From the Guidelines
To investigate a 70-year-old man with widespread truncal livedo reticularis and a history of dizzy spells and hyperlipidemia, I recommend a comprehensive workup focusing on potential vascular, autoimmune, and hematologic causes, starting with a complete blood count, comprehensive metabolic panel, lipid profile, and inflammatory markers (ESR, CRP) as the initial step. This approach is crucial in identifying potential underlying conditions that may be contributing to his symptoms, such as antiphospholipid syndrome or atherosclerotic disease, which can cause both cutaneous manifestations and cerebrovascular symptoms 1.
Given his history of hyperlipidemia, it is essential to optimize management of his lipid levels, as this may contribute to his symptoms, and recognize "capture moments" in his care, such as the establishment of general care or identification of high-risk features for ASCVD, to guide therapeutic decisions 1. The identification of ASCVD, including asymptomatic disease, can represent another high-yield capture moment in lipid therapy escalation, and clinical events like MI, stroke, or hospitalization can also prompt a re-evaluation of his lipid management strategy 1.
The workup should also include specific tests for antiphospholipid syndrome, such as anticardiolipin antibodies, lupus anticoagulant, and anti-β2 glycoprotein I, as well as cryoglobulins, cold agglutinins, and protein electrophoresis to evaluate for paraproteinemias. Assessing for autoimmune conditions with ANA, ANCA, rheumatoid factor, and complement levels is also necessary.
- Key tests to consider:
- Complete blood count
- Comprehensive metabolic panel
- Lipid profile
- Inflammatory markers (ESR, CRP)
- Anticardiolipin antibodies
- Lupus anticoagulant
- Anti-β2 glycoprotein I
- Cryoglobulins
- Cold agglutinins
- Protein electrophoresis
- ANA
- ANCA
- Rheumatoid factor
- Complement levels Given his age and dizzy spells, carotid doppler ultrasound and echocardiogram are important to evaluate cardiovascular status. Consider skin biopsy of affected areas if diagnosis remains unclear.
By taking a comprehensive approach to his workup and management, we can better understand the underlying causes of his symptoms and develop an effective treatment plan to improve his quality of life and reduce his risk of morbidity and mortality.
From the Research
Investigation Approach
To investigate a 70-year-old man with widespread livedo reticularis, mainly truncal, who has a history of dizzy spells and hyperlipidemia, the following steps can be taken:
- Consider ordering a complete blood count (CBC) to assess for any underlying hematologic disorders, as livedo reticularis can be associated with various conditions, including vasculitis, thrombophilia, and hematologic malignancies 2
- Measure erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels to evaluate for inflammation, as livedo reticularis can be a manifestation of an underlying inflammatory process 3, 4, 5
- Interpret ESR and CRP results in the context of the patient's clinical presentation, taking into account factors that can affect these measurements, such as age, sex, and renal disease 4, 5
Laboratory Tests
The following laboratory tests may be useful in the investigation:
- Complete blood count (CBC) to assess for anemia, leukocytosis, or thrombocytosis 2
- Erythrocyte sedimentation rate (ESR) to monitor chronic inflammatory conditions 3
- C-reactive protein (CRP) to diagnose and monitor acute inflammatory conditions 4
- White blood cell count and differential to assess for infection or inflammation 6
Clinical Considerations
When interpreting laboratory results, consider the following:
- The patient's age and sex, as these can affect ESR and CRP measurements 4, 5
- The presence of renal disease, as this can increase ESR levels 4
- The patient's history of hyperlipidemia, as this can increase the risk of cardiovascular disease 6
- The patient's symptoms of dizzy spells, as these can be related to various conditions, including cardiovascular disease or vasculitis 6