A 72-year-old patient with a history of heavy smoking, chronic bronchitis, arterial hypertension (AHT) and prostitutes syndrome developed two years earlier.
Current illness: started on June 4, 2004, with precordial oppressive pain.
Acute myocardial infarction was diagnosed and received systemic fibrinolytic treatment with streptokinase.
Angor recurred, performing an emergency coronary angiography (CACG) where coronary arteries were observed without significant lesions.
Immediately after the beginning of the procedure, the patient presented severe coldness and pain in both lower limbs, predominantly distally, with tapered toes.
Concomitantly, epigastric pain, nausea and vomiting appeared.
On physical examination, the patient presented with cramping of the toes, dry necrosis in the third, fourth and fifth right fingers and third and fifth left fingers.
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Cardiovascular: irregular rhythm 110 bpm, preserved distal pulses, symmetrical in 4 limbs.
Laboratory tests.
Azoemia: 140 mg/dL.
Creatininemia: 5.8 mg/dL (renal function 3 previous months normal).
Creatinine clearance: 11 ml/min. Blood count, blood ionogram and blood glucose: normal.
urine output: density 1015; protein 2.09 g/L; leukocytes++++.
Target specific antigen: 2.4 ng/mL.
Ultrasound urinary tract: preserved renal size and parenchymal thickness, mild left foot dilation, grade III prostatic hypertrophy.
EKG: atrial fibrillation with a mean frequency of 90 bpm.
Chest radiography: normal.
Echocardiogram: left ventricular hypertrophy, left atrial dilatation, left ventricular ejection fraction: 57%.
Arterial Doppler lower limbs: hemodynamically significant bilateral lesions in the iliac and common femoral sector; distal arteries without significant lesions.
Colonoscopy: edema and superficial ulcerated lesions covered by fibrin, from the lower rectum to the proximal sigmoid, where the lesions were more extensive and prevented the study (aspect of ischemic colitis).
Biopsy of the sigmoid colon: without elements of specificity.
Gastroscopy: ulcerated lesions in the anterior and posterior duodenum.
Eye fundus: Cholesterol embolism in the left retina.
Skin biopsy: cholesterol crystals occluding the lumen of medium-sized vessels; vascular thrombosis in small-caliber vessels.
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Location and treatment.
During the evolution, an episode of massive gastrointestinal bleeding (reiterated on two occasions) that required the use of transfusions stood out, followed by sustained diarrhea.
This prevented her transfer to magnetic resonance angiography for evaluation of the thoracic and abdominal aorta.
Ocular level showed great decrease of visual acuity.
There was a marked worsening of pain in both lower limbs, requiring opioids, so it was decided to perform unilateral lumbar sympathectomy, with favorable outcome.
Under medical treatment, creatinine levels stabilized, highlighting the difficult management of hypertension, which required multiple drugs.
As a tentative treatment of the underlying disease, anticoagulant therapy (enoxaparin 1 mg/kg body weight every 12 h) and corticosteroids (prednisone 0.5 mg/kg body weight) were initiated, and gastrointestinal bleeding was suspended.
I'm sorry. ~~~ I'm sorry.
In the control: there was spontaneous decrease of distal phalanges of the third toe of both feet and fifth toe of left foot, stabilization of the figures of renal failure.
Azoemia: 80 mg/dL.
Creatininemia: 2.5 mg/dL.
She is currently under medical treatment and has not repeated episodes of visual acuity deterioration or gastrointestinal bleeding.
