The patient
A 58-year-old man attended my surgery and noted that his fingers went white, especially when exposed to the cold. His fingers went pale, then blue and finally red. There was associated pain and tingling. He first noticed this when he was fly fishing and his hands got wet.
First instinct
This looked like typical Raynaud's phenomenon. However there are quite a number of specific causes and none was immediately obvious.
Differential diagnosis
The most likely cause is idiopathic Raynaud's disease, typically in young women (60-90% of cases). Raynaud's disease can be secondary to:
• connective-tissue disorders such as rheumatoid arthritis, scleroderma, SLE, CREST syndrome (calcinosis, Raynaud's, esophageal abnormalities, sclerodactyly, telangiectasia)
• obstructive arterial diseases (arteriosclerosis obliterans, thoracic outlet syndrome)
• myxoedema
• drugs such as the ergot-derived drug methysergide
• trauma to the hand from vibrating tools
• dysproteinaemias.
Getting on the right track
I performed Allan's test on him, which gave a positive result in both hands. In Allan's test, the patient makes a tight fist and the examiner uses pressure to occlude both the radial and ulnar arteries. The patient opens his hand, which is now pale. The examiner releases pressure over one artery. A positive test is when there is delayed reperfusion. The test is repeated for each artery and hand. This patient had been a miner for 10 years, starting when he was 20, and regularly used vibrating tools. Vibration white finger is a prescribed disease that can be claimed for from the Department of Work and Pensions.
But the symptoms had come on only recently. He gave no history of relevant drug use. He did not complain of fatigue or weight gain.
However, he mentioned that he had developed bilateral ankle, knee and wrist pain, which was associated with morning stiffness for about 45 minutes.
The hidden clue
Both wrists were swollen with some restriction of movement. There was evidence of synovitis. On further questioning, he revealed his mother had rheumatoid arthritis.
Outcome
Blood tests showed he had mild anaemia, with a haemoglobin of 12.6g/dl and a normochromic and normocystic picture. His liver and renal profiles were normal. T4 and TSH were normal. However, his ESR was elevated at 54mm/hr and his C-reactive protein was also elevated at 33. His rheumatoid factor was positive at 36 (up to 20 is a negative). A diagnosis of rheumatoid arthritis was made. He managed his Raynaud's phenomenon by using neoprene gloves when fishing.
Dr Hercules Robinson is a GP in Caithness
Patient with Raynaud's phenomenon Raynaud's
