A 20-year-old patient with Raynaud's type cold hypersensitivity and neuritis who has smoked since age 15. What do you suspect?

• A. Raynaud phenomenon
• B. Buerger disease
• C. Atherosclerosis
• D. Erythromelalgia

Answer: (B)

Thromboangiitis obliterans (Buerger disease) fits this pattern. In young smokers, distal ischemia with Raynaud-type cold hypersensitivity and neuropathy points to a vasculitis of small- to medium-sized vessels. The disease causes segmental thrombosing vasculitis with inflammatory thrombi that can extend to adjacent veins and nerves (vasa nervorum), leading to neuritis and distal ischemic symptoms. Smoking is the major risk factor, and stopping smoking can halt progression, which helps explain why this presentation is most likely in a 20-year-old with a long smoking history.

Raynaud phenomenon alone wouldn’t explain neuropathy or the strong smoking association; atherosclerosis is unlikely at this age; erythromelalgia typically presents with burning pain and warmth rather than cold-induced symptoms and neuropathy.