Cases from the Osler Medical Service at Johns Hopkins University

A 57-year-old man was seen because of an acutely painful middle finger. For 2 months he had had intermittent pain and numbness in the fingers of both hands that led him to stop operating a printing press at work. His medical history was remarkable only for a 40-year history of cigarette smoking. He was afebrile. Examination revealed an exquisitely tender third finger, cool beyond the proximal interphalangeal joint, with rubor and distal pallor (Figure 1). This and other digits demonstrated nailbeds with splinter hemorrhages (Figure 2). No Janeway lesions or Osler nodes were noted. Pulses were intact at the wrist. The results of initial routine laboratory tests, including an erythrocyte sedimentation rate, were normal. Transesophageal echocardiography revealed no source of embolization.