DIGITAL INFARCTS
----------------


Two interesting cases which I might have brought to grands rounds, but will
describe here for the fun or interest or help  from colleagues on the list.
I will be brief.

Case One: 40 year old female with Rhematoid Arthritis, Sweets (inactive),
and Fibromyalgia. Now developing digital infarts, mainly periungual, some
DIP,  2mm. Her current meds are Methotrexate, Prednisone (7.5 wean),
Pemoline (a stimulant), Trental, and Piroxicam.  The lesions are tender,
last weeks, and she desires a treatment that will work.

Diane Thaler
------------

I would check for cryoglobulin / cryofibrinogen / serum immune
electrophoresis.

I expect someone has biopsied the lesions for H&E, DIF; and checked the
urinalysis to make sure she does not have the same thing going on in her
kidneys.

Maybe increase the Trental to 800 mg tid if she can tolerate it, and perhaps
add ASA 325 mg / day (or even Ticlid). Watch out for increased MTX effect if
you add ASA.

She desires a treatment that will work? How about an infusion of tPA? That
might break up thrombi, but the side effects could ruin her whole day. 

If the infarcts are not objectively severe, it might be best to explain that
"You can sometimes get 90% of your side effects trying to get rid of the last
10% of your problem."

Kevin C. Smith MD FRCPC

Thanks for the helpful advice. The problem with the Trental is she feels
she can only tolerate her present dose BID-stomach wise.  If she does have
cryoglobulins, how would you treat her? Your last sentence quote is great,
it is something I myself forget.   Diane Thaler

If she's got cryoglobulins I'd rule out Hepatitis B,C & E. If she's got one
of those I'd see what the state of the art treatment is - maybe some
alpha-interferon (eg. Intron-A).

KC Smith MD FRCPC