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Blue Toe Syndrome

What is Blue Toe Syndrome?

The development of blue discoloration into one or more toes without an incidence of traumatic injury, extreme cold-provoked lesion, and absence of generalized cyanosis is termed as Blue Toe Syndrome. Blue Toe Syndrome is a localized tissue ischemia, develops due to blockage of small blood vessels present in the foot.

This syndrome is most common in elderly patients, usually, occurs after undergone invasive vascular procedure. Immediate medical concern requires for Blue Toe Syndrome, as it can diffuse to different organs and causes the systemic ischemic condition.

The alternatively the syndrome is also known as Trash Foot or Purple Toe Syndrome^1,2

Causes

The secondary characteristic of atherothrombotic embolisation or cholesterol crystal formation is Blue Toe Syndrome. Atherothrombotic embolisation or cholesterol crystal formation causes blockage of small vessels. The usual reason behind the Blue Toe Syndrome development is atheroembolic disease or an aneurysm.

The consequences of blockage of small blood vessels in toes are a reduction of arterial flow, venous outflow impairment, and abnormality in the systemic circulation. The discoloration of toes in Blue Toe Syndrome may be subsided or persistent, which depends on the pathogenesis of the condition.

Embolization in Blue Toe Syndrome often causes ulceration, atherosclerotic plaque sited in the aorto-iliac-femoral arterial system. The Blue toe syndrome is triggered by vascular surgery, an angiographic procedure. It has been even seen that in some cases, thrombolytic treatment or anticoagulant therapy can cause Blue Toe Syndrome^1,2,3.

Symptoms

The onset of Blue Toe Syndrome is sudden and rapid. Blue Toe Syndrome may occur only single toe or even multiple toes also affected, but mainly restricted in one foot. The following are the most common symptoms present in Blue Toe Syndrome:

In initial stage, pain is confined into foot only, but it can spread to upper part of the leg also due to negligence of the condition or delayed treatment
A net-like bluish-purplish skin discoloration termed as Livedo Reticules
Peripheral pulses present in affected foot.
Individuals above 50 years of age usually have Blue Toe Syndrome^1,2,4

Diagnosis

The diagnosis of Blue toe syndrome is a complex procedure.

At the initial diagnosis is started during a physical examination. Loss of foot pulses is one of the primary findings during a physical examination, which indicates obstructed blood vessels in the foot. But usually, unaffected foot pulses make a diagnosis of Blue toe syndrome difficult. Thorough medical history analysis is also important in the diagnosis of Blue toe syndrome.
The main aim of the diagnosis of Blue toe syndrome is to identify the underlying cause of the obstructed blood vessels in the foot. It is difficult to identify the exactly affected blood vessels from the whole peripheral proximal arterial tree.
CT scan or Ultrasound scans can be performed to detect the possible underlying causes of formation of a balloon-like knot packed with blood in the blood vessel’s wall (an aneurysm) or plaque deposits (atherosclerosis).
Skin sample testing in the laboratory also performed to detect cutaneous abnormalities^2,3.

Treatment

The identification and treating of the underlying cause of Blue toe syndrome are essential to complete cure of the syndrome.

Pharmacotherapy

Available medicines are usually prescribed for reduction of the symptoms.

Antiplatelet drugs or Anti-coagulants are widely prescribed drugs. Aspirin is most common prescribed medicine, which assists in reducing the pain and also helps in restore blood circulation by the thinning the blood component.
Vasodilators like alpha-1 blocking agents are also prescribed to reduce the constriction or spastic condition of the blood vessels. However, there is no evidence that this treatment approach is successful in blue toe syndrome.
Some experts recommend colchicine or corticosteroids as an adjuvant therapy in diffuse and multi-visceral embolisation.
some experts suggested providing prostanoid drugs to treat ischaemic lesions caused by microembolisation.

However, Large-scale randomized clinical trial require searching effective medical treatment for Blue toe syndrome

Invasive therapy

Stenting

The procedure performing for the opening of the blood vessels and to prevent blood flow restriction by inserting a mesh tube into the affected blood vessel.

Bypass Surgery

A surgical process conducted for diverting the blood flow from obstructed blood vessels. In which a healthy blood vessel is taken from another part of the body and attached above and below the affected area to maintain the regular blood flow without obstructing the systemic circulation. Thus Ischemia can be prevented^2,3.

Complications

Untreated Blue toe syndrome often causes gangrene formation. In Gangrene insufficient blood supply causes tissue necrosis. Early detection and treatment commencement prevent tissue necrosis. In certain cases, surgery is conducted to remove dead tissues and antibiotic is prescribed to settle the infection at the initial level. therefore, the scope of gangrene development become less.
In complicated case or progression of the disease to extended organs need to be affected limb amputation to restrict the further progression of the disease.
Some time Blue toe syndrome is converted to Raynaud’s Disease, where both finger toes can be affected. Suggested treatment for this is medication, avoidence of exposure to cold, relaxation etc².

Pictures

References

Hirschmann JV, Raugi GJ. Blue (or purple) toe syndrome. J Am Acad Dermatol. 2009 Jan;60(1):1-20; quiz 21-2. doi: 10.1016/j.jaad.2008.09.038. Retrieve from https://www.ncbi.nlm.nih.gov/pubmed/19103358
Blue Toe Syndrome; FOOT-PAIN-EXPLORED.COM; Retrieve from http://www.foot-pain-explored.com/blue-toe-syndrome.html
Pavel Poredos, (2004); Blue Toe Syndrome: An article from the e-journal of the ESC Council for Cardiology Practice; European Society Of Cardiology; Retrieve from https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-2/Blue-Toe-Syndrome-Title-Blue-Toe-Syndrome
Blue Toe Syndrome; FOOT-PAIN-EXPLAINED; Retrieve from http://www.foot-pain-explained.com/blue_toe_syndrome.html