Snapshot A 24-year-old Asian male presents with gangrene of eight of his ten finger tips. He is known to be a heavy smoker, though he denies his tobacco habit when interviewed. Introduction Buerger’s disease is a rare disease in which the distal vessels become blocked in the hands and feet it is also known as thromboangiitis obliterans Epidemiology patients are classically young males (20-40 years old) who are heavy cigarette smokers or users of chewing tobacco uncommon in children without associated immune disease more recently, a higher percentage of women and people over the age of 50 have been recognized to have this disease most common in Asia, Southeast Asia, India and the Middle East also appears among African-Americans more so than Caucasians Etiology thought to be caused by inflammation and/or vascular spasms in the distal arterioles attributed to cigarette smoking in young adults Presentation Symptoms claudication in the feet and/or hands may occur initially with activity usually progresses to pain at rest may radiate proximally numbness and/or tingling in the limbs Raynaud's phenomenon skin ulcers discoloration of the hands and feet pale, red, or blue coldness of the hands and feet symptoms may worsen with cold exposure or emotional distress Physical exam skin breakdown and ulceration large, erythematous, tender, superficial blood vessels may be appreciated decreased temperature in the hands and feet diminished or absent pulse in affected limb(s) necrosis and gangrene of the distal extremities fingers and toes Evaluation Angiography/arteriography diagnostic gold standard may show blockage of blood vessels Doppler ultrasound may show blockage of blood vessels Blood labs may be used to rule out other identifiable causes of vasculitis or inflammation Biopsy of blood vessel(s) only performed in cases when the diagnosis is unknown shows segmental thrombosing vasculitis with inflammatory infiltrate Differential PVD, scleroderma, CREST syndrome, arterial insufficiency, necrotizing fasciitis Treatment Non-operative symptomatic treatment and lifestyle modifications smoking cessation is critical avoid exposure to cold perform activities to increase circulation apply warmth exercise gently daily aspirin vasodilators there is no known cure for this disease Operative surgical sympathectomy cuts nerves to the affected areas may enhance pain control limb amputation may be necessary to avoid spread of infection Prognosis, Prevention, and Comlications Prognosis can be excellent (i.e. complete resolution of symptoms) with smoking cessation in some cases, however, amputation is unavoidable Prevention patients with history of Raynaud's disease or thromboangiitis obliterans should abstain from tobacco use Complications gangrene amputation worsening of circulation if untreated