A 58-year-old patient complains of pain in the lower left extremity, which aggravates during walking, sensation of cold and numbness in the both feet. The patient has been suffering from this condition for 6 years. Objectively: the skin is pale and dry, with hyperkeratosis. On the left shin hair is scarce, "furrow" symptom of inflamed inguinal lymph nodes is positive. Pulse cannot be detected over the pedal and popliteal arteries and is weakened over the femoral artery. In the right limb popliteal artery pulsation is retained. What is the most likely diagnosis?

Answer options

1. Buerger’s disease (thromboangiitis obliterans)
2. Raynaud’s disease
3. Femoral artery thrombosis
4. Obliterating endarteritis
5. Arteriosclerosis obliterans of the lower extremities

Explanation

Intermittent claudication occurs because of anaerobic muscle metabolism and is classically described as debilitating cramp-like pain felt in the muscles that are: reliably brought on by walking; not present on taking the first step (unlike osteoarthritis); reliably relieved by rest both in the standing and sitting positions; usually within 5 min.As disease progression occurs the claudication distance decreases and perfusion to the leg may be so severely compromised that anaerobic respiration occurs even at rest, typically affecting the foot and/or calf. The pain is exacerbated by lying down or elevation of the foot due to loss of the gravitational effects on perfusion pressure in the foot. The patient characteristically describes pain that is worse at night and lessened by hanging the foot out of bed or by sleeping in a chair (effects of gravity restored). Chronically ischemic limb tends to equilibrate with the temperature of its surroundings and may feel quite warm under the bedclothes. Chronic ischemia does not produce paralysis and sensation is usually intact. Elevation of the limb reveals the severity of the ischemia, with venous guttering and foot pallor that changes to a red/purple color when the limb can hang down again (dependent rubor or the sunset foot sign) Diminution of a femoral and/or popliteal pulse can often be appreciated by comparing it with its opposite number; however, pedal pulses are either clinically palpable or absent. Pulsation distal to an arterial occlusion is usually absent. Bailey & Love’s short practice of surgery. –27th edition. – P. 943.