A 28-year-old woman comes to the clinician with pain and numbness of both hands over the last 6 months. Cold temperatures seem to precipitate these episodes. Medical history includes exercise-induced asthma, lower back pain, and hypothyroidism. The patient takes levothyroxine daily. She does not use alcohol or illicit drugs but has a 10-pack-year smoking history. Laboratory studies show normal complete blood count and chemistry panel. TSH is 4.7 µU/mL. Antinuclear antibody screen is negative. Physical examination findings are shown in the image below. In addition to smoking cessation, which of the following is the best initial therapy for this patient?

Question

A 28-year-old woman comes to the clinician with pain and numbness of both hands over the last 6 months.  Cold temperatures seem to precipitate these episodes.  Medical history includes exercise-induced asthma, lower back pain, and hypothyroidism.  The patient takes levothyroxine daily.  She does not use alcohol or illicit drugs but has a 10-pack-year smoking history.  Laboratory studies show normal complete blood count and chemistry panel.  TSH is 4.7 µU/mL.  Antinuclear antibody screen is negative.  Physical examination findings are shown in the image below.  In addition to smoking cessation, which of the following is the best initial therapy for this patient?

Quizplus · Accepted Answer

11ec25c8_d519_618f_bc81_79810c1e84b1_MD0003_00 Clinical features suggest that this patient has primary Raynaud phenomenon (RP), an increased vascular response to cold temperature or emotional stress without an underlying cause. Primary RP occurs usually in women age <30 with symptoms of symmetrical episodic attacks and without evidence of peripheral vascular disease, connective tissue disease, tissue injury, or abnormal nailfold capillary examination. Abnormalities such as dilated or dropout vessels in the nailfold capillaries are predictive for future development or the presence of a connective tissue disease. Episodes can also involve tingling, numbness, and pain with skin color changes of pallor (white attack) or cyanosis (blue attack). Laboratory studies (eg, antinuclear antibodies, erythrocyte sedimentation rate) are usually negative. Primary RP does not require further evaluation. Treatment mainly involves avoiding aggravating factors (ie, cold stimuli, emotional stress). Dihydropyridine calcium channel blockers (eg, nifedipine, amlodipine) are the drugs of choice for continuing symptoms. (Choices B, D, and E) Clonidine, angiotensin II converting enzyme inhibitors, and beta blockers are not helpful for treatment of RP. In fact, some studies have shown that nonselective beta blockers may worsen the condition. (Choice C) Although hypothyroidism can lead to generalized cold intolerance, sharply demarcated digit color changes are not typical of cold-induced vasospasm caused by hypothyroidism. Educational objective: Primary Raynaud phenomenon is an increased vascular response to cold temperature or emotional stress. It is usually found in women age <30 with symptoms of symmetrical episodic attacks without evidence of peripheral vascular disease, tissue injury, or abnormal nailfold capillary examination. Treatment involves mainly calcium channel blockers (eg, nifedipine, amlodipine) and avoiding aggravating factors. References: Current medical and surgical management of Raynaud's syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/23618525) The association of Raynaud syndrome with ß-blockers: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/22261435)

A 28-Year-Old Woman Comes to the Clinician with Pain and Numbness