26 COULD BUERGER DISEASE BE BURNED OUT

Objective Although Buerger disease is a disease of young smoker men, old age does not rule out the disease if other clinical, pathologic, and angiographic manifestations are present. Case A 76-year-old man presented to a university outpatient clinic due to bilateral foot pain and numbness of several years with recent worsening. The patient smoked two packs of cigarettes per day for 50 years. He continued to be an active smoker. On examination, signs of healed ulcers were noted on the dorsum of the feet and multiple toes. Several of his toes were cyanotic. Peripheral pulses were normal over both femoral and popliteal arteries but were absent over both posterior tibial and dorsalis pedis arteries. His hands revealed diminished radial and ulnar pulses bilaterally without significant skin changes. A decrease in sensation in both feet and lower legs was noted. Laboratory data revealed a normal ESR of 20. Antinuclear antibodies, rheumatoid factor, cryoglobulins, anticentromere antibodies, anti -cl-70, and antiphospholipid and anticardiolipin antibodies were normal or negative. A transesophageal echocardiogram revealed mild to moderate aortic valve stenosis without any cardiac source of emboli. A skin biopsy obtained from the dorsum of the left foot revealed normal skin with changes in the subcutaneous tissue consistent with fresh venous thrombosis. Inflammatory cell infiltrations were also noted in the subcutaneous tissues. Arteriogram of the lower extremity revealed widely patent vessels until the level of the lower calf, where blood flow disappeared in both legs. Segmental narrowing was noted in the left superficial femoral and popliteal arteries with little collateralization. Discussion An age less than 40 years, current or recent history of tobacco abuse, distal extremity ischemia, and exclusion of autoimmune and hypercoagulable diseases are the criteria for diagnosing Buerger disease. Old age, however, does not exclude Buerger disease. If other diagnostic criteria are met, it is recommended to perform histopathologic and angiographic studies. If these studies are consistent with Buerger disease, the diagnosis can be made. Our patient met the diagnostic criteria for Buerger disease except for the older age at onset. He seemed to differ from patients with classic Buerger disease in that there was no clinical proximal progression of the disease despite active smoking.