Case report

A 76 year old retired fisherman presented with a progressive four week history of cold, painful, blue fingers. Systematic enquiry was unremarkable apart from generalised lethargy over the preceding six weeks. He had osteoarthritis of his left hip and had taken indomethacin 25 mg thrice daily for five years. He was an ex-smoker of 20 cigarettes/day for 40 years.

On examination he was apyrexic. There was severe ischaemia of both hands with gangrene and necrosis of the fingertips (fig 1). Both feet were cyanosed, but there was no overt ischaemia or necrosis. All peripheral pulses were palpable with a blood pressure in both arms of 160/90. There were no large vessel bruits or cardiac murmurs. Abdominal distension was noted but there was no tenderness or organomegaly. His fundi were normal. The remainder of the physical examination was unremarkable.

Laboratory investigations revealed a hypochromic, normocytic anaemia with a haemoglobin of 9.4 g/dl and a white cell count of 19.1. × 10⁹ with a neutrophilia. The erythrocyte sedimentation rate (Westergren) was 133 mm/1st h with a C reactive protein of 180 mg/l (normal range <10 mg/l). Urine analysis revealed 2+ protein, 3+ blood and granular casts but no red cell casts. Urine and blood cultures were sterile. The urea was 19.7 mmol/l and the serum creatinine 180 μmol/l with a creatinine clearance of 43.6 ml/min and a urinary total protein of 0.13 …