Raynaud Phenomenon: Differential Diagnoses & Workup

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Raynaud Phenomenon: Differential Diagnoses & Workup
Medscape

Author: Jeffrey R Lisse, MD, FACP, Professor, Department of Internal Medicine; Chief, Section of Rheumatology, University of Arizona School of Medicine
Coauthor(s): Mayra Oberto-Medina, DO, Fellow, Section of Rheumatology, University of Arizona

Updated: Apr 5, 2006

Differential Diagnoses
Acromegaly
Localized Fibrosing Disorders: Linear Scleroderma, Morphea, Regional Fibrosis

Acute Myelogenous Leukemia
Lung Cancer, Non-Small Cell

Antiphospholipid Antibody Syndrome and Pregnancy
Lung Cancer, Oat Cell (Small Cell)

Antithrombin Deficiency
Lymphoma, B-Cell

Arteriovenous Fistulas
Mixed Connective-Tissue Disease

Atherosclerosis
Multiple Myeloma

Buerger Disease (Thromboangiitis Obliterans)
Paroxysmal Nocturnal Hemoglobinuria

Carcinoid Lung Tumors
Peripheral Arterial Occlusive Disease

Cold Agglutinin Disease
Pheochromocytoma

Cryoglobulinemia
Polycythemia Vera

Dermatomyositis
Polymyositis

Diabetes Mellitus, Type 1
Protein C Deficiency

Diabetes Mellitus, Type 2
Protein S Deficiency

Extremity Vascular Trauma
Rheumatoid Arthritis

Frostbite
Scleroderma

Graft Versus Host Disease
Sjogren Syndrome

Heart-Lung Transplantation
Stimulants

Hemoglobinuria, Paroxysmal Cold
Systemic Lupus Erythematosus

Hepatitis B
Toxicity, Arsenic

Hepatitis C
Toxicity, Cocaine

Hypothermia
Toxicity, Cyanide

Injecting Drug Use
Toxicity, Lead

Other Problems to Be Considered

Acrocyanosis
Alfa-interferon
Antineoplastics (eg, vinca alkaloids, bleomycin, cisplatin)
Beta-adrenergic blocking drugs
Bromocriptine
Carpal Tunnel Syndrome
Chilblains
Cryoglobulinemia, mixed or type 3, associated with hepatitis B and C
Cryoglobulinemia, monoclonal or type I
Cyclosporine
Ergot alkaloids
Fabry disease
Leukemia
Livedo reticularis
Lymphoma
Mycoplasma with cold agglutinins
Myeloma
Oral contraceptives
Overlap syndromes
Peripheral Vascular Disease
Scleroderma, diffuse and localized (CREST syndrome)
Thoracic Outlet Syndrome
Thromboembolic disease
Vasculitis
Vibration injury
Vinyl chloride exposure
Waldenström macroglobulinemia

Workup
Laboratory Studies

* Complete blood cell count - To evaluate polycythemic disorders, underlying malignancies, or autoimmune disorders
* Blood urea nitrogen - To evaluate possible renal impairment or dehydration
* Creatinine - To evaluate possible renal impairment
* Prothrombin time - To observe for any evidence of hepatic dysfunction
* Activated partial thromboplastin time - To observe for any evidence of antiphospholipid antibody disorder or hepatic dysfunction
* Serum glucose - To evaluate patient for diabetic disease
* Thyroid-stimulating hormone - To observe for thyroid disorders
* Optional laboratory tests
o Antinuclear antibody - May be positive in autoimmune disorders and should be ordered in patients with features of these disorders
o Serum viscosity - Elevated in hyperviscosity syndromes such as paraproteinemias
o Serum creatine kinase - Elevated in muscle damage such as polymyositis and dermatomyositis
o Rheumatoid factor - May be elevated in rheumatoid arthritis, other autoimmune disorders, and some forms of cryoglobulinemia (monoclonal proteins in multiple myeloma and Waldenström macroglobulinemia have an increased frequency of rheumatoid factor activity)
o Hepatitis panel - Positive for B or C infection in many patients with cryoglobulinemia
o Cold agglutinins - Present in Mycoplasma infections and lymphomas
o Heavy metal screen - To observe for patients with neuropathic pain from poisoning
o Growth hormone - To evaluate patients for acromegaly
o Serum vanillylmandelic acid - To evaluate for pheochromocytoma
o Metanephrine - To observe for pheochromocytoma in appropriate patients
o Catecholamines - To observe for pheochromocytoma
o Leukocyte alkaline phosphatase - To evaluate for leukemias in appropriate patients
o Antiphospholipid antibodies studies - Including dilute Russell viper venom studies, anticardiolipin antibodies, and anti-beta-1-glycoprotein-2 antibodies.

Imaging Studies

* Thermography, isotope studies, and arteriography have all been used, but none has proven superior to clinical assessment in office practice.
* A fixed, nonreversible, cyanotic lesion requires further evaluation of the vasculature.

Other Tests

* Acid hemolysis test
* Sucrose lysis test

Procedures

* Serum protein electrophoresis
* Liver or kidney biopsy
* Measurement of digital blood pressures before and after immersion in cold water (The difference should be less than 30 mm Hg.).

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