Restricted blood flow, or ischemia, in the nose of a cold agglutinin disease (CAD) patient can be successfully treated using a combination that includes aspirin, heparin, nitroglycerin ointment, and hyperbaric oxygen therapy, a case report details.
CAD most commonly manifests in the extremities, with symptoms in the head or neck being relatively rare. Still, such manifestations are known to happen, and they often lead to long-term damage. Treatments for such instances vary and can include anticoagulants, immune-targeted therapies, and even surgery.
The case report describes an 84-year-old female patient with CAD who was admitted to a hospital with unusual blue coloring (a condition sometimes referred to as acrocyanosis) at the tip of her nose, which occurred after a hip replacement surgery. The discoloration was accompanied by a loss of sensation in the affected area, as well as pain in surrounding areas of the nose.
Clinical assessment determined that the discoloration was due to ischemia — a lack of blood flow to the affected area — which, if prolonged, can kill tissue, primarily from a lack of oxygen. Over several days in the hospital, the blue discoloration spread across the whole nose, indicating a worsening condition.
The patient was treated with a “multimodal management protocol” that included aspirin and an anticoagulant (enoxaparin, which is a type of heparin). “Heparin and ASA [aspirin] have both been extensively studied in the treatment of acute thrombotic disease, and have both previously been used in the management of cutaneous [skin-affecting] ischemia resulting from CAD,” the study’s authors noted.
Treatment also included nitroglycerin ointment, applied to the skin. Nitroglycerin is a vasodialator — it widens blood vessels, decreasing blood pressure and allowing blood to flow more easily. Its use in acrocyanosis due to CAD has not been previously reported.
The last major component of this treatment, hyperbaric oxygen therapy (HBOT), involves breathing pure oxygen; in this case, the hope was to increase the delivery of oxygen to the ischemic tissue. “Our local experience suggests HBOT is often an afterthought in management when other measures are not effective,” the team wrote.
This combination of therapies was ultimately effective: the blue coloring faded, and the patient was discharged after about two and a half weeks. At a follow-up visit several weeks later, her nose was back to its normal color, with no lack of sensation and no pain present.
“We describe a patient with CAD who developed severe acrocyanosis and ischemia of the nose that resolved completely with aspirin, [heparin], nitroglycerin ointment and HBOT,” the authors concluded.