Cocaine-Related Vasculitis Causing Upper-Limb Peripheral Vascular Disease

TO THE EDITOR:

In the patient with upper-limb peripheral vascular disease described by Drs. Kumar and Smith (1), an interesting differential diagnosis is present. The authors found that laboratory studies excluded connective tissue disorders and confirmed their patient's use of cocaine. However, several other causes should have been considered before the occlusive arterial disease in the patient's hands was attributed to “cocaine vasculitis.” First, chronic repetitive blunt trauma to the hands in certain occupations and hobbies can cause palmar and digital occlusive arterial disease; this occurs most often in the dominant hand but can occur in both hands (2). Second, in patients with recurrent deep venous thrombosis and digital artery occlusions (like Kumar and Smith's patient), hypercoagulable disorders such as antithrombin III deficiency, deficiency of protein C and protein S, and hyperhomocystinemia should be excluded (3). We agree that the onset of occlusive arterial disease of small and medium-sized arteries in a person older than 40 years of age is not likely to be thromboangiitis obliterans (Buerger disease), but this disorder cannot be completely excluded in veteran smokers. Indeed, evidence of involvement of the small and medium-sized arteries of the wrist or hand as well as the lower extremity is one of the criteria for a confident clinical diagnosis of thromboangiitis obliterans (4). It is to be hoped that the patient stopped using tobacco as well as cocaine, regardless of the cause of his disorder.