The Journal of Tehran University Heart Center the locked-in syndrome13 and pharmacological treatment includes fibrinolytic therapy and anticoagulation for the prevention of thrombosis. Steroids can be helpful by decreasing the intracranial pressure. A number of acquired conditions can cause the uncontrolled activation of the coagulation system. The most common is the anticardiolipin antibody syndrome, which is sometimes but not always associated with lupus-rheumatoid arthritis, scleroderma, or Sjogren’s syndrome. These patients may have a false-positive syphilis test and elevated partial thromboplastin time (PTT). Diagnoses in the third category are often considered after a source of proximal emboli and a coagulation work-up having failed to suggest a cause of blue or purple toe. Painful digital discoloration accompanied by ulceration suggests vasculitis, involving blood vessels. Definitive diagnosis usually requires histological documentation because vasculitic syndromes have no pathognomonic clinical features or lab test results. We here in add a new case, which is severe inflammatory reaction begotten by cardiopulmonary bypass. MRI can show abnormally single or multiple intensity regions, and prophylactic treatment with an H2 receptor antagonist is recommended to prevent the development of a stress ulcer in such patients. Prolonged ventilatory support, tracheostomy, respiratory physiotherapy, intensive nursing care, appropriate antibiotic prophylactic treatment, and adequate nutritional support for hepatic failure and management of acute renal failure are essential. The blue toe syndrome resulting from generalized cardiopulmonary bypass inflammation is extremely rare and has not been reported so far. We sought to treat our patient with vasodilator drugs and amputation of toe. Hepatic failure presenting as functional obstruction of the biliary tract is normally managed with a low fatty diet and nutritional support and stool softener. The diagnosis of the syndrome depends mainly on the clinical picture and demonstration of brain stem infarction.14 The prognosis for life is usually poor; however, there have been reports of survival and recovery from the locked-in syndrome following pontine infarction.15 Conclusion The blue toe syndrome is devastating squeals of post cardiopulmonary bypass strong inflammatory response. Neither the use of heparin-coated circuits nor the administration of a high-dose regimen of steroids or aprotinin prevented or attenuated the inflammatory response in our patient. Because multiple avenues are present to elicit the post cardiopulmonary bypass inflammatory response, further research seems necessary to determine the best strategy for its prevention. 152 Feridoun Sabzi et al References 1. Boyle EM, Pohlman TH, Johnson MC, Verrier ED. Endotelial cell injury in cardiovascular surgery: the systemic inflammatory response. Ann Thorac Surg 1997;63:227-284. 2. Karp JS, Hurtig HI. locked-in state with bilateral midbrain infarcts. Arch Neurol 1974;30:176-178. 3. Zampella EJ, Duvall ER, Langford KH. Computed tomography and magnetic resonance imaging in traumatic locked-in syndrome. Neurosurgery 1988;22:591-593. 4. Thiel A, Schmidt H, Prang H, Nau R. Treatment of patients with thromboses of basilar artery and locked-in syndrome. An ethical dilemma. Nervenarzt 1997;68:653-658. 5. Acharya VZ, Talwar D, Elliott SP. Enteroviral encephalitis leading to a locked-in syndrome. J Child Neurol 2001;16:864-866. 6. Ara JR, Marzo ME, Brieva L, Uson M, Capablo JL. “Locked-in” syndrome due to hyperglycemia. Rev Neurol 1997;25:1091-1092. 7. Al-Sardar H, Grabau W. Locked-in syndrome caused by basilar artery ectasia. Age Ageing. 2002;31:481-482. 8. Blackshear JL, Oldenburg WA, Cohen MD. Making the diagnosis when the patient has ‘blue toes’. Geriatrics 1994;49:37-39. 9. Sabzi F, Teimori H. Assessment of liver function test change after open heart surgery. JMCIRI 2008;2:285-301. 10. Jerome B, Posner MD, Clifford B, Saper MD, Schiff N, Plum F. Specific causes of structural coma. In: Plum F, ed. Diagnosis of Stupor and Coma. 4th ed. New York: Oxford university press; 2007. p. 112-145. 11. Lie JT. Diagnostic histopathology of major systemic and pulmonary vasculitic syndromes. Rheum Dis Clin North Am 1990;16:269- 292. 12. Karmody AM, Powers SR, Monaco VJ, Leather RP. “Blue toe” syndrome. An indication for limb salvage surgery. Arch Surg 1976;111:1263-1268. 13. Royston D. Preventing the inflammatory response to open heart surgery: the role of aprotinin and other protease inhibitors. Int J Cardiol 1996;53:11-37. 14. Park SA, Sohn YH, Kim WC. Locked-in syndrome with bilateral peduncular infarct. J Neuroimaging 1997;7:126-128. 15. Leon-Carrion J, Van Eeckhout P, Dominguez-Morales Mdel R, Perez-Santamaria FJ. The locked- in syndrome: a syndrome looking for a therapy. Brain inj 2002;7:571-582.