LAUSR

A 30-year-old woman presented to our clinic with a 1-month history of progressive pain in the fingers and toes. She took no regular medication, rarely drank alcohol, and smoked. Physical examination showed black discoloration and dry gangrene of the distal fingers (Panel A-1). Similar changes were visualized on the toes of the right foot (Panel A-2), and purple discoloration of the 3rd to 5th toes of the left foot, with broken skin on the front dorsum (Panel A-3). There was associated edema but no sclerodactyly or telangiectasias. The dorsal pedis pulses were weak. Laboratory tests revealed significantly abnormal cardiac and renal function: brain natriuretic peptide (BNP) of 14,243.3 pg/mL (normal 45–84 μmol/L), creatine kinase (CK) of 869 U/L (normal 26–140 U/L), creatine kinase-MB (CK-MB) of 143.5 ng/ mL (normal 0–5 ng/mL), troponin I of 50.988 μg/L (normal 0–0.05 μmol/L), and creatinine of 528 μmol/L (normal 45– 84 μmol/L). The test for hepatitis B virus (HBV) was positive; antineutrophil cytoplasmic antibodies, antinuclear antibodies, antiphospholipid antibodies, and cryoglobulin were negative. The cultures of skin purulent secretion indicated the growth of Stenotrophomonas maltophilia. The electrocardiogram showed poor anterior wall R-wave escalation and ST-segment elevation. Vascular computerized tomography examination showed lumen segmental stenosis of the coronary artery (Panel B-1: arrow) and the entire lower limb arteries (Panel B-2: arrow). Skin biopsy revealed a necrotizing vasculitis affecting medium and small arteries in the deep dermis and subcutis (Panel B-3: arrows). Images in Vascular Medicine: Rapid limb deterioration due to polyarteritis nodosa