Raynaud Phenomenon
Raynaud Phenomenon: Excerpt from Field Guide to Bedside Diagnosis
Differential Overview
❑ Idiopathic
❑ Systemic lupus erythematosus
❑ Scleroderma
❑ Drugs
❑ Thoracic outlet syndrome
❑ Subclavian atherosclerosis
❑ Cryoglobulinemia
❑ Chronic vibration exposure
❑ Frostbite
Diagnostic Approach
Cold is the usual precipitant. A classic triphasic response, occurring in 20%, begins with sharply demarcated blanching of the extremities, followed by cyanotic (slate-blue) discoloration with a dull aching caused by vascular stasis. With rewarming, the digits become livid purple, then deep red. The radial pulse remains normal throughout. “White attacks” are consistent with true digital arterial closure whereas cyanosis or mottling may be caused by arteriovenous shunt closure or small arteriole vasospasm. Pain suggests severe tissue ischemia and an underlying disease. Raynaud phenomenon should be distinguished from the common phenomenon of cold hands or feet, without cutaneous color change.
Fever, arthralgias, or constitutional symptoms are subtle indicators of an emerging connective tissue disease. There may be a long interval between the initial appearance of Raynaud phenomenon and the diagnosis of a connective tissue disease.
Unilateral Raynaud phenomenon results from proximal vascular disease such as thoracic outlet syndrome or subclavian atherosclerosis. Unidigital Raynaud is due to trauma or embolism to the palmar artery.
Nailfold capillaries can be examined through a drop of oil using an ophthalmoscope set at 40 diopters. Enlarged or distorted capillary loops suggest an underlying connective tissue disease, or the potential to develop one. The findings below are for nailfold capillary microscopy in scleroderma, CREST, and mixed connective tissue disease.
Clinical Findings
Idiopathic It occurs most often in young women as part of a generalized vascular hyperreactivity, associated with phenomena such as migraine.
Systemic lupus erythematosus Raynaud phenomenon appears in 30% to 50% of patients with SLE. Malar rash, fever, serositis, and arthritis suggest the underlying diagnosis.
Scleroderma Of persons with scleroderma, 90% have Raynaud phenomenon, and it is the initial manifestation in 70%. It is part of the classic CREST syndrome of subcutaneous Calcifications, Raynaud, Esophageal dysmotility, Sclerodactyly, and Telangiectasias. Using immersion oil and the ophthalmoscope set at 40 diopters, abnormal cuticular capillary loops consisting of enlargement, decreased numbers, and distortion of the normal delicate thin vessel structure can be seen in 80% of patients.
Drugs Ergotamine, narcotics, cocaine, amphetamines, beta-blockers, bleomycin, cisplatin, vinblastine, cyclosporine, interferon-alpha and vinyl chloride can each cause Raynaud phenomenon.
Thoracic outlet syndrome Intermittent compression of the subclavian artery can produce a cold hand, but the pulse will be absent, the symptoms will not be associated with cold exposure, and the vasospasm is not as distal and well demarcated. An Adson maneuver will be positive (absent radial pulse with the head turned toward the affected side, and breath held in inspiration).
Subclavian atherosclerosis A unilateral diminished pulse, blood pressure asymmetry, subclavian bruit, and arm claudication are the usual clinical findings.
Cryoglobulinemia Raynaud phenomenon is associated with acrocyanosis of the tip of the nose and ears on cold exposure.
Chronic vibration exposure Raynaud phenomenon occurs as a consequence of occupations such as jackhammer operator and miner.
Frostbite Abnormal digital thermoregulation may be a recurring problem following frostbite injury.
Pictures
Book Source Details
- Book Title: Field Guide to Bedside Diagnosis
- Author(s): David S. Smith
- Year of Publication: 2007
- Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Field Guide to Bedside Diagnosis
Authors: David S. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 0-78178-165-5
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» Next page: Raynaud's disease (Handbook of Diseases)
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