Symmetrical Peripheral Gangrene Research Articles

Rehabilitation of a quadruple amputee with leukemia: A challenging endeavor

Making a person with quadruple amputation walk again is a challenging task for the rehabilitation team. Quadruple amputation secondary to symmetrical peripheral gangrene is a rare clinical scenario posing challenges in rehabilitation. Literature regarding rehabilitation of persons with multiple amputations is limited. This case describes the rehabilitation of a 57-year-old lady suffering from acute myeloid leukaemia who underwent quadruple amputation. She had undergone bilateral transtibial and bilateral transradial amputation after vasopressor-induced symmetrical peripheral gangrene. In view of expected guarded level of functional independence, ambulatory independence was the primary goal at admission to Department of PMR. The various steps taken in rehabilitation and modifications made to assistive devices are described in this article. Challenges faced during various phases of training, and subsequent ambulation are detailed in this article. Overcoming limitations, the client was made to be an indoor ambulator with appropriate prostheses and mobility aids. She was partially independent for activities of daily life after in-patient rehabilitation. The background of leukaemia and subsequent chemotherapy also affected the rehabilitation of this patient. Although various studies have described cases of quadruple amputation rehabilitation achieving functional independence and ambulation, the absence of specific guidelines and protocols make rehabilitation of persons with multiple amputations inefficient. This case study also shows the need for personalized goal setting for persons with multiple amputations. Realistic goal setting, psychological counselling, and an interdisciplinary approach are imperative in rehabilitation of persons with quadruple amputation. Flexible functional scales specific to persons with multiple amputations are necessary to evaluate such persons objectively. Studies with larger sample size, longer follow-ups, and comprehensive review of existing literature are needed to standardize rehabilitation of quadruple amputation and evaluate the various factors that may affect rehabilitation outcome.

Symmetrical peripheral gangrene caused by urosepsis: Case reports and literature review.

Symmetrical peripheral gangrene (SPG) is a serious and rare complication in patients with urosepsis, characterized by distal limb symmetry impairment. In this study, 3 cases of SPG caused by urosepsis were reported, and the Chinese and English literature on SPG caused by urosepsis was reviewed. The demographic, clinicopathological, treatment, and follow-up data of the patients were summarized and analyzed. SPG was diagnosed with clinical symptoms. We conducted urological invasive surgery, administered anti-infective therapy, implemented fluid resuscitation and blood product transfusion, provided mechanical ventilation support, optimized myocardial contractility, administered heparin and B vitamins, utilized papaverine for vasodilation, performed hemodialysis and plasma exchange, peripheral skin warming along with other treatment modalities. Two patients died and 1 patient underwent autoamputation. Our cases and literature review demonstrate that timely and accurate diagnosis, effective infection control, correction of hypoperfusion, organ function support, early management of disseminated intravascular coagulation, avoidance of premature amputation, and multidisciplinary comprehensive treatment are crucial for the successful treatment of SPG caused by urosepsis.

Symmetric Peripheral Gangrene Secondary to Sepsis

Symmetrical peripheral gangrene (SPG) is described as rapid onset of peripheral and symmetrical gangrene in the lack of large vessel occlusive disease with high mortality rate.1 Hereby reporting an event of Upper limb symmetrical gangrene caused by septic shock in MODS, Acute myocarditis and was managed by inotropes. The case shows Symmetrical peripheral gangrene as a complication of sepsis owing to systematic imbalance that disturbs the organ dysfunction mainly coagulation and microcirculation. Primary recognition and quick management of sepsis and weaning off the inotropes at the initial opportunity are essential to evade Symmetrical peripheral gangrene. Keywords Symmetric peripheral gangrene, MODS, Sepsis, Myocarditis, Inotropes

Limb Ischemic Necrosis Secondary to Microvascular Thrombosis: A Brief Historical Review.

Ischemic limb injury can be broadly classified into arterial (absent pulses) and venous/microvascular (detectable pulses); the latter can be divided into two overlapping disorders-venous limb gangrene (VLG) and symmetrical peripheral gangrene (SPG). Both VLG and SPG feature predominant acral (distal) extremity ischemic necrosis, although in some instances, concomitant nonacral ischemia/skin necrosis occurs. Historically, for coagulopathic disorders with prominent nonacral ischemic necrosis, clinician-scientists implicated depletion of natural anticoagulants, especially involving the protein C (PC) system. This historical review traces the recognition of natural anticoagulant depletion as a key feature of nonacral ischemic syndromes, such as classic warfarin-induced skin necrosis, neonatal purpura fulminans (PF), and meningococcemia-associated PF. However, only after several decades was it recognized that natural anticoagulant depletion is also a key feature of predominantly acral ischemic microthrombosis syndromes-VLG and SPG-even when accompanying nonacral thrombosis is not present. These acquired acral limb ischemic syndromes typically involve the triad of (a) disseminated intravascular coagulation, (b) natural anticoagulant depletion, and (c) a localizing explanation for microthrombosis occurring in one or more limbs, either deep vein thrombosis (helping to explain VLG) or circulatory shock (helping to explain SPG). In most cases of VLG or SPG there are one or more events that exacerbate natural anticoagulant depletion, such as warfarin therapy (e.g., warfarin-associated VLG complicating heparin-induced thrombocytopenia or cancer hypercoagulability) or acute ischemic hepatitis ("shock liver") as a proximate factor predisposing to severe depletion of hepatically synthesized natural anticoagulants (PC, antithrombin) in the setting of circulatory shock.

Relationship Between Symmetrical Peripheral Gangrene Patients and Using Vasopressors in the Intensive Care Unit.

Symmetrical peripheral gangrene (SPG) is a rare yet severe condition characterized by peripheral ischemic lesions without significant vascular occlusion. Its clinical presentation includes peripheral cyanosis, mottling, and symmetrical ischemia of distal limbs, often progressing to gangrene. Recent years have seen a rise in SPG cases, with mortality rates ranging from 40% to 90%. The condition is associated with systemic diseases, such as sepsis, vasculitis, and coagulopathy. DIC frequently complicates SPG, reflecting a disturbed procoagulant-anticoagulant balance and depletion of natural anticoagulants. While vasopressor therapy, particularly high-dose administration, has been implicated in SPG pathogenesis due to sustained vasoconstriction or idiosyncratic responses, recent evidence suggests it may not be the underlying cause. Studies indicate a low incidence of ischemic limb necrosis associated with high-dose vasopressors, with DIC and shock liver potentially explaining limb ischemia instead. The characteristic temporal interval between the onset of shock liver and limb ischemic necrosis suggests a more complex pathophysiology. The role of infectious agents, such as bacteria and viruses, in SPG pathogenesis is under investigation, with both direct vascular invasion and immune-mediated mechanisms proposed. Diagnosis involves ruling out other causes of acral gangrene through clinical examination, laboratory tests, imaging studies, and biopsy. Treatment strategies aim to halt disease progression, eliminate causative factors, and prevent complications. While anticoagulants, vasodilators, and adjunctive therapies like hyperbaric oxygen show promise, the efficacy of interventions varies, emphasizing the need for individualized management. Notably, hemoadsorption has emerged as a promising treatment, demonstrating significant improvement in SPG cases. Amputation remains a lastresort option in irreversible cases. Early recognition and multidisciplinary management are crucial for improving outcomes. Further research is needed to better understand SPG's etiology and develop effective treatments through collaborative efforts.

Delayed Diagnosis of Vasopressor-induced Symmetrical Peripheral Gangrene in Septic Shock Patient

Vasopressors are powerful vasoconstrictors used in critically ill patients to raise blood pressure after volume resuscitation attempts fail. These medications, while lifesaving, carry the risk of severe and under-reported side effects, digital ischemia, and gangrene due to decreased digital perfusion. We here present a case of vasopressin-induced digital gangrene in a female patient who underwent elective surgery for nephrolithiasis without any pre-existing peripheral vascular disease or smoking. The patient developed bilateral upper and lower limb symmetrical acronecrosis. The causality assessment as per the World Health Organisation – Uppsala Monitoring Centre scale was suggestive of a “Possible adverse” event. The patient denied surgical intervention, eventually developed multiorgan failure, and died of cardiopulmonary arrest. Although lifesaving, vasopressors due to alpha constricting activity can cause severe limb ischemia with dreadful consequences. These drugs should be used judiciously with careful monitoring and tapering as soon as possible when the condition improves. The consequences could be dreadful if timely surgical intervention and measures are not taken.

Symmetrical peripheral gangrene: A rare case with unpredictable presentation and tragic outcome

Symmetrical peripheral gangrene (SPG) is a rare condition characterized by acute ischemic damage in multiple extremities without any obstruction or vasculitis in the supplying vessels. It commonly affects the toes, hands, scrotum, and earlobes, increasing the risk of limb amputation and significantly impacting the patient’s quality of life. The underlying vascular injury mechanism is disseminated intravascular coagulation, and SPG can manifest unpredictably in conditions associated with septic shock, low output states, vasospastic conditions, myeloproliferative disorders, or hyper viscosity syndrome. In this case study, a 19-year-old woman presented with bluish-black blisters on her feet and legs, accompanied by pain. The blisters gradually increased in size and burst, resulting in a watery discharge tinged with blood. Despite various investigations and treatments involving multiple departments, the patient ultimately succumbed to septic shock and passed away on June 13, 2023, as confirmed by a house officer and a senior resident.

A career in solving clinical-pathological conundrums: Heyde syndrome, anti-platelet factor 4 disorders, and microvascular limb ischemic necrosis.

Hematology is a clinical specialty with strong roots in the laboratory; accordingly, the lab can help solve perplexing clinical problems. This review highlights clinical-pathological conundrums addressed during my 35-year hematology career at McMaster University. Heyde syndrome is the association between aortic stenosis and bleeding gastrointestinal (GI) angiodysplasia where the bleeding is usually cured by aortic valve replacement; the chance reading of a neonatal study showing reversible deficiency of high-molecular-weight (HMW) multimers of von Willebrand factor (vWF) following surgical correction of congenital heart disease provided the key insight that a subtle deficiency of HMW multimers of vWF explains Heyde syndrome. The unusual immunobiology of heparin-induced thrombocytopenia (HIT)-a highly prothrombotic, antibody-mediated, anti-platelet factor 4 (PF4) disorder featuring rapid appearance and then disappearance (seroreversion) of the pathological heparin-dependent platelet-activating antibodies-permitted identification of key clinical features that informed development of a scoring system (4Ts) to aid in HIT diagnosis. Atypical clinical presentations of HIT prompted identification of heparin-independent anti-PF4 antibodies, now recognized as the explanation for vaccine-induced immune thrombotic thrombocytopenia (VITT), as well as VITT-like disorders triggered by adenovirus infection. Another unusual feature of HIT is its strong association with limb ischemia, including limb necrosis secondary to deep-vein/microvascular thrombosis (venous limb gangrene). The remarkable observation that supratherapeutic warfarin anticoagulation predisposes to HIT- and cancer-associated venous limb gangrene provided insight into disturbed procoagulant/anticoagulant balance; these concepts are relevant to microvascular thrombosis in critical illness (symmetrical peripheral gangrene), including a pathophysiological role for proximate "shock liver" (impaired hepatic synthesis of natural anticoagulants).

Identification of risk factors and clinical outcomes for symmetric peripheral gangrene: A new scoring system using a common data model database.

Background: Symmetrical peripheral gangrene (SPG) is a destructive clinical condition where amputation is often the final treatment option. We aimed to identify the predictors of SPG using the common data model (CDM) and propose a new scoring system for predicting hospitalized patients at risk of developing SPG. Methods: A cohort of patients treated with intravenous noradrenaline, epinephrine, and vasopressin between 2011 and 2020 was retrospectively analyzed using the CDM database. The main outcome was amputation performed as a resuscitation measure. We investigated risk factors including demographic characteristics, comorbidities, and preoperative laboratory values. Based on demographic variables such as age and sex, a 1:10 propensity score matching (PSM) was performed. The odds ratio (OR) was calculated using logistic regression analysis. Results: Amputation was performed in 308 (0.4%) patients out of a cohort of 73,902 patients. Age, sex, hypertension, diabetes mellitus (DM), renal disease (RD), heart failure, anemia, hypercholesterolemia, peripheral vascular disease (PVD), and laboratory markers such as albumin, eosinophils, hematocrit, lymphocytes, monocytes, neutrophils, ESR, aPTT, creatinine, and BUN were statistically significant. Logistic regression analysis revealed statistically significant differences in DM (OR 5.51), RD (OR 2.90), PVD (OR 9.67), and cerebrovascular disease (CVD) (OR 0.49). Compared to the group without amputation, logistic regression analysis after matching the age and sex group with 1:10 PSM showed statistically significant results in DM (OR 3.59), RD (OR 2.59), PVD (OR 7.76), and CVD (OR 0.40). Conclusion: Early recognition of high-risk patients may help medical providers prevent severe outcomes, including amputation surgery.

A Rare Case of Symmetrical Peripheral Gangrene in Central Venoarterial Extracorporeal Membrane Oxygenator in a Pediatric Patient, an Unusual Complication of Extracorporeal Membrane Oxygenation

Symmetrical peripheral gangrene is an unusual complication of extracorporeal membrane oxygenation (ECMO) which can arise due to low cardiac output state, high inotropic support, inadequate anticoagulation, disseminated intravascular coagulation, and sepsis. In symmetrical peripheral gangrene, there is no evidence of large vessel occlusion or vasculitis. It can be due to the absence of pulsatile flow in the peripheral arteries that result in stasis and microthrombi formation which causes occlusion of small arterioles. A 10-month-old male child who underwent anomalous left coronary artery from pulmonary artery repair and required central venoarterial ECMO support post-surgery due to severe myocardial dysfunction developed symmetrical peripheral ischemia with gangrenous changes in the right-hand fingers while on extracorporeal membrane oxygenation (ECMO). The limb ischemic changes improved to normal after the child convalesced from heart failure. We describe these changes and the management here.

Symmetrical Peripheral Gangrene resulting from application of henna: a rare clinical occurrence

Symmetrical Peripheral Gangrene (SPG) is a rare clinical syndrome characterized by bilateral symmetric distal limb ischemia leading to gangrene with no evidence of major vascular occlusive disease. The peripheral pulses are usually palpable as a result of the sparing of larger vessels. The mechanism of vascular occlusion is poorly understood. Disseminated intravascular coagulation has been implicated as the final common pathway in its pathogenesis. Initial management is resuscitation followed by amputation when the gangrene becomes demarcated. We report a rare case of symmetrical peripheral gangrene of both hands and feet in a 28-year-old female who presented with pain and darkening of all her fingers and toes for 2 days following the application of henna, with no medical history of the known predisposing conditions. She had amputation of the digits of her hands and tarsometatarsal amputation of her feet bilaterally. She had an uneventful postoperative period and was discharged to see the outpatient department. While reported cases of SPG due to numerous etiologies can be found in the literature, this is to our findings the first time we are seeing it resulting from the cosmetic use of henna. The intriguing case presented here was brought about by the application of henna used as a cosmetic agent and was characterized by a very rapid clinical course with no other apparent predisposing etiology.

Symmetrical peripheral gangrene: potential mechanisms and therapeutic approaches in severe COVID-19

Symmetrical peripheral gangrene is a rare condition that is characterized by ischemic damage and tissue death (gangrene) in the extremities. Recent reports have shed light on SPG in patients with severe COVID-19. This condition presents with symmetrical cyanosis of the extremities and common COVID-19 symptoms and what the most frightening is within a few days, cutaneous necrosis occurred and patients died. Skin biopsy results have shown the presence of microthrombi in small vessels. The formation of SPG in COVID-19 patients results from immunothrombosis, endothelial dysfunction, and procoagulant platelets, leading to a hypercoagulation state and microvascular thrombosis. Thrombotic microangiopathy, shock, disseminated intravascular coagulation, and anticoagulant depletion promote the development of SPG in COVID-19. At the early stage, SPG patients with COVID-19 exhibit similar clinical manifestations. TMA causes early damage to microvasculature in SPG, and the shock state further exacerbates the ischemic injury due to local hypo-perfusion. The disturbed procoagulant-anticoagulant balance caused by DIC and anticoagulant depletion, combined with the pre-ischemic state brought on by TMA and shock, leads to the rapid formation of extensive microthrombi in the late stage of COVID-19 associated SPG. This review will delve into the clinical features, possible mechanisms, and potential therapeutic managements for COVID-19 associated SPG.

Should inotropes be depended on as the only savior in haemodynamic crisis? a case study of symmetrical peripheral gangrene of limb extremities in a patient with traumatic brain injury

Should inotropes be depended on as the only savior in haemodynamic crisis? a case study of symmetrical peripheral gangrene of limb extremities in a patient with traumatic brain injury

Symmetrical peripheral gangrene in a patient with septic shock and a multi-drug resistant <i>Klebsiella pneumoniae</i> infection

Symmetrical peripheral gangrene (SPG) can sometimes occur without definite disseminated intravascular coagulation. The differential diagnosis comprises the exclusion of many non-infectious diseases and the effort to isolate the microbic agent in the case of septic shock. Between bacterial causes, Klebsiella pneumoniae is one of the bacteria that can trigger SPG through hypervirulence and hypercoagulopathy mechanisms. We report a case of SPG associated with septic shock and a multi-drug resistant K. pneumoniae infection.

Symmetrical peripheral gangrene in an atypical case of Plasmodium falciparum malaria with HIV coinfection

Malaria is a vector-borne tropical disease well known for causing a multitude of complications. One such rare but familiar complication is symmetrical peripheral gangrene (SPG). SPG is a distinct entity resulting from a horde of infectious and non-infectious illnesses. We report the case of a 32-year-old male infected with Plasmodium falciparum malaria and Human Immunodeficiency Virus who presented to us with renal failure and developed SPG of both feet 3 days into admission.

Catecholamine-Refractory Anaphylactic Shock to Vecuronium in a Patient with Tetralogy of Fallot: A Case Report

Serious anaphylactic reactions to anesthetics can be life-threatening events. Vecuronium is promoted as a neuromuscular blocking drug that is least likely to cause anaphylaxis due to its low histamine-releasing potential. Perioperative hypoxemia in patients with tetralogy of Fallot (TOF) due to anaphylactic reactions can be easily misdiagnosed as anoxic spells. We report a patient with TOF who suffered from symmetrical peripheral gangrene after undergoing catecholamine-refractory anaphylactic shock to vecuronium perioperatively. CPB (cardiopulmonary bypass) is the most effective support for severe anaphylactic shock during the perioperative period. Intradermal test screening for anaphylaxis to anesthetics is an effective method for prevention and diagnosis.

Symmetrical Peripheral Gangrene Resulting from the Application of Henna: A Rare Clinical Occurrence

Symmetrical Peripheral Gangrene Resulting from the Application of Henna: A Rare Clinical Occurrence

Association of non-fatal symmetrical peripheral gangrene and COVID-19.

Association of non-fatal symmetrical peripheral gangrene and COVID-19.

Symmetrical Fingertip Gangrene in a Factory Worker Exposed to Paint Thinner

Symmetrical peripheral gangrene involving the fingertips is a frequent manifestation of atherosclerotic or embolic thrombi. It may indicate an underlying systemic vasculitis or suggest an environmental exposure to freezing temperatures. We present a case of a factory worker who inadvertently got exposed to paint thinner at workplace, leading to gangrenous changes in his exposed fingertips. The clinical examination and investigations could not reveal any inflammatory or hypercoagulable state, and arterial vasospasm was found to be the most possible reason attributable to this event. The patient was managed with antiplatelet drugs and arterial vasodilators. In a case of bilateral symmetrical finger gangrene, physicians must systematically search for a professional or occupational as a putative factor.

Ischemia of lower limbs in the activity of a general practitioner — family physician: from widely spread to rare disorders (literature review with some results of the own clinical observations)

The most common cause of ischemic disorders of the lower limbs is peripheral artery disease of atherosclerotic origin, the prevalence of which is constantly increasing. In Europe, ischemic heart disease is responsible for 20 % of men’s death and 22 % of women’s death, stroke is the cause of death in 10 % of men and 15 % of women. At the same time, other cardiovascular diseases, including peripheral artery disease, are the cause of 12 % of men’s death and 15 % of women’s death. Primary care physicians very often don’t have necessary awareness about diseases of peripheral arteries of the lower limbs in contrast to atherosclerotic lesions of coronary and cerebral vessels. Late diagnosis and lack of proper treatment result in severe complications, disability and death of such patients. The article contains literature data and current recommendations about diagnosis and treatment of the ischemic lesions of the lower limbs, namely intermittent claudication, chronic ischemia of the lower limbs with a risk of limb loss and acute ischemia of the lower limbs, which are necessary in the activity of a general practitioner — family physician. In the clinical practice, there are also cases of ischemic lesions of the limbs due to unusual and rare causes. The article contains literature data and own observations of such rare disorder, namely symmetrical peripheral gangrene.