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Acute blue finger can occur in a wide variety of medical conditions. Evidence from the literature concluded that it is generally a benign condition, not suggestive of arterial embolisation and with no threat from digit loss. (1) Introduction A 43-year-old female was referred with 6- week history of generalized episodic large joint pains, stiffness and swelling, and 1 week history of sudden onset blue finger. Examination was unremarkable. Blood investigations showed strongly positive rheumatoid factor, CRP and ESR. Duplex ultrasound examination of left upper limb arteries was normal. A presumptive diagnosis of seropositive inflammatory arthritis (possible new onset rheumatoid arthritis - ACR/EULAR RA classification score =6) associated with atypical Raynaud’s phenomenon was made, and the patient was started on high dose steroids and a 5-day course of Prostacyclin infusion. Significant improvement was noted; however, the patient started to complain of severe pain of left 5 th digit. Examination at this point revealed a collapsing pulse, and a soft, ejection systolic murmur. Therefore, a revised differential diagnosis considered subacute infective endocarditis, as suggested by modified Duke Criteria. As the Prostacyclin infusion had stopped, both the collapsing pulse and the soft systolic murmur disappeared suggesting that they were temporary findings secondary to the vasodilation and hyperdynamic circulation caused by Prostacyclin. CT angiography showed significant narrowing (70% stenosis) of the left subclavian artery origin with otherwise normal arteries. A final unifying diagnosis of left subclavian artery stenosis secondary to arteritis associated with digit ischaemia from emboli was made, with a further inclusive diagnosis of seropositive inflammatory arthritis being considered. Subclavian artery stenosis is uncommon. It can lead to critical symptomatic ischemic changes affecting the brain, the heart and more frequently the upper extremities. Arm claudication, rest pain and finger necrosis from embolic debris can occur. (2) The left Subclavian artery is involved more than the right. Atherosclerosis is considered the most common cause of this condition. Treatment is generally according to the presenting signs and symptoms. Medical, endovascular or surgical options are available. Medical therapy involves antiplatelet agents, statin therapy, BP and diabetes control and smoking cessation. Endovascular techniques include all means of endovascular revascularization. Open Surgical subclavian bypass is usually reserved for those with severe symptoms who have failed endovascular intervention. Discussion Case Presentation References Treatment Combination therapy with heparin anticoagulation and a single antiplatelet agent were commenced. Revascularization via percutaneous intervention with stenting of the left Subclavian artery was undertaken, without complications. Despite revascularization, the 5 th digit could not be salvaged. Auto-amputation was allowed to ensue. The patient was discharged with opioid analgesics, antiplatelet therapy, tapering dose steroids and a finger glove for support. Smoking cessation advice and leaflets were given on discharge. At 4 weeks follow-up, the distal phalanx of left 5th digit looked darkest in colour, more ischaemic and beginning to demarcate. Inflammatory markers including ESR and CRP showed a trend toward reduction. The decision to start DMARDs was left to be made in the future, as appropriate. The Society of Acute Medicine 7 th International Conference Thursday 3- 4 October 2013 Farag M, Elmasry M, Mabote T, Elsayed A, Sunthareswaran R Northern Lincolnshire & Goole NHS Foundation Trust - United Kingdom 1) Cowen R, Richards T, Dharmadasa A, Handa A, Perkins JMT. The Acute Blue Finger: Management and Outcome. Ann R Coll Surg Engl. 2008;90(7):557-560 2) Ochoa VM, Yeghiazarians Y. Subclavian artery stenosis: A review for the vascular medicine practitioner. Vasc Med. 2011;16(1):29-34 Conclusion Early exclusion of a vascular cause in acute blue finger remains the ultimate goal of management to prevent potentially catastrophic complications. A Diagnostic Challenge Written informed consent was obtained from patient for sharing of this case report and accompanying images. Day 1 Admission Joint pains, Acute blue finger, RF 256, ESR 40mm/h, CRP 32mg/L, Presumed RA with Raynaud’s Syndrome Day 5 Temp 38, Collapsing pulse, Systolic murmur, Suspected Subacute IE Day 7 Negative blood cultures X3, Normal TTE Day 8 CT scan results, Heparin anticoag -ulation Day 13 Definitive treatment with PCI and Stenting of left Subclavian artery Day 18 Discharge with follow-up Case Timeline
