MetroCreative Tobacco users are at risk of developing numerous diseases, including Buerger’s disease, which affects blood vessels and blood flow increasing the chance of tissue death, commonly known as gangrene.

A 48 year old woman presented to her podiatrist with complaints of some numb toes. Her left 4th and the 5th toes were painful and discolored, even tending towards black. This individual did not have diabetes or hypertension, and she didn’t smoke (although her husband and son were smokers). Her podiatrist performed an exam, finding no warmth to the toes, especially the 4th and 5th. Not only were these two digits cold, the skin had also become blackened, with the patient relating significant pain. This was superficial gangrene, tissue death.

Our next case involves a 19-year-old female college student who experienced numbness and coldness of the outer toes of her left foot. Her medical history was unremarkable except for 3 years of cigarette use. Gangrene developed rapidly, the skin turning cold and lifeless. Labs of her blood were unremarkable. A study of her arterial blood flow revealed blockage in the arteries of both legs and arms, but the disease was recognized too late, and nothing could be done. Unfortunately, a below-knee amputation was performed.

Both of these people suffered from Buerger’s Disease, a condition technically referred to as thromboangiitis obliterans, which affects blood vessels in the body, most commonly in the arms and legs. Blood vessels swell, which can prevent blood flow, and also potentially allow clots to form. Pain will result, associated with the tissue damage from the blockage of flow. Without sufficient supply, tissue death ensues, which is the definition of gangrene (the death or decay of body tissues).

The use of tobacco products is the key to the disease since it happens to no one else. But smoking has been affiliated with the development of disease for decades. The association with lung cancer was first identified in 1912 when a physician published a study making the link of tobacco with a risk for lung cancer. In 1956, the Surgeon General spearheaded a study which found a definitive relationship between the two.

The association of Buerger’s disease with smoking is nearly absolute, with 96% of those afflicted with this condition either a consumer of tobacco products or living with one. But this is not a particularly common condition, affecting about 20 people out of every 100,000. It rarely occurs in the pediatric population nor in the elderly, typically those 20 to 45 years of age. Males have historically been afflicted more commonly, but this appears to be changing, likely attributable to the trend towards increased tobacco use amongst women.

As to symptoms, they can vary. Pain is a frequent one, sometimes with burning or tenderness in your legs or feet when walking. The small muscles of the forefoot may produce claudication pain, which is due to muscles being deprived of blood when they are working harder. And this is most commonly experienced when we are walking so it’s often mistaken for a musculoskeletal condition.

With disease progression, pain may develop when lying in bed at night since gravity is no longer assisting in bringing blood to the feet. This phenomenon is termed “rest pain” and is relieved by dependency, hanging the legs off the bed or standing. Color change may be seen, the toes turning pale or red, sometimes even bluish. When clotting occurs, some area will be deprived of blood and tissue death develops. These changes may manifest as ulcerations developing on the toes or fingers. Alternatively, depending on what vessels are affected, gangrene may result. Although rare, a stroke or heart attack can result.

Interestingly, although the disease has been recognized for over a hundred years, we still don’t thoroughly understand it or what causes it. The use of tobacco products is still the foundation of the condition, but what is happening physiologically is uncertain. It is theorized that something in tobacco hurts the lining of our blood vessels. Genetic factors may increase the odds you develop Buerger’s disease if you smoke. Another favored hypothesis is that Buerger’s is somehow an autoimmune disease (where the body attacks some tissue or organ, in this case the lining of our blood vessels).

Diagnosis is surprisingly difficult since there is no definitive study or blood test. Science can’t even agree on what criteria should be used to make the diagnosis. Historically, there have been 5 factors required, including a history of smoking, age of onset, some degree of vessel disease, and others. Diagnostic ultrasound, where sound waves are used to create a picture of the vessels, has found some success. Angiography uses a radioactive contrast material (making it an invasive study), injected into the circulatory system, allowing direct visualization of blocked vessels.

Currently, there is no cure for Buerger’s disease, although discontinuing any and all exposure to tobacco is essential. Quitting can sometimes cause the symptoms to resolve completely, or at least reduce them. Apparently, cutting back is not sufficient since even one cigarette a day can make it worse. A surgical procedure called a sympathectomy has been used to treat Buerger’s. A nerve is cut, causing a relaxation of arteries, which reduces the vessels resistance to blood flow. But this technique is irreversible, meaning if the results are undesirable, the nerve can’t be repaired. But surgical reconstruction of the arteries is not possible because the vessels are inflamed, not diseased, the hallmark of the disease.

The 48 year old woman, our case study, was prescribed pain relievers and medications causing relaxation of arteries. The aforementioned sympathectomy procedure was performed, along with amputation of the necrotic fingers. She was able to go on with life, with a newfound appreciation of the dangers of second-hand smoke.

Obviously, the topic of cigarettes invites a blanket condemnation since we know it can lead to various lung diseases, along with a well-recognized increased risk of cancer. And yet, 28 million Americans still consume tobacco products, more than one in ten. What is it going to take to reduce that number? Maybe learning about the pain and perils of Buerger’s disease.

Dr. Conway McLean, DABFAS, FAPWHc, has offices in L’Anse and Marquette. He is a physician who specializes in treating lower leg, ankle and foot problems.