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.

Severe Acral Necrosis Complicating Thrombotic Microangiopathy in Two Toddlers

Acral ischemia/necrosis is one of the rarest but most dreadful complications of thrombotic microangiopathy in pediatric patients. It is more reported with thrombotic thrombocytopenic purpura than with hemolytic and uremic syndrome. Even with anticoagulant therapy, it is often irreversible, leading to amputation.

Microcirculatory assessment of vascular diseases

Summary. The term “microcirculation” refers to the terminal vascular network of the body, which includes arterioles, capillaries, venules as well as initial lymphatic vessels. Additionally, it insinuates to their unique function in thermoregulation, fluid balance, maintenance of cellular exchange, and metabolism. Disturbances of microvascular function were identified to precede macrovascular involvement in the presence of cardiovascular risk factors and is the hallmark of terminal disease stages like critical limb or acral ischemia. Nevertheless, despite its obvious significance in vascular medicine assessment of microvascular function became increasingly neglected in the clinical institutions during the last decades and seems to play a subordinary role in medical education. We therefore provide an overview over relevant and clinically practicable methods to assess microcirculation in vascular medicine with critical estimations of their pros and cons and their perspectives in the future.

Acute Digital Ischemia Associated with Closed Injury

Injury of an artery has a significantly worse prognosis for the patient than a venous injury. Blunt injuries of lower limb digital arteries with the development of acute ischemia present a very rare phenomenon. A crush mechanism with a defect of the non-wetted surface of vessel’s inner part and the development of subsequent thromboischemic lesion is essential for the development of ischemia. We report a blunt injury of the right lower limb in a patient after incorrect stepping with subsequent lesion of digital arteries and the development of acute acral ischemia of the right toes.

Thrombangitis obliterans: Subpopulationen der Leukozyten und zirkulierende Immunkomplexe

Background: The etiology of thrombangitis obliterans is still unclear. Although cellular infiltration of the vessel wall is known, no studies on peripheral blood mononuclear cells are reported. Therefore, we assessed leucocyte subpopulations and circulating immune complexes in patients with thrombangitis obliterans and a control group of normal people. Patients and methods: 31 patients (40 ± 2 years, 24 male, 7 female) with thrombangitis obliterans were included, based on the following criteria: age of manifestation, acral ischemia in legs and arms, previous thrombophlebitis or phlebitis saltans. Manifestation of atherosclerosis or other vasculitic manifestations were excluded. Leucocyte subpopulations, levels of C-reactive protein (CRP) and circulating immune complexes (CIC) were investigated. An age-matched control group (n = 25) was recruited from voluntary blood donors. Results: Leucocyte counts in the thrombangitis group (mean ± SD: 10839 ± 782/nl) were significantly different from the control group (6205 ± 414/nl, p < 0.0001). The same was true for absolute counts of granulocytes, monocytes and lymphocytes. The results were independent from CRP, which was elevated only in 6 patients. Relative counts of naive helper T-cells were significantly lower in the patient group. HLA-DR expression on B-cells was lower on the patients’ lymphocytes. The concentrations of IgA, IgG and IgM in CIC were higher in the thrombangitis patients compared to the control group. C1q-binding capacity and phosphatidylserine antibodies showed no differences. Conclusions: Patients suffering from thrombangitis obliterans show alterations of leucocyte counts and their subpopulations as well as alterations of the humoral (IgCIC) immune system.

Acute acral ischemia in all fingers probably due to an infection with borrelias

Akute akrale Durchblutungsstörungen der Finger können sowohl Ausdruck eines embolischen Geschehens als auch Manifestation einer Vaskulitis oder Kollagenose sein. Häufig ist die Suche nach der Ursache schwierig. In vielen Fällen führt auch eine detaillierte serologische Suche nach Gerinnungsstörungen oder immunologischen Parametern sowie apparative Diagnostik nicht zu einer Klärung. Anhand eines Fallbeispiels möchten wir über einen möglichen Zusammenhang zwischen einer Borrelieninfektion Stadium III und akralen Durchblutungsstörungen berichten. Außer passager erhöhten Jo-1- und Skelettmuskel-Antikörper-Titern fand sich serologisch und klinisch kein Hinweis auf das Vorliegen einer Autoimmunerkrankung. Unter multimodaler Therapie (antibiotisch, rheologisch, immunsuppressiv) gelang es, die schweren akralen Durchblutungsstörungen zu beseitigen und damit akrale Nekrosen zu verhindern. Als Konsequenz unserer Beobachtung empfehlen wir bei drohenden akralen Nekrosen unklarer Genese auch die Bestimmung des Borrelien-Antikörper-Titers, um eine Borrelieninfektion nicht zu übersehen.