5.1. Extremity InvolvementClaudicat

5.1. Extremity Involvement

Claudication in the arch of the foot is an early sign and is suggestive of, or even specific to, TAO. This condition is a manifestation of infrapopliteal vessel occlusive disease. As the disease progresses, typical calf claudication and eventually ischemic pain at rest and ischemic ulcerations on the toes, feet, or fingers may develop. Ischemia of the upper limbs is clinically evident in 40–50% of patients, but may be detected in 63% of patients by Allen’s test [29] and in 91% of patients by arteriogram of the hand and forearm [30]. In the Allen’s test, the examiner places the thumbs to occlude the radial and ulnar arteries of one hand of the patient. The patient opens the fist and the examiner then releases pressure from the radial artery but not the ulnar artery. If the radial artery distal to the wrist is patent, there is prompt return to colour to the hand (negative test). If the artery is occluded, the hand will remain pale (positive test). The maneuver is repeated with the pressure released from the ulnar artery but not the radial artery.
5.2. Superficial Thrombophlebitis

Superficial thrombophlebitis is observed in 40–60% of cases. Deep vein thrombophlebitis is unusual and suggestive of an alternative diagnosis, such as Behcet’s disease. This superficial thrombophlebitis is migratory and recurrent and affects the arms and legs. Migrating phlebitis (phlebitis saltans) in young patients is therefore highly suggestive of TAO [31].
5.3. Systemic Signs and Symptoms

Systemic signs and symptoms are very rare in patients with TAO. There has been occasional reports involvement of visceral vessels. Digestive ischemia may manifest as abdominal pain, diarrhea, weight loss, or melena. Intestinal perforation and mesenteric infarction may occur. There have been reports of TAO initially presenting as small bowel ischemia and colonic obstruction [32, 33].

In some of these cases, visceral artery damage results more likely from atherosclerosis, favored by or associated with TAO. Thus, when TAO occurs in an unusual location, diagnosis should be made only after the identification of typical inflammatory vascular lesions on histopathological examinations.

Central nervous system involvement has been reported in TAO which may present as transient ischaemic attacks or ischaemic stroke. Postmortem histological examinations have demonstrated inflammation of the small- and medium-sized arteries of the leptomeninges or even of the meninges or veins [34].

Coronary artery involvement is extremely rare [35]. There have been reports of coronary artery involvement presenting as acute myocardial infarction [36].

TAO may present with joint manifestations [37]. On careful history taking about 12.5% may report joint problems before the preocclusive phase [38]. Patients present recurrent episodes of arthritis of the large joints, with transient, migratory single-joint episodes accompanied by local signs of inflammation. The wrists and knees are the most frequently involved joints. The duration of signs and symptoms ranges from 2 to 14 days. The arthritis is nonerosive. Joint problems precede the diagnosis of TAO by about 10 yrs on average.
6. Laboratory Tests and Imaging

There are no specific laboratory tests to aid in the diagnosis of TAO. A complete serologic proile to exclude other diseases that may mimic TAO should be obtained as in Table 3. A proximal source of emboli should be excluded with echocardiography (two-dimensional and/or transesophageal) and arteriography. Proximal arteries should show no evidence of atherosclerosis, aneurysm, or other source of proximal emboli. A pathologic specimen is needed to diagnose Buerger’s disease in cases of proximal artery involvement or in unusual locations.

Hasil (Bahasa Indonesia) 1:

5.1. ekstremitas keterlibatanClaudicatio di lengkungan kaki adalah tanda awal dan sugestif dari, atau bahkan khusus untuk, TAO. Kondisi ini merupakan manifestasi penyakit infrapopliteal kapal occlusive. Sebagai penyakit berlangsung, claudicatio khas betis dan akhirnya iskemik nyeri saat istirahat dan ulserasi iskemik pada jari-jari kaki, kaki, atau jari dapat mengembangkan. Iskemia dari tungkai atas klinis terbukti di 40-50% pasien, tetapi dapat dideteksi dalam 63% pasien oleh Allen tes [29] dan 91% pasien dengan arteriogram tangan dan lengan [30]. Dalam test Allen, pemeriksa menempatkan ibu jari untuk occlude arteri radial dan ulnar satu tangan pasien. Pasien membuka tinju dan pemeriksa kemudian melepaskan tekanan dari arteri radialis tetapi tidak arteri ulnar. Jika arteri radialis distal di pergelangan tangan paten, ada cepat kembali ke warna tangan (tes negatif). Jika arteri yang tersumbat, tangan akan tetap pucat (tes positif). Manuver diulang dengan tekanan yang dilepaskan dari arteri ulnar tetapi tidak arteri radialis.5.2. dangkal ThrombophlebitisTromboflebitis superfisial diamati dalam 40-60% kasus. Dalam vena tromboflebitis tidak biasa dan sugestif dari diagnosis alternatif, seperti Behcet's penyakit. Tromboflebitis dangkal ini bermigrasi dan berulang dan mempengaruhi lengan dan kaki. Bermigrasi flebitis (flebitis saltans) pada pasien muda sangat sugestif Tao [31].5.3. Systemic Signs and SymptomsSystemic signs and symptoms are very rare in patients with TAO. There has been occasional reports involvement of visceral vessels. Digestive ischemia may manifest as abdominal pain, diarrhea, weight loss, or melena. Intestinal perforation and mesenteric infarction may occur. There have been reports of TAO initially presenting as small bowel ischemia and colonic obstruction [32, 33].In some of these cases, visceral artery damage results more likely from atherosclerosis, favored by or associated with TAO. Thus, when TAO occurs in an unusual location, diagnosis should be made only after the identification of typical inflammatory vascular lesions on histopathological examinations.Central nervous system involvement has been reported in TAO which may present as transient ischaemic attacks or ischaemic stroke. Postmortem histological examinations have demonstrated inflammation of the small- and medium-sized arteries of the leptomeninges or even of the meninges or veins [34].Coronary artery involvement is extremely rare [35]. There have been reports of coronary artery involvement presenting as acute myocardial infarction [36].TAO may present with joint manifestations [37]. On careful history taking about 12.5% may report joint problems before the preocclusive phase [38]. Patients present recurrent episodes of arthritis of the large joints, with transient, migratory single-joint episodes accompanied by local signs of inflammation. The wrists and knees are the most frequently involved joints. The duration of signs and symptoms ranges from 2 to 14 days. The arthritis is nonerosive. Joint problems precede the diagnosis of TAO by about 10 yrs on average.6. Laboratory Tests and ImagingThere are no specific laboratory tests to aid in the diagnosis of TAO. A complete serologic proile to exclude other diseases that may mimic TAO should be obtained as in Table 3. A proximal source of emboli should be excluded with echocardiography (two-dimensional and/or transesophageal) and arteriography. Proximal arteries should show no evidence of atherosclerosis, aneurysm, or other source of proximal emboli. A pathologic specimen is needed to diagnose Buerger’s disease in cases of proximal artery involvement or in unusual locations.