UNASSIGNED: We report an observation of a young patient presenting with severe type 1 cryoglobulinemic vasculitis revealing a monoclonal gammopathy of clinical significant. Treatment with Melphalan-Thalidomide Prednisone improved the symptoms. Early diagnosis would prevent serious tissue damage.
UNASSIGNED: Monoclonal gammopathy encompass diverse clinical forms. Only the cancerous form, multiple myeloma (MM), is treated based on specific diagnostic criteria. A new clinical entity, monoclonal gammopathy of clinical significance (MGCS), warrants special attention due to its need for specific treatment. It involves patients with signs of potentially severe organ involvement that do not meet MM criteria. We present the case of a 34-year-old Malagasy woman with severe type I cryoglobulinemic vasculitis associated with noncancerous monoclonal gammopathy, showing a favorable outcome after treatment with Thalidomide. Symptoms included toe necrosis, a severe ulcer on the left calf evolving for 3 months, and stocking-like dysesthesias. Investigations revealed monoclonal gammopathy at 30.1 g/L, proteinuria at 1 g/24 h, medullary plasma cell at 6%, and circulating cryoglobulin of Ig kappa type. CRAB criteria (anemia, hypercalcemia, renal insufficiency, and osteolysis) were absent. Treatment with Thalidomide, combined with corticosteroids and local care for 4 months, resulted in ulcer healing, disappearance of dysesthesias, and persistent normalization of gammaglobulin. Our case underscores the importance of specific treatment for MGCS.

Non-healing claw horn disorders are a serious problem in dairy herds because of the long duration of the disorder and the chronic pain derived from it, seriously affecting animal welfare and causing decreased production and premature culling from the herd. In a clinical trial, 40 cows in 13 herds (12 dairy herds and 1 herd with cow-calf operations) with toe necrosis (TN, 27x) or a non-healing white line disorder (NHWLD, 13x) were treated topically with an unguent-containing zinc sulphate and acetyl acid in combination with a parenteral injection of tilmycosin. An evaluation was conducted 3 months after treatment using locomotion scoring (LS), a clinical observation of the lesion, and the lactation value (the lactation value is the Net Profit of the individual animal divided by the average Net Profit of the entire herd. The mean is 100, so >100 is related to better production (combination of kg milk, %fat, and protein)) (LV) before and after treatment. The mean LS improved significantly from 4.0 (SD: 0.2) before treatment to 1.2 (SD: 0.4) 3 months after treatment (p < 0.001). The clinical presentation showed that all of the cows were cured from horn shoe infection (both TN and NHWLD). The LVs of the treated cows increased significantly from 111.2 (SD: 12.2) to 116.8 (SD: 15.1; p = 0.003).

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We report the case of a 51-year-old patient who presented necrosis affecting all of the toes in a context of confusion and declining general health. The etiology work-up disclosed a lung mass. Biopsy and search for extension led to the diagnosis of adenocarcinoma with liver metastasis. Unfortunately, symptomatic treatment of the digital necrosis did not lead to improvement and the patient was given palliative care. Digital necrosis generally affects the fingers. Localization on the toes is atypical and few cases have been reported in the literature.

A 71-year-old female had worked on a farm in the mountains and noticed itching of the left 3rd toe. She visited a local hospital due to a color change to purple in this area. Attachment of a tick was observed between the left 2nd and 3rd toes, and it was extracted. However, due to persistent pain, she was referred to our department of cardiovascular medicine for close examination and treatment. Lower extremity angiography showed that vascular visualization was poor in the area supplied by the arteries distal to the tick bite site, but the other blood vessels of the toe were clearly visualized. Toe amputation was performed and pathological examination of a surgical specimen revealed that most blood vessels near the necrosis were occluded by thrombi. We speculated that tick bite reactions were associated with thrombogenic vasculopathy. This report shows a patient who developed toe necrosis due to poor blood circulation after an interdigital tick bite.

Toe lesions in cattle include apical white line disease, thin soles, toe ulcers, toe necrosis, digital dermatitis-associated toe ulcers/toe necrosis, and fracture of the claw capsule and the apex of the distal phalanx. For anatomic reasons, the early stages of toe abnormalities (thin sole, apical white line disease, toe ulcer) are at risk of developing into a bone infection. The prevalence of toe lesions differs in dairy herds and feedlots: it is low at the animal level in feedlots and dairies; however, the herd prevalence of toe lesions can reach 50% in dairy herds with endemic digital dermatitis infection.

Toe necrosis may have vast different etiologies. These include ischemia, embolus, and others. (1) The most common etiology is ischemia. It is a reduction in blood supply to a viable tissue that can lead to susceptibility to infection and tissue death. Peripheral ischemia, which is rooted in the lower limbs, is a major risk factor for toe necrosis because the basal metabolic requirements of tissue are not being sufficiently met. As a result, pain, ulcers, and gangrene commonly occur. (2) Other causes of direct and indirect toe necrosis and related lower limb gangrene include mechanical trauma, infectious, pharmacological sensitivity, cancer, blue toe syndrome, and other granulomatous diseases, such as Churg-Strauss syndrome. We present a case series of toes necrosis which resulted from different etiologies and their management.

Peripheral vascular disease is a rare feature of pheochromocytoma. This potentially catastrophic but curable tumor should be suspected in combination of distal necrosis with hypertension and palpable pulses. We report such an unusual case of pheochromocytoma presenting as toe necrosis.