Asymptomatic lower extremity acrocyanosis: report of two cases and review of the literature

Abstract

Vasospastic disorders affecting the lower extremities are unusual entities. Two cases of asymptomatic foot discoloration with lower extremity dependency are presented. In the first case, an elderly gentleman was admitted to the hospital with a contralateral foot infection. His physical exam revealed pulse examination within normal limits and his blood work failed to identify any known causes for vasospasm. His foot infection was successfully treated with sensitivity-directed antibiotics. The second case is that of a young man with a history of quadriplegia secondary to a remote diving accident, who presented with a three-month history of foot discoloration while sitting up in his wheelchair, which resolved with recumbent leg positioning. A review of the possible diagnoses for these patients' presentation is presented herein.

Secondary Acrocyanosis in a Paraplegic Patient With Spinal Cord Injury

“…Secondary acrocyanosis can affect digits asymmetrically and sometimes is associated with pain and tissue damage [1]. It is postulated that acrocyanosis involves excessive venous pooling secondary to anatomical or functional sympathetic denervation, similar to orthostatic hypotension [6][7][8]. The major vasculature beds in the gut and lower extremities are controlled by the more caudal T5-L2 spinal sympathetic neurons [9].…”

“…A spinal cord injury frequently produces sympathetic denervation. In patients with long-standing spinal cord injury, venous capacity and compliance are reduced in the lower extremities [ 6 , 10 , 11 ]. The loss of sympathetic vasomotor tone is responsible for the reduction in venous vascular function as the walls of the veins contain smooth muscle innervated by the sympathetic nervous system [ 7 , 11 ].…”

“…The venous emptying rate is significantly reduced in patients with spinal cord injuries [ 11 ]. In the patient with spinal cord injury, secondary acrocyanosis of the lower extremities may result from venous dilation and pooling due to the loss of normal sympathetic vasomotor tone in the abdomen and extremities, commonly seen after a mid-thoracic or cervical cord lesion [ 6 ].…”

“…The first reported case described a patient with an incomplete C5-C6 spinal cord injury sustained 21 years before the presentation of secondary acrocyanosis [ 5 ]. The second reported case presented a C5 quadriplegic patient presenting secondary acrocyanosis 19 years after a diving accident [ 6 ]. Our case is the first to report secondary acrocyanosis in a paraplegic patient with spinal cord injury, as all prior reported cases involved the cervical spine.…”

“…A distinction should be made between primary acrocyanosis without detectable underlying disease and secondary acrocyanosis with a specific underlying condition. Secondary acrocyanosis due to spinal cord injury is extremely rare, with only two cases reported in the English literature attributed to cervical spine injuries [ 5 , 6 ].…”