Abstract / Summary
Blue toe syndrome is characterized by painful blue or violaceous discoloration of one or more toes caused by impaired digital arterial perfusion.We present a 72-year-old woman with peripheral arterial disease, diabetes mellitus, antiphospholipid syndrome, and prior thromboembolic disease who developed dusky-blue discoloration of the left third toe.Initial arterial duplex demonstrated no major arterial occlusion, while computed tomography angiography with runoff showed distal infrarenal aortic soft plaque and distal tibial/pedal arterial disease.The aortic lesion was considered the suspected proximal embolic source in the setting of concomitant distal tibial and pedal arterial disease.The patient underwent endovascular aortic repair for proximal source control, but the left third toe nevertheless progressed to dry gangrene and required amputation.Over the following months, she developed nonhealing wounds, infections with Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA), worsened distal perfusion, and osteomyelitis.There were multiple limb salvage procedures, including angioplasty, toe amputation, common plantar embolectomy, plantar bypass, transmetatarsal amputation, Achilles tendon lengthening, antibiotic bead placement, and external fixation.Following these procedures, however, the foot developed worsening ischemic and infected tissue loss and needed an emergency left below-knee amputation.Final pathology demonstrated significant findings, including gangrenous necrosis, chronic osteomyelitis, calcific atherosclerosis, and tibial vessel occlusions.This case showcases how blue toe syndrome can progress despite source control when severe distal runoff disease, poor wound oxygenation, and recurrent infections are present.