An unusual cause of toe necrosis
A 50-year-old male presented with history of pain in both lower limbs and ulcer in partially amputated left great toe since 8 months. He had history of pain in both lower limbs with blackish discoloration of left great toe for which he had undergone partial left great toe amputation by local practitioner before 8 months. He was a non-smoker. He had been treated for limb pain symptomatically before being referred to our institute. Before referral to the vascular surgery unit, CT angiography was done which incidentally detected left hypervascular suprarenal mass.\nOn examination, the patient was found to have tachycardia and hypertension. There were no peripheral signs of pheochromocytoma. Abdominal examination was unremarkable. Pulses were weak in both lower limbs as compared to hand, and great toe was partially amputated with ulcer [].\nLaboratory data showed hemoglobin (Hb) 11 gm/dl and random blood glucose 121 mg/dl. Coagulation profile and lipid profile were normal. Urine vanillylmandelic acid (VMA) was 10.3 (2–8 mg/24 h), urine epinephrine 16.8 (0–20 mg/24 h), urine norepinephrine 133.4 (15–80 mg/24 h), and serum cortisol after overnight dexamethasone suppression test was 46.72 (171–536 nmol/l).\nCT angiography revealed relatively delayed runoff in lower limb arteries with marginally reduced caliber in right lower limb arteries and hypervascular left suprarenal mass suggestive of pheochromocytoma. Contrast-enhanced computed tomography (CECT) abdomen revealed a 5.2 × 3.5 × 5.8 cm hypervascular mass lesion replacing left adrenal, suggestive of pheochromocytoma [].\nPatient was started on antihypertensive. After adequate alpha and beta blockade, he underwent left adrenalectomy []. Histological examination showed a well-circumscribed and encapsulated tumor with monomorphic cells arranged in alveolar and nesting pattern, separated by thin vascularized septae. Individual cells were monomorphic with round nuclei, granular chromatin, inconspicuous nucleoli, and moderate to abundant granular cytoplasm. The features were suggestive of a pheochromocytoma.\nPostoperatively, his BP was normal. On follow-up, his toe ulcer healed completely.