Consulted to see in-patient 41 y/o AA female admitted by medicine team for newly diagnosed Lupus with concern for acute vasculitic changes to lower extremity and multiple other complicating issues.  She has no prior medical history and has not been in the hospital before.

On exam the patient has palpable pulses at the ankle, but cool, ischemia toes 1,2,3 L foot only.  She has significant pain to her L forefoot not relieved by narcotics.

Vascular surgery already consulted and detailed workup including angiogram have been performed with no planned intervention.

All indicators seem to point to acute changes secondary to vasculitis.  Any treatment / supportive ideas for this case instead of just watching while the forefoot demarkates?

Have you considered microemboli, which can occur secondary to cardiac arrhythmias like atrial fibrillation or flutter ?

Yes, Medicine has worked all that up and so far negative.

I think the standard here is to watch and let it demarcate.

However, since you asked for other options lets explore the following.

Lets assume for a moment the etiology is some embolic event. What would be the risk in trying TPA to break up the emboli? If you catch it quick enough, you might be able to re-perfuse the ischemic islands and avoid soft-tissue envelope loss.

I am thinking way outside the box here. But if it is good enough to break up clots in the brain, why not the foot?

I would be really interested to hear everyone else's thoughts on this. Thanks

Upon further review, it has been documented to break up clots in the UE:

An open-label study to evaluate the safety and efficacy of tissue plasminogen activator in treatment of severe frostbite.

Twomey JA, Peltier GL, Zera RT.

J Trauma. 2005 Dec;59(6):1350-4; discussion 1354-5.

Before and after tPA administration A-gram. Taken from:

Kevin J. Bruen; James R. Ballard; Stephen E. Morris; Amalia Cochran; Linda S. Edelman; Jeffrey R. Saffle
Reduction of the Incidence of Amputation in Frostbite Injury With Thrombolytic Therapy
Arch Surg. 2007;142(6):546-553.

see my comment on facebook entry.  Can you interface the facebook comments here?  Would be nice.

Dr. Kline,

That project is on our list of things to do.

Here is a link to our Facebook Page that your comment is on, http://www.facebook.com/pages/PRESENT-Podiatry/42902394110

If you haven't become fan already please do.

Here is my comment just to update the thread:

IV antibiotics to treat vasculitis and allow to demarcate. No rush to amputation required. May also consider antiinflammatories including prednisone and methotrexate. Is there positive serology for ANCA-associated vasculitis? Have other sources of possible vascular emboli been ruled out, i.e. SBE?

Great feedback.  I tried a few PT Nerve blocks just to see if I could get some sympathetic blockade, but no improvement.  Int Med has her on predisone already and she is anticoagulated.  Things seem to be demarkating and stable at this point with no additional tissue loss.  We plan to discharge her soon, likely some HBOT, and then plan for amputation of the distal toes 1,2,3.

I have a similar case right now in the hospital, but circumstances a little different.  Had a young, 42 year old gentlemen with severe sepsis that went into acute renal and respiratory failure.  His infection resulted from sepsis of the knee and the actual skin around both knee joints were completely black and ischemic with large, geographic eschars.  He underwent multiple knee I&D's while we co-managed the ischemic changes to his toes. 

He was placed on a ventilater with trach and almost died.  His left foot developed distal gangrene to multiple toes after use of dopamine and central vascular shunting response from life threatening sepsis.  He is now off the vent and beginning to respond.  Luckily, the toes have demarcated very well and he will sustain limited toe amputations without loss of limb. I think the point to take from both of these cases is to never be too quick to amputate before all systemic treatment options have been exhausted and these ischemic areas demarcate.

Oh, btw, really like everyones responses here and also the other Dr. Kline's (no relation) suggestion of use of TPA.  It's always good to "think outside the box" !  That is how breakthroughs in the field of medicine are made!