A NEW HAND FINDING THAT COULD POINT TOWARD LIVER DISEASE A. Phelps MD, S. Gillet BS, C. Carlos BS, C. Talley MD, M. Maylin, MD Department of Internal Medicine, Tulane Health Sciences Center, New Orleans, LA
INTRODUCTION: Any patient presenting with an arterial thromboembolism (ATE) without history of recent trauma or intervention to the presenting limb should have a thorough work up. This case illustrates the importance of exhausting all possibilities to obtain the diagnosis
CASE: A 66-year-old man with recently treated hepatitis C, hypertension, and a 120-pack year smoking history presented with three days of progressively worsening gangrene of the digits without a history of trauma. He was cachectic with dusky skin and digits two through four on the right hand were cold bilaterally, with black discoloration noted distally on the second digit. Radial pulse was 2+ bilaterally. TSH, A1C, ABI andWBI were within normal limits. Autoimmune workup, including ANA, anticardiolipin, and beta2-glycoprotein I antibodies, returned negative. EKG and telemetry monitoring did not reveal any arrhythmias. Transesophageal echocardiogram had no evidence of valvular disease or vegetations. Pathology report from a skin biopsy of the right index finger noted thromboembolism with medium-sized vessel vasculitis. Malignancy workup began with a CT chest, which incidentally revealed three large hypoechoic liver masses, the largest measuring 9.6 x 7.5 cm, in addition to mediastinal and hilar lymphadenopathy. A diagnosis of hepatocellular carcinoma was made by IR guided liver biopsy. DISCUSSION: A thorough cardiac workup for a patient with ATE should be obtained as the majority of arterial embolisms that travel to the extremities originate in the heart. EKG and telemetry monitoring to assess for atrial fibrillation, echocardiogram to assess for valvular disease, endocarditis, myxoma, and left ventricular dysfunction, and risk stratification with hemoglobin A1C, lipid panel, and TSH should all be performed initially. If no source is identified, further workup should focus on causes of hyper coagulable states. Antiphospholipid syndrome should be excluded with testing for anticardiolipin and beta2- glycoprotein I antibodies. Malignancy should be considered as a possible etiology with age appropriate cancer screening as early stage cancer carries a significantly increased risk of ATE. Recognition of malignancy as a potential cause arterial thromboembolism could lead to earlier diagnosis and treatment.
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