Images in Clinical Medicine
Unilateral Livedo Reticularis
N Engl J Med 1998; 338:1127April 16, 1998
- Article
Figure 1 Symptoms of intermittent claudication and a painful ulceration of the right heel developed in a 50-year-old woman who smoked one pack of cigarettes per day and had diet-controlled diabetes mellitus. Her only regular medication was flurbiprofen. On examination, right pedal pulses were not palpable and there was a mottled purple discoloration of the right foot consistent with a diagnosis of livedo reticularis, with a small ulceration on the heel (Panel A). The platelet count and the partial-thromboplastin time were both normal. A skin-biopsy specimen taken from the area of ulceration showed organizing thrombi in vessels, but no clefts to suggest atheroemboli (Panel B; hematoxylin and eosin, ×10). Arteriography revealed stenosis of the right popliteal artery (arrow in Panel C). There was no evidence of other disorders associated with livedo reticularis, such as the antiphospholipid syndrome, polyarteritis nodosa, cryoglobulinemia, atheroemboli, disseminated intravascular coagulation, endocarditis, or decompression sickness. In addition, the patient took no drugs known to cause livedo reticularis (in particular, amantadine, catecholamines, and quinidine). The unilateral presentation suggested a local, as opposed to systemic, cause. The stenosis of the right popliteal artery was the presumed source of thromboemboli, leading to both livedo reticularis and cutaneous ulceration. Balloon angioplasty resulted in prompt reinstitution of pedal pulses and resolution of the symptoms and skin findings.
Charles L.G. Halasz, M.D.
College of Physicians and Surgeons of Columbia University, New York, NY 10032Edward B. Strauss, M.D.
Norwalk Hospital, Norwalk, CT 06856
