Painful digital infarction in a male smoker treated as Buerger's disease

A 40-year-old male smoker presented with a 3-week history of painful digital infarction involving the hands. Histology was unhelpful, showing lichen simplex chronicus. A provisional diagnosis of a vasculitic disease was made. Treatment included aspirin, azathioprine, iloprost, methylprednisolone, nifedipine and prednisolone. After failure of these treatments an alternative clinical diagnosis of Buerger's disease was made. Treatment was to advise the patient of the importance of continuing to abstain from smoking, to perform bilateral video-assisted thoracoscopic sympathectomies and to commence folate supplementation. This led to marked improvement of his symptoms and healing of the digital infarction.