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Cocaine abuse and connective tissue disease
Volume 10 Number 3 March, 1984
Correspondence
Dermatologists must consider occlusive vascular disease in the differential diagnosis of a painful lesion at the end of the digit. The diagnosis can, in most cases, be readily established by finding decreased pulses and blood pressure on the affected extremity, thus avoiding the complications of delayed treatment.
Francico A. Kerdel, B.Sc., M.B., B.S. Howard P. Baden, M.D. Harvard Medical School Massachusetts General Hospital Department of Dermatology Boston, MA 02114 REFERENCES 1. Lazarus GS, Goldsmith LA: Diagnosis of skin disease. Philadelphia, 1980, F. A. Davis Co., pp. 427-432. 2. Welling RE, Cranley JJ, Krause RJ, Hafner CD: Obliterarive arterial disease of the upper extremity. Arch Surg 116:1593-1596, 1981. 3. Whelan TJ: Management of vascular disease of the upper extremity. Surg Clin North Am 62:373-389, 1982. 4. DePalma RG, Broadbent RV: Management of occlusive disease of the subclavian and innominate arteries. Am J Surg 142:197-202, 1981. 5. Gross WS, Flanigan DP, Kraft RO, Stanley JC: Chronic upper extremity arterial insufficiency. Etiology, manifestations, and operative management. Arch Surg 113:419423, 1978. 6. Martin J, Gaspard DJ, Johnston PW, et al: Vascular manifestations of the thoracic outlet syndrome--a surgical urgency. Arch Surg 111:779-782, 1976. 7. Dorazio RA, Ezzet F: Arterial complications of the thoracic outlet syndrome. Am J Surg 138:246-250, 1979. 8. Gerety RL, Andrus CH, May AG, et al: Surgical treatment of occlusive subclavian artery disease. Circulation 64(suppl):228-230, 1981. 9. Sachatello CR, Ernst CB, Griffen WO: The acutely ischernic upper extremity: Selective management. Surgery 76:1002-1009, 1974. Cocaine abuse and connective tissue disease To the Editor: We would like to draw the attention of dermatologists to a possible association between cocaine abuse and connective tissue disease. Case 1. For 3 years, a 40-year-old white male mechanic had swelling and sausage-shaped deformities of the fingers, together with an inability to make a tight fist or to oppose his thumb to his fifth digit. In cold, damp weather his hands became white, mottled, and red-blue. He had used cocaine regularly on weekends for a 3-year period and noted that his symptoms became markedly worse with heavier use of the drug. He was also a smoker of cigarettes and a user of marijuana and amphetamines. In addition to the preceding changes,
525
his hands exhibited atrophic, depressed, calloused scars on the finger pads; peeling, atrophic ulcers over the distal interphalangeal joints; and diffuse sclerosis extending 2 inches above the wrists. There were no calcium deposits in the skin, and only minimal telangiectasia was present at the base of one fingernail. There were no signs or symptoms suggesting systemic or internal organ disease. Skin biopsy specimens showed thickening and sclerosis of the dermal collagen and linear deposition of IgG at the dermoepidermal junction. Anticentromere antibodies were present in the serum at a titer of 1 : 160 (normal, less than 1:40). The following tests were normal or negative: complete blood count, fluorescent antinuclear antibody (FANA), antiextractable nuclear antigens (ENA), anti-deoxyribonucleic acid (DNA), anti-SSA, anti-SSB, cryoglobulins, cryofibrinogens, cold agglutinins. Case 2. A 24-year-old white male sheet metal worker had a 2-month history of episodes of blanching of the fingers, wtfich was succeeded by blue and red mottling. Persistent sausage-shaped swelling of the fingers developed, as did sores at the fingertips. Similar color changes occurred in the toes, but without sores. He had used cocaine regularly (nasal sniffing and smoking "free-base") for 4 to 5 years. He did not use tobacco or amphetamines. In addition to the color changes, there were atrophic scars on all fingertips, but there was no sclerosis. Bilateral ulceration of the nasal mucosa without septal perforation was noted. The patient denied any symptoms suggestive of systemic disease. The FANA was positive in a 1:1,280 dilution with a nucleolar pattern. The following were normal or negative: CBC, erythrocyte sedimentation rate (ESR), urine, SMA 12, VDRL, hepatitis B antigen, antiENA, anti-DNA, anti-centromere antibodies, and cryoglobulins. Both of these patients have in common a history of regular cocaine abuse, acral vasospasm, and laboratory evidence of connective tissue disease. While it has been known for many years that cocaine is a potent vasoconstrictor, we have been unable to find in the medical literature any reference to an association of its abuse with connective tissue disease. We would like to suggest that there may be such an association and would urge clinicians to keep cocaine abuse in mind when consulted by patients with vasospastic disorders.
Daniel J. Trozak, M.D. 2020 Coffee Rd. Modesto, CA 95355 William M. Gould, M.D. 750 Welch Rd. Palo Alto, CA 94304
Correspondence
Dermatologists must consider occlusive vascular disease in the differential diagnosis of a painful lesion at the end of the digit. The diagnosis can, in most cases, be readily established by finding decreased pulses and blood pressure on the affected extremity, thus avoiding the complications of delayed treatment.
Francico A. Kerdel, B.Sc., M.B., B.S. Howard P. Baden, M.D. Harvard Medical School Massachusetts General Hospital Department of Dermatology Boston, MA 02114 REFERENCES 1. Lazarus GS, Goldsmith LA: Diagnosis of skin disease. Philadelphia, 1980, F. A. Davis Co., pp. 427-432. 2. Welling RE, Cranley JJ, Krause RJ, Hafner CD: Obliterarive arterial disease of the upper extremity. Arch Surg 116:1593-1596, 1981. 3. Whelan TJ: Management of vascular disease of the upper extremity. Surg Clin North Am 62:373-389, 1982. 4. DePalma RG, Broadbent RV: Management of occlusive disease of the subclavian and innominate arteries. Am J Surg 142:197-202, 1981. 5. Gross WS, Flanigan DP, Kraft RO, Stanley JC: Chronic upper extremity arterial insufficiency. Etiology, manifestations, and operative management. Arch Surg 113:419423, 1978. 6. Martin J, Gaspard DJ, Johnston PW, et al: Vascular manifestations of the thoracic outlet syndrome--a surgical urgency. Arch Surg 111:779-782, 1976. 7. Dorazio RA, Ezzet F: Arterial complications of the thoracic outlet syndrome. Am J Surg 138:246-250, 1979. 8. Gerety RL, Andrus CH, May AG, et al: Surgical treatment of occlusive subclavian artery disease. Circulation 64(suppl):228-230, 1981. 9. Sachatello CR, Ernst CB, Griffen WO: The acutely ischernic upper extremity: Selective management. Surgery 76:1002-1009, 1974. Cocaine abuse and connective tissue disease To the Editor: We would like to draw the attention of dermatologists to a possible association between cocaine abuse and connective tissue disease. Case 1. For 3 years, a 40-year-old white male mechanic had swelling and sausage-shaped deformities of the fingers, together with an inability to make a tight fist or to oppose his thumb to his fifth digit. In cold, damp weather his hands became white, mottled, and red-blue. He had used cocaine regularly on weekends for a 3-year period and noted that his symptoms became markedly worse with heavier use of the drug. He was also a smoker of cigarettes and a user of marijuana and amphetamines. In addition to the preceding changes,
525
his hands exhibited atrophic, depressed, calloused scars on the finger pads; peeling, atrophic ulcers over the distal interphalangeal joints; and diffuse sclerosis extending 2 inches above the wrists. There were no calcium deposits in the skin, and only minimal telangiectasia was present at the base of one fingernail. There were no signs or symptoms suggesting systemic or internal organ disease. Skin biopsy specimens showed thickening and sclerosis of the dermal collagen and linear deposition of IgG at the dermoepidermal junction. Anticentromere antibodies were present in the serum at a titer of 1 : 160 (normal, less than 1:40). The following tests were normal or negative: complete blood count, fluorescent antinuclear antibody (FANA), antiextractable nuclear antigens (ENA), anti-deoxyribonucleic acid (DNA), anti-SSA, anti-SSB, cryoglobulins, cryofibrinogens, cold agglutinins. Case 2. A 24-year-old white male sheet metal worker had a 2-month history of episodes of blanching of the fingers, wtfich was succeeded by blue and red mottling. Persistent sausage-shaped swelling of the fingers developed, as did sores at the fingertips. Similar color changes occurred in the toes, but without sores. He had used cocaine regularly (nasal sniffing and smoking "free-base") for 4 to 5 years. He did not use tobacco or amphetamines. In addition to the color changes, there were atrophic scars on all fingertips, but there was no sclerosis. Bilateral ulceration of the nasal mucosa without septal perforation was noted. The patient denied any symptoms suggestive of systemic disease. The FANA was positive in a 1:1,280 dilution with a nucleolar pattern. The following were normal or negative: CBC, erythrocyte sedimentation rate (ESR), urine, SMA 12, VDRL, hepatitis B antigen, antiENA, anti-DNA, anti-centromere antibodies, and cryoglobulins. Both of these patients have in common a history of regular cocaine abuse, acral vasospasm, and laboratory evidence of connective tissue disease. While it has been known for many years that cocaine is a potent vasoconstrictor, we have been unable to find in the medical literature any reference to an association of its abuse with connective tissue disease. We would like to suggest that there may be such an association and would urge clinicians to keep cocaine abuse in mind when consulted by patients with vasospastic disorders.
Daniel J. Trozak, M.D. 2020 Coffee Rd. Modesto, CA 95355 William M. Gould, M.D. 750 Welch Rd. Palo Alto, CA 94304