Cutaneous vasculitis is a devastating extra-articular manifestation of rheumatoid arthritis. The potential consequences of digital vasculitis are necrosis, ischemia, infarction, and eventually gangrene.
A 54-year-old woman with a long history of rheumatoid arthritis developed an acute onset of severe diffuse occlusive cutaneous vasculitis beyond the head of the metacarpals (documented by angiogram). Despite treatment with high-dose prednisone and Cytoxan, her symptoms were poorly controlled. Cervical sympatholysis via continuous epidural infusion of bupivacaine was then initiated to manage her pain as well as to treat the vasoconstrictive sequelae of the cutaneous vasculitis.
The cervical epidural infusion relieved the pain and produced significant resolution of the symptoms.
This case highlights the rational use of continuous cervical epidural block for the management of pain and improvement in blood flow to vasoconstricted upper extremities and digits resulting from vasculitis due to rheumatoid vasculitis.