Peripheral Arterial Disease

77. A 35-year-old man with a history of superficial thrombophlebitis and bronchitis

reports with bilateral
foot pain of two days duration. Over the past year, he has had several episodes of
severe burning pain
involving the foot arches and several toes. On a scale of 1 to 10, the severity of the
pain is 7 to 9, and
the pain persists both at rest and with ambulation. The patient smokes one to two
packs of cigarettes a
day, drinks one or two beers daily, and uses no illicit drugs. On examination, he is
slender; his feet are
red and cold, and there are ulcerations around the margins of several toenails. The
femoral pulses are
intact, and the dorsalis pedis and posterior tibialis pulses are absent bilaterally. The
pain is not worsened
by deep palpation. Microscopic capillaroscopy is negative for dilated capillaries.
What is the most likely diagnosis for this patient?
A. Plantar fasciitis
B. Spinal stenosis
C. Raynaud phenomenon
D. Atherosclerotic claudication
E. Thromboangiitis obliterans
Key Concept/Objective: To know the features of thromboangiitis obliterans and to be
able to distinguish this disorder from other diseases in the differential diagnosis of foot pain
Thromboangiitis obliterans (also called Buerger disease) causes inflammatory
blockage of
arterioles in the distal extremities and is seen in male smokers who are less than 40
years
of age. Other typical features include a history of recurrent thrombophlebitis, rest
pain,

and findings of dependent rubor and an absence of distal pulses. Plantar fasciitis is
usually not painful when the patient is at rest; it is exacerbated by weight bearing and
deep palpation on examination and is not accompanied by loss of distal pulses. Spinal
stenosis usually occurs in older patients and presents as lower extremity pain that is
exacerbated by
standing or walking and is relieved by rest. Atherosclerotic claudication is also seen
in
older patients. It follows a steadily progressive course, beginning with exerciseinduced
pain and progressing slowly (over months to years) to pain at rest. In addition,
larger, more
proximal vessels are usually affected, with corresponding exercise-induced pain in
the buttocks, thighs, or calves. Raynaud phenomenon is seen mostly in women; it is caused
by
vasospasm of small arterioles, more often in the hands than in the feet.