Thromboangiitis Obliterans

Case presentation: A 39-year-old male smoker with a 2-year history of calf discomfort on ambulation culminating in left femoral-to-peroneal artery bypass presented with right leg discomfort and recurrent painful subcutaneous nodules on his feet and calves. Biopsy of a nodule from his right foot was interpreted as vasculitis with thrombosis and fibrinoid necrosis in subcutaneous vessels, and the patient was prescribed immunosuppressive therapy with prednisone and azathioprine. His symptoms progressed, and the patient referred himself to the vascular medicine clinic for a second opinion. On examination, the patient had tender erythematous nodules on his right foot and calf following the course of the right lesser saphenous vein consistent with extensive superficial thrombophlebitis. The right femoral, popliteal, and pedal pulses were palpable. The left femoral-to-peroneal graft and left pedal pulses were also palpable. Ankle:brachial indices were normal in each leg. The constellation of arterial occlusive disease and superficial thrombophlebitis in a young smoker was most consistent with thromboangiitis obliterans.