A patient with nodular phlebitis and prior Raynaud diagnosis; chronic hand ulcers; better since quitting smoking—what do you suspect?

• A. Wegener's granulomatosis
• B. Buerger disease
• C. Varicose veins
• D. Raynaud phenomenon

Answer: (B)

The key point is a tobacco-related inflammatory vasculitis that causes distal extremity ischemia with nodular phlebitis and hand ulcers, often seen in people with a history ofRaynaud phenomenon. Thromboangiitis obliterans (Buerger disease) fits this pattern: it targets small- to medium-sized vessels in the limbs, creating occlusive thrombi that lead to ischemia, ulcers, and even nerve involvement. The strong link to smoking and the potential to halt progression or improve symptoms after quitting smoking are characteristic clues, making this the best fit for the presentation.

Wegener's granulomatosis would typically involve granulomatous inflammation with upper airway and kidney involvement and is not driven by smoking or by nodular phlebitis. Varicose veins are venous dilation and insufficiency, not the ischemic ulcers and inflammatory thrombi seen in Buerger disease. Raynaud phenomenon alone is a vasospastic process without the chronic ischemic ulcers and nodular phlebitis described, nor the smoking-related course.