A 30-year-old Asian man comes to the clinic due to painful, ulcerated fingers. His symptoms began with pain and discoloration of the fingers several weeks ago, which progressed to ulceration at the fingertips. He also reports pain in the hands that occurs with activity and is relieved by rest. Medical history is unremarkable. The patient has smoked 2 packs of cigarettes a day for the last 5 years. He occasionally drinks alcohol but does not use illicit drugs. Vital signs are within normal limits. No heart murmurs are heard and the lungs are clear. Examination of the hands is shown in the exhibit.
Radial pulses are diminished. There is erythema and tenderness along a superficial vein of the left forearm. Hemoglobin A1c and a fasting lipid panel are within normal limits. Which of the following pathologic findings is most likely to be seen within the affected vessels?

Question

A 30-year-old Asian man comes to the clinic due to painful, ulcerated fingers.  His symptoms began with pain and discoloration of the fingers several weeks ago, which progressed to ulceration at the fingertips.  He also reports pain in the hands that occurs with activity and is relieved by rest.  Medical history is unremarkable.  The patient has smoked 2 packs of cigarettes a day for the last 5 years.  He occasionally drinks alcohol but does not use illicit drugs.  Vital signs are within normal limits.  No heart murmurs are heard and the lungs are clear.  Examination of the hands is shown in the exhibit. 
 Radial pulses are diminished.  There is erythema and tenderness along a superficial vein of the left forearm.  Hemoglobin A1c and a fasting lipid panel are within normal limits.  Which of the following pathologic findings is most likely to be seen within the affected vessels?

Quizplus · Accepted Answer

11ec160b_38e0_a361_9249_396ce1490f96_MD0001_00 This patient's presentation is consistent with thromboangiitis obliterans (Buerger disease), a segmental, inflammatory vasculitis that affects the small- and medium-sized arteries and veins of the distal extremities. It typically affects young, heavy smokers (age <45) and is more common in men. Toe and/or finger ischemia and ischemic ulcerations are the most common manifestation, and patients with involvement of proximal arteries can develop claudication affecting the lower legs, feet, or hands. Raynaud phenomenon and superficial thrombophlebitis (erythema, tenderness along veins) may also occur as early manifestations of the disease. In thromboangiitis obliterans, chronic exposure to tobacco products is thought to cause direct endothelial injury or trigger a delayed-type hypersensitivity reaction against the endothelium. Histopathology shows highly cellular, inflammatory intraluminal thrombi (ie, containing neutrophils, multinucleated giant cells) in the arteries and veins with sparing of the vessel wall and internal elastic lamina. This segmental, thrombosing vasculitis often extends contiguously into veins and nerves, a feature rarely seen in other types of vasculitis. (Choice A) Granulomatous inflammation of the media occurs in the large vessel vasculitides Giant cell arteritis (temporal arteritis) and Takayasu arteritis. Giant cell arteritis typically affects patients age >50 and presents with unilateral headache, jaw claudication, and transient vision loss. Takayasu arteritis usually affects young women of Asian descent and presents with diminished pulses often accompanied by angina and/or carotid artery pain. (Choice B) Lipid-filled intimal plaques that bulge into the arterial lumen are seen in patients with atherosclerosis. (Choice C) Hyperplastic arteriolosclerosis is characterized by thickening of the arteriolar wall due to the concentric proliferation of smooth muscle cells and reduplicated basement membranes, giving the arterioles an onion-skin appearance. These changes occur as an adaptive response of arterioles to severe (malignant) hypertension. (Choice E) Transmural inflammation of the arterial wall with fibrinoid necrosis can be seen in several types of systemic vasculitis, including polyarteritis nodosa (PAN). PAN affects small and medium-sized arteries and can involve numerous organs (eg, kidney, gastrointestinal system, skin). Patients commonly present with fever, hypertension, abdominal pain, and/or cutaneous lesions (eg, nodules, livedo reticularis). Educational objective: Thromboangiitis obliterans (Buerger disease) is a segmental, inflammatory vasculitis that affects the small- and medium-sized arteries and veins of the distal extremities with inflammatory, intraluminal thrombi and sparing of the vessel wall. It is usually seen in young, heavy smokers, and can present with digital ischemia and ulceration, extremity claudication, Raynaud phenomenon, and superficial thrombophlebitis.

A 30-Year-Old Asian Man Comes to the Clinic Due to Painful