“Purple Toe: A Syndrome from Head to Toe”

A 79-year-old man, with history of HTN, CAD and dyslipidemia, presented with two-week history of painful toes that started as ‘purple’ discoloration on the left side then extended to involve most of his toes bilaterally. Two months prior to this presentation, he sustained a left internal capsule stroke along with concomitant worsening of kidney function. One month later, a change in the mental status was noted in the inpatient rehabilitation unit, and a CT head revealed a new left parietal stroke. Physical exam revealed purple toes with severe tenderness to touch and a dry small ulcer on the left forth toe (Figure 1). Dorsalis pedis pulses were detectable. Ankle-Brachial Index was 1.16 and 1.18 on the right and the left, respectively. Funduscopic examination showed bilateral cataracts. Laboratory workup showed eosinophilia and creatinine reached a plateau of 2.0 from a baseline of 1.3. Vasculitis workup including ANA, C-ANCA, P-ANCA, cryoglobulins and complements, was negative. A transesophageal echocardiogram revealed significant non-mobile atheromatous burden of the thoracic aorta and aortic arch. A computed tomographic scan of the abdomen and pelvis showed thoracic aortic aneurysm and infrarenal abdominal aortic aneurysm with 4.3 x 3.5 cm dimensions. Clinical diagnosis of cholesterol emboli syndrome was made. The patient was managed with aspirin and statin. A trial of intravenous prostaglandin I2 for 48 hours did not improve his symptom. Although the purple toes continued to slowly get worse, the patient survived and was discharged to a nursing home facility. Figure 1: Purple discoloration of the bilateral toes of the patient with developing ulceration at the tip of the left toe resulting from underlying cholesterol embolization (Purple Toe Syndrome).