Cleveland Clinic Journal of Medicine (CCJM)A 74-year-old Woman with Purple Toes

This case study presents a complex diagnostic journey of a 74-year-old woman with purple toes, highlighting the intersection of multiple thrombotic risk factors including polycythemia vera, antiphospholipid syndrome (APS), and medication management challenges. The case demonstrates the importance of systematic differential diagnosis and the clinical reasoning process when evaluating vascular complications.

Key Clinical Considerations:

• Diagnostic approach to purple digits requires careful assessment of peripheral pulses, with palpable pulses not excluding microembolic phenomena or thrombotic events.
• Patients on direct oral anticoagulants (DOACs) cannot undergo complete lupus anticoagulant testing due to interference with assays, necessitating strategic timing of APS workup.
• Multiple thrombotic risk factors (polycythemia vera with JAK2 mutation and APS) require tailored anticoagulation approaches, with evidence favoring warfarin over DOACs in APS.
• Development of arterial thrombosis while on DOAC therapy warrants reassessment of anticoagulation strategy and comprehensive thrombophilia workup.
• Conservative management with anticoagulation is typically first-line for aortic thrombi, with endovascular intervention reserved for refractory cases.

HCN Medical Memo
This case emphasizes the need for systematic diagnostic approaches when evaluating complex vascular presentations. It highlights the importance of considering multiple concurrent thrombotic risk factors and their impact on anticoagulation choice. The case demonstrates how medication choices (DOACs vs. warfarin) can significantly affect both diagnostic workup capabilities and treatment outcomes in patients with multiple prothrombotic conditions.

Vascular Medicine Summaries