A 24-year-old male smoker presents with pain in both feet at rest and blackening of the tips of two toes. Examination shows absent dorsalis pedis pulses but normal popliteal and femoral pulses. Angiography shows segmental occlusions of tibial and digital arteries with corkscrew collaterals. Biopsy of an involved vessel would most likely show:

• A An organizing thrombus with acute and chronic inflammation extending into the adjacent soft tissue, sparing the vessel wall architecture ✓
• B Granulomatous inflammation with giant cells and fragmentation of the internal elastic lamina
• C Fibrinoid necrosis of the entire wall thickness with aneurysmal dilatation
• D Concentric fibrous intimal thickening with medial hypertrophy only

Explanation

This is thromboangiitis obliterans (Buerger disease), a segmental thrombosing vasculitis of medium and small vessels, chiefly tibial, radial, and digital arteries, almost exclusively in heavy smokers. The thrombus is sharply limited to the vessel lumen with acute and chronic inflammation and microabscesses, and extends into contiguous tissue, while the wall architecture is relatively preserved. Granulomas suggest giant cell arteritis, fibrinoid necrosis suggests polyarteritis nodosa, and concentric intimal thickening alone is nonspecific atherosclerotic change.

Reference: Robbins and Cotran Pathologic Basis of Disease, 10th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.