic changes of microcirculation and improvements of clinical symptoms. In the test group, there were eight subjects with marked response (50.0 %), six subjects with partial response (37.5 %), and two subjects with no response (12.5 %), with the overall response rate of 87.5 %. In the control group, there were three cases (18.8 %), one case (6.4 %), and 12 cases (75 %), respectively, with the overall response rate of 25.0 %. The inter-group difference of response was statistically significant (Χ (2) = 12.987, P = 0.002 < 0.05). In the test group, there was one case of administration site redness which could be resolved spontaneously. No other adverse drug reactions were reported. No any complaints were reported for the control group. The inter-group difference of nail-fold microcirculation was not statistically significant (P > 0.05). The post-therapeutic points of nail-fold microcirculation in the test group decreased significantly (P < 0.05), but no significant changes were observed for the control group (P > 0.05). The post-therapeutic waveform changes of photoelectric plethysmography were significant for the test group in comparison to the control. The safety and efficacy of alprostadil liposomal preparation have been demonstrated in the treatment of blue toe syndrome.

A case of cholesterol embolism confirmed by skin biopsy and successfully treated with statins and steroids.

Although cholesterol embolism syndrome was recognized as a clinicopathologic entity more than 50 years ago, it is attracting growing attention recently. It is a multisystemic disorder in which cholesterol crystals released from atherosclerotic plaques obstruct small arterioles, resulting in local ischemia and end-organ damage. There are no established treatments, and with the limited treatment options available, it is important to make the diagnosis as early as possible. We present the case of a 68-year-old man with cholesterol embolism who had a few fluttering atheromas in the aorta, as demonstrated by transesophageal ultrasonography. The diagnosis was confirmed by skin biopsy, and treatment with statins and steroids proved effective, as renal failure progressively improved. This case emphasizes the importance of early diagnosis and shows the possible therapeutic effects of statins and steroids for patients with this syndrome.

Spontaneous dissection of the popliteal artery in a young man. A rare cause of the blue toe syndrome.

Spontaneous arterial dissection in peripheral arteries of the extremities is an extremely rare event. We report a case of a spontaneous dissection of a nonaneurysmal popliteal artery in an otherwise healthy 36-year-old man that came to clinical attention as an acute blue toe syndrome. The diagnosis was primarily made by high-resolution duplex ultrasound that revealed a dissection flap (length: 15.5 mm; thickness: 0.4 mm) together with the partially thrombosed false lumen at the dorsal wall of the left popliteal artery (degree of local diameter reduction: 56%). Further work-up by means of contrast-enhanced MR-A and conventional DSA confirmed a moderate stenosis of the popliteal artery compatible with focal dissection and excluded other causes such as popliteal artery entrapment syndrome. Under full-dose intravenous anticoagulation with unfractionated heparin that was switched to oral anticoagulation with vitamin K antagonists (target INR: 2-3) and conservative management of the blue toe the patient made a gradual, but eventually complete clinical recovery over 8 weeks.

Cholesterol crystal embolization mimicking vasculitis: success with corticosteroid and cyclophosphamide therapy in two cases.

Cholesterol crystal embolization is a potential complication of atherosclerosis. Approximately one-third of the patients who develop this problem have a history of vascular surgery, angiography or angioplasty hours to weeks before onset. The skin and the kidneys are most frequently involved, but any organ can be affected. Livedo reticularis of the lower extremities and acrocyanosis (known as "blue toe syndrome") are the most common cutaneous manifestations. Histological examination is the only way to definitively diagnose cholesterol crystal embolization. Recently, it has been proposed that cholesterol embolization is associated with vasculitis, and some authors have labeled this condition a "vasculitis look-alike." There is still no specific treatment for this problem, even in cases that progress to renal failure. However, a few case reports in the literature have noted successful treatment with corticosteroids and cyclophosphamide in patients with deteriorating renal function. In this article, we describe two cases of severe cholesterol crystal embolization accompanied by renal dysfunction) and blue toe syndrome. Both patients benefited from corticosteroid and cyclophosphamide therapy.

Cholesterol crystal embolization (CCE) after cardiac catheterization: a case report and a review of 36 cases in the Japanese literature.

Cholesterol crystal embolization (CCE) is a complication of atherosclerosis. A 67-year-old Japanese man underwent coronary artery bypass grafting. After the surgery, he underwent coronary angiography via the right femoral artery. Twelve days later, he suddenly developed acalculous cholecystitis and was treated with antibiotics. Gradual deterioration in renal function, purplish discoloration of the distal portion of his toes, and eosinophilia were noted. We performed a skin biopsy and made a diagnosis of CCE. Cilostazol and intravenous heparin improved the symptoms and decreased the creatinine level. We retrospectively studied the clinical features of 36 cases registered with a diagnosis of CCE in the Japanese literature.

Blue toe syndrome: a rare complication of acute pancreatitis.

CONTEXT: Blue toe syndrome is an unusual complication of acute pancreatitis. It is characterized by tissue ischemia secondary to cholesterol crystal or atherothrombotic embolization leading to the occlusion of small vessels. Clinical presentation can range from a cyanotic toe to a diffuse multiorgan systemic disease that can mimic other systemic illnesses. CASE REPORT: Here we describe a young male who developed this complication after acute alcoholic pancreatitis.