Cutaneous Arteritis Presenting With Chronic Limb-Threatening Ischemia

An 81-year-old man presented to the emergency department with a chief complaint of pain and color change in his right first toe for the past 5 days. He had a history of smoking, and his medical history included diabetes. Physical examination revealed cyanosis in the bilateral toes, and similar cyanosis in the bilateral fingers (Figure A). No other skin rashes were observed. Ankle pressure index was normal bilaterally. He had not had an episode of fever. Blood samples showed an inflammatory reaction, but other autoantibodies were negative. Contrast-enhanced computed tomography revealed bilateral below-knee arteries were occluded. Lower extremity angiography revealed the bilateral anterior tibial, peroneal, and posterior tibial arteries were occluded (Figure B, Supplementary Movie). Upper extremity angiography revealed peripheral circulation disturbance (Figure C,D). A skin biopsy from the dorsum of the right foot showed an infiltrate of lymphocytes and histiocytes around blood cells in the dermis (Figure E). Because there were no systemic symptoms, a diagnosis of cutaneous arteritis (CA) was made, and prednisolone 30 mg/day was started. After the start of treatment, the pain and cyanosis in the lower extremities improved.

Figure.

(A) Cyanosis of the bilateral toes. (B) Arteries show occlusion below the knee. (C,D) Peripheral circulatory disturbance (C: arterial phase, D: venous phase). (E) Skin biopsy from the dorsum of the right foot shows an infiltrate of lymphocytes and histiocytes around blood cells in the dermis.

Symptoms of CA are often skin conditions such as livedo subcutaneous nodules and ulcers, and fever and joint pain may also be present. Prednisolone is the preferred treatment, but in some cases it can progress to systemic nodular arteritis.¹ The marked response to steroids suggested that diabetes was unlikely to be a factor in this case.

Consent Statement

The identity of the patient has been protected, and the patient provided informed consent for the publication of this report and images.

Disclosures / Acknowledgments

None.

IRB Information

The present study was approved by the Kin-ikyo Chuo Hospital Ethics Committee (Reference number: 2023-05).

Supplementary Files

Supplementary Movie. Lower extremity angiography.

Please find supplementary file(s);

https://doi.org/10.1253/circj.CJ-23-0436

Reference

• 1.   Parachiristodoulou E, Kakoullis L, Tiniakou E, Parperis K. Therapeutic options for cutaneous polyarteritis nodosa: A systematic review. Rheumatology 2021; 60: 4039–4047.