Acral Necrosis in a COVID-19-Infected Man Treated with Botulinum Toxin Type A

COVID-19 has been associated with acral ischemia and digital necrosis. Standard treatment of acral ischemia and digital or acral necrosis includes ongoing therapy with vasodilators and anticoagulants. However, these treatments are not always efficient to avoid the progression of necroses, which in the worst case can lead to amputation. Here, we report a case in which interdigital Botox^® (botulinum toxin type A) nerve cord injection stopped the progression of acral necroses arising from an underlying vasculopathy due to COVID-19. Moreover, Botox^® injection eliminated inflammation in the affected acral area within 2 weeks. This is the first case report to suggest Botox^® injection as a new and improving treatment for acral necroses due to COVID-19.

Coxiella burnetii Infection Associated with Thromboangiitis Obliterans-like Phenomena with Digital Auto-amputation: A Case Report and Review of Q fever Associated Autoimmunity

We present a case of a patient with chronic Q fever who presented with digital necrosis, auto-amputations, and positive anti-centromere antibody, mimicking a scleroderma vasculopathy or thromboangiitis obliterans. Coxiella burnetii infection has long been associated with the presence of auto-antibodies and autoimmune phenomena including vasculitis. Clinicians should consider Q fever testing in patients with new onset autoimmune diseases or auto-antibodies and appropriate exposure histories.

Novel Combined Approach for Digital Necrosis Secondary to Raynaud’s Phenomenon

The presence of severe Raynaud’s Phenomenon (RP), with permanent pain or digital necrosis is a rare condition. Cervical sympathectomy or distal sympathectomy or A botulinum toxin have demonstrated efficacy after medical treatment failure. We report the case of a 38-year-old female patient with an acute onset of severe RP in both hands secondary to systemic sclerosis. Medical treatment failed, so a novel approach by a combination of a modified distal sympathectomy and injection of A botulinum toxin on digital neuromuscular bundles was performed. Remission of the pain occurred immediately after the procedure and 45 days later she had complete healing of the digital wounds and recovered full mobilization of both hands. The patient remained asymptomatic 6 month after the procedure, and a Doppler ultrasound showed tri-phasic flows distal to the surgical site. This novel technique is described, and a brief review of the literature is performed.

Accidental adrenaline auto-injector-induced digital ischaemia: a proposed treatment algorithm

Increased numbers of adrenaline auto-injectors (AAIs) are in circulation in the UK. The rate of accidental auto-injection injuries has increased during this time. Various treatment strategies are described in the literature. We present the case of a 32-year-old, right-hand-dominant man who sustained an unintentional AAI injury to the volar aspect of his right thumb. On presentation to the emergency department, the thumb was ischaemic. There was no improvement with simple conservative measures (warm soaks). The patient was referred to our tertiary hand surgery service and a digital block using 2% lidocaine promoted reversal of ischaemia within 2 hours with no long-term sequelae. Phentolamine rescue, on standby, was not necessary in this case. In this case report, we highlight the therapeutic challenges associated with managing AAI injury and propose an evidence-based treatment algorithm to prevent risk of severe adverse outcomes such as digital necrosis.