BUERGER’S DISEASE (THROMBOANGIITIS OBLITERANS)
WITH RARE MANIFESTATION

Buerger’s disease or Thromboangiitis obliterans is a nonatherosclerotic segmental inflammatory disease that affects the small and medium arteries, veins, and nerves of the extremities. It usually affects men below 45 years old, correlates with tobacco as predisposing factor, and manifests in subacute or chronic manner. The authors present the case of a 53-year-old male, with acute limb ischemia in the four extremities. The patient clinical signs also resembled small to medium vessel vasculitis with progressive worsening: slow healing, necrosis and finally loss of substance. Patient had history of heavy smoking (24 pack per years). The Doppler ultrasonography revealed vasculitis and segmental thrombosis in four extremities. The CT angiography of lower extremities showed occlusion of the 1/3 bilateral distal tibialis anterior and posterior arteries with minimal corkscrew apperance around the left posterior tibial artery, without any calcification. The histopathological result demonstrated calcification and hyalinization of fibrocolagen stroma connective tissue, endothelial cells proliferation forming vessel structure, partially formed microvascular structure with thickened wall, narrowed lumen containing thrombus, tunica intima fibrosis, and inflamatory lymphocytes cells. He was submitted therapy with antiplatelet drugs, cilostazol, statin, low molecular weight heparin (later replaced by oral anticoagulant), pulse dose steroid, antibiotics, and analgetics. In follow-up, there were no improvement of active vascular lesions and pain symptoms. After several days of treatment, he underwent amputation of both lower extremities and left hand.

 

 

Figure 1 cyanotic lesion of the lower extremities with purpura

 

 

Figure 2 cyanotic lesion of the upper extremities

Figure 3 The CT angiography result showed occlusion of the 1/3 bilateral distal tibialis anterior and posterior arteries with minimal corkscrew apperance