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JAMA Oncology Clinical Challenge
March 2016

Bilateral Foot Gangrene

Author Affiliations
  • 1Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
  • 2Division of Hematology, Mayo Clinic, Rochester, Minnesota
JAMA Oncol. 2016;2(3):387-388. doi:10.1001/jamaoncol.2015.6156

A man in his 60s with hypertension, hyperlipidemia, and obesity presented with severe, constant bilateral lower extremity pain along with skin changes. One year prior to presentation, he developed shoulder girdle and neck pain. Per records from outside institutions, his lower extremity pain was initially treated as gout. Over the next months, bilaterally symmetric metacarpophalangeal and metatarsophalangeal arthralgias developed, which were reportedly treated with prednisone acetate, methotrexate, and adalimumab for presumed inflammatory arthritis. Five months prior to presentation, lower extremity pain unresponsive to scheduled doses of nonsteroidal anti-inflammatory drugs and gabapentin led him to resign from his job. Three weeks prior to presentation, reportedly predominantly distal purplish discoloration of both feet started. He also reported a 1-week history of corneal inflammation (which responded to prednisone), night sweats, and epistaxis. At an outside hospital, nifedipine and intravenous heparin sodium therapy were initiated for impending gangrene.

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