Purple Toes and Livido Reticularis in a Patient With Cardiovascular Disease Taking Coumadin

REPORT OF A CASE A 68-year-old white man was admitted to the Veterans Administration Hospital in Dayton, Ohio, on March 18, 1989, with a chief complaint of painful purple discoloration of the fifth toe for 3 days. He had a 2-year history of hypertension and coronary artery disease with four-vessel bypass surgery 8 years ago. One month before admission, the patient had an episode of transient ischemic attack, and a new onset of atrial flutter/fibrillation was detected. This was thought to be due to emboli from the left atrium, and the patient was treated with oral coumadin (5 mg/d) and digoxin (0.125 mg/d). On physical examination, the patient was noted to have exquisitely tender blue-purple third and fifth toes (Fig 1). The remaining toes showed a dull red discoloration. There was a livido reticularis pattern on his left knee (Fig 2). The remainder of the physical examination was normal, except