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Question for Dr. Z or others about Buerger's disease

Posted by Kathryn B. on 2/19/03 at 20:03 (109906)

Hi there, Dr. Z! I am the one who you helped get on the right track about Raynaud's. Unfortunately, this is not the end of the mystery yet for me. My rheumatologist thinks that my Raynaud's is secondary to Buerger's disease. My orthopedic foot specialist, on the other hand, is convinced that it is simply primary Raynaud's disease. The rheumatologist, as well, found no signs of any other connective tissue disorder. I could not pin him down about why he felt that Buerger's was the diagnosis. All of my lab work was normal, and he has not performed any doppler, arteriogram, or biopsy. I get the impression that he has made this diagnosis primarily because I increased my smoking at the stressful time that I developed symptoms.

My rheumatologist is pleased with the condition of my feet at the last office visit. He felt like it was because I had decreased my smoking, which I had. At the same time, my feet did better immediately after I first saw him and the orthopedic foot specialist on consecutive days. I think the stress relief after multiple diagnoses and proceedures really calmed my nerves, after months of pursuing a diagnosis, and that these symptoms have mostly been stress-induced. I only cut down the smoking a week later.

Now, I know that I must quit smoking for either condition, and for my overall health. I have no question that I have 'earned' Buerger's, if I have it. But it does stress me out more to think about, as I know that there are more risks involved with this disease, especially compared to primary Raynaud's. I just don't want to carry this diagnosis and adjust to it if I don't have it. If I do, I know I will manage.

But the things that don't seem to fit are statistics (though I know there are exceptions). I am a forty-nine year old female. But, more importantly, I was told that I have excellent pulses by the orthopedic foot specialist, and she checked even those in the forefoot area. Also, this came on quickly, bilaterally, during stress and affects all of my toes. Finally, though I have had pain, I am aware of the nature of ischemic pain, and the pain I have had does not at all seem to fit that category. I feel much more of a hard pain in cold (and this has gotten much, much better. I am off pain medicine and can shop and all again, even on cold days). Xanax helps tremendously, which makes me think more of spasm. I walk all day at work, and generally just get a sore foot pain by about 2 pm or so, which has gotten better. Never pain with walking a block or so that is relieved by rest and then ready to go again. The rest doesn't help, and I really don't have to quit walking. That achy foot pain seems to occur more when I am stressed and getting crampy from stress. I had prickly metatarsalgia in warm weather last year when this started, but that was when I was most stressed and had had about two weeks of foot cramps. I am not having that at all now when we have warmer weather. I wake up with a bit of soreness in the mornings, but it isn't much and I never have it laying around reading before bed or through the night.

My GP wants me to get a doppler, then decide on from there about referal to a vascular specialist and maybe an ateriogram. This suits me better than the stop smoking/wait to see how you do suggestion of my rheumatologist. I want to know what I have. Though neither disease seems very treatable, who knows when some treatment may come out for one, and I want to know if I have it.

But, I guess the main thing I am interested in right now while waiting on the further work-up, is whether you think this Buerger's disease is the more likely condition (even though you haven't done an examination). More than anything, I am better at quitting smoking (which I have done before) when I am more relaxed, while others do better when they have the daylights scared out of them. A headstart feeling a bit more at ease right now could get me on the right track, even if I have to face the Buerger's diagosis later. I just don't want to deal with it without testing, just because my rheumatologist takes a smoking history as a primary criteria. )I guess that, even if he is right, I could quit smoking better if I didn't know that for awhile!) But any comments would certainly be appreciated.

Re: Question for Dr. Z or others about Buerger's disease

Dr. Z on 2/19/03 at 20:27 (109910)

Boy that was along one. So here is my first comment and then I would think about everything you stated.

They need to determine if there is any lower extremity lesion in your arteries, so a doppler ultrasound is very important. Smoking well that is another very tough thing to get rid of . No real major treatments except life style changes such as weight lost if needed etc. So go to a vascular specialist and see what he wants to do at this point and worry about the rest when you are ready

Re: Question for Dr. Z or others about Buerger's disease

Ed Davis, DPM on 2/19/03 at 22:49 (109948)


Raynauds is a vasospastic disorder. In other words, spasm of arteries restricts blood flow as opposed to clogging of the arteries. As such, age is not a factor here. You need a complete vascular study (see a vascular surgeon) that includes doppler, plethysmography (looks at the small blood vessels at the tips of your toes). That study should nclude 'provocation' by exposure to cold to your feet with plethysmographic readings before and after the cold exposure.

Re: Question for Dr. Z or others about Buerger's disease

Kathryn B. on 2/20/03 at 18:23 (110124)

Thanks to both of you for your help. My GP has ordered the doppler and plans to refer me to a vascular specialist. I guess I did go on and on, but I was so frustrated with my rheumatologist not giving me any reason for his diagnosis and not recommending any testing. And the orthopedic specialist did not suspect this.

Re: Question for Dr. Z or others about Buerger's disease

Dr. Z on 2/20/03 at 18:30 (110125)

I was joking with the on an on. Hey you have a very smart GP who sounds like he or she knows how to manage your health. Don't let this doctor get away, very hard to find a GP that is on top of your health and knows who to send you to.

I once knew a GP who was in his 80'S and very well respected . I asked him how he became so very known and respected. He told me its not what you know it is who you know. The doctor had the names of all the finest specialist and know exactly how to use them and when. This just pop into my memory, the doctor is long dead but your GP's approach reminded of this stroy . Now look who is going on and on

Re: Question for Dr. Z or others about Buerger's disease

Kathryn B. on 2/21/03 at 20:45 (110254)

Yes, my GP is really great! He takes plenty of time with patients and he does know who to send them too. Not just that,he never minds when I come in with internet advice for great message board docs:) I am calming down a bit now. I had just been doing well with not smoking and with relaxing after the Raynaud's diagnosis, even though that is not great to have. The Buerger possibility is so frightening, that I have wanted to smoke more than ever despite the prospects. Time to try again. I guess it was aggravating, too, not being given a single reason why he thinks this and not being given any advice for testing for it. But, thank you again!!