You are a family practitioner. A 28 year old female complained of sporadic disco
ID: 224505 • Letter: Y
Question
You are a family practitioner. A 28 year old female complained of sporadic discoloration in her fingers and toes when exposed to dramatic changes in temperature, especially cold. The digits initially turn white, then blue, then red, then return to normal coloration. Discoloration is sometimes accompanied by mild tingling of numbness, and is more likely to occur during periods of emotional stress. As a physician, it is your responsibility to determine the cause of the disease so that you can develop an appropriate diagnosis and plan of treatment. To do this, you must first learn normal cardiovascular physiology and then deduce what changes in the normal physiology could result in the outward symptoms. Provide a detailed answer.
Explanation / Answer
The patient seems to be suffering from Raynaud phenomenon. The disease is defined as 'episodic, symmetric, acral vasospasm characterized by pallor, cyanosis, suffusion, and a sense of fullness or tautness, which may be painful.' The series of discoloration of fingers and toes is characteristic of this phenomenon (pallor- white, cyanosis- blue, suffusion-resulting in reddening). The condition is induced by temperature fluctuation, especially cold as well as stress. The vasospasm i.e. constriction of blood capillaries result in this discoloration. Lesser flow of blood results in pallor (whiteness), followed by cyanosis (bluishness). Subsequently, when blood flow is resumed, redness is observed.
Several mechanisms have been suggested for Raynaud's phenomenon whic include increased sympathetic nervous system activity, circulating vasoactive hormones, decreased intravascular pressure, increased digital vascular reactivity to vasoconstrictive stimuli. (The sympathetic nervous system mediates the digital vasoconstrictive response to cold exposure and emotional stress). All the above cases result in decreased blood supply to the digits (fingers and toes).
Diagnosis- Apart from the characteristic symptoms under specific conditions, certain other diagnostic techniques can be used. Assessment of Temperatures of the fingers or toes (may be as low as 700F). Other tests include assessment of digital pulse volume recordings and measurement of digital systolic blood pressure and digital blood flow.
Treatment and Prophylaxis- avoid unnecessary cold exposure and wear warm clothing. If the symptoms still persist, Calcium channel blockers (e.g. nifedipine) and sympathetic nervous system inhibitors (e.g. prazosin)can be given.
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