Symmetrical Peripheral Gangrene Research Articles

Symmetrical Peripheral Gangrene, a Serious Complication of Sepsis

Symmetrical peripheral gangrene (SPG) is a rare but devastating complication of septicemia, with a high mortality rate. About half of the patients who survive require amputation of the affected limb. The common etiologies include both infective and non-infective etiologies. Aggravating factors include asplenia, immunosuppression, and previous cold injury to extremities, diabetes mellitus, renal failure, increased sympathetic tone and use of vasopressors. [1] SPG is defined as symmetrical distal ischemic damage at two or more sites in the absence of large vessel obstruction or vasculitis, sometimes used synonymously as purpura fulminans. Disseminated intravascular coagulation (DIC) and hemorrhagic infarction of skin with uninvolved proximal arteries are hallmark of this condition [2].

A rare but formidable complication of sepsis: symmetrical peripheral gangrene

Symmetrical peripheral gangrene (SPG) is a rare clinical entity. It was first described in late 19 th century and since then has been reported with array of medical conditions mainly those complicated with shock, sepsis, and disseminated intravascular coagulation (DIC). Here in, we describe a patient with sepsis and SPG. Clinicians should be aware of this entity as early recognition can help in reducing morbidity and mortality.

Bilateral symmetrical digital gangrene of upper and lower limbs due to purpura fulminans caused by Streptococcus pyogenes: A rare entity.

Sir, We report an unusual case of 72-year-old female with acute gastroenteritis due to Streptococcus pyogenes, leading to low cardiac output state and acute kidney injury, who developed bilateral symmetrical peripheral gangrene (SPG) of upper and lower limbs [Figures ​[Figures11 and ​and2].2]. All peripheral pulses were palpable and color Doppler of upper and lower limb vessels indicated normal flow. Investigations revealed hemoglobin 10.9 g/dL, platelet count 44,000 cells/mm3, PT INR 1.72, low antithrombin-lll levels and deranged liver function. Plasma was positive for fibrin degradation products and D-dimers. She was shifted to Intensive Care Unit suspecting septic shock and resuscitated with intravenous (IV) fluids and dopamine infusion. In view of persisting hypotension and desaturation, she was intubated and mechanically ventilated. Unfractionated heparin was started to treat digital gangrene, attributing it to the pro-thrombotic state of sepsis. She developed bleeding per vaginally and orally in course of 2 days while her PT-INR rose to 2.8, platelet count decreased to 11,000 cells/mm3 and fibrinogen levels were 65 mg/dL, indicative of consumptive coagulopathy. This was treated with transfusion of six units FFP, four units each of cryoprecipitate and platelet, and bleeding was controlled within 2 days. Figure 1 Digital gangrene of both lower limbs, involving forefoot on the right side Figure 2 Digital gangrene of both upper limbs After 72 h, blood culture was positive for S. pyogenes, sensitive to ceftriaxone, amoxicillin/ampicillin and tetracycline/doxycycline, which was started immediately. The diagnosis of pupura fulminans (PF) due to S. pyogenes leading to SPG was made. Her general condition improved within 72 h with no further progression of gangrenous areas, which were well delineated in a week. She was discharged against medical advice on day 11 due to the economic constraint. Pupura fulminans is an acute life-threatening complication of disseminated intravascular coagulation (DIC) manifested by rapidly progressive cutaneous hemorrhage and necrosis leading to SPG.[1] Clinical features include tissue necrosis, intact peripheral pulse, elevated serum lactate, association with vasospastic disorders and multi-organ failure. This is attributed to the pro-thrombotic state of DIC, which leads to widespread microvascular thrombosis.[2] Common pathogens responsible for PF include Meningococci, Pneumococci, Staphylococci, Klebsiella and Enterococci.[3] S. pyogenes the causative organism in our case has not been reported till now in the literature. Awareness of this clinical condition will help in the prompt recognition, early administration of treatment to prevent the spread of gangrenous areas and avoidance of expensive investigations like angiography or unwanted surgical procedure in the critically ill patient. Aggressive resuscitation using IV fluids, vasopressor infusions, correction of acid-base and electrolyte imbalance and mechanical ventilation can stop the spread of gangrenous area along with rapid recovery. Mortality associated with SPG can be reduced by early recognition and administration of culture sensitive antibiotics. Although heparinization is associated with thrombotic (peripheral gangrene) as well as bleeding tendencies (consumptive coagulopathy), posing therapeutic dilemma, it remains the mainstay of treatment to control thrombosis.[4] Amputation of gangrenous areas is deferred till the general condition of the patient improves, and the gangrenous area is well-demarcated.[3] Protection of gangrenous extremities with antiseptic dressing, halting the spread and demarcation by topical nitroglycerine paste, phentolamine, epoprostenol or sympathetic blockade can be tried.[2] Novel modalities of treatment include plasmapheresis, papaverine, streptokinase, hyperbaric oxygen therapy, dextran-40, epsilon aminocaproic acid, ketanserin, and hirudin.[1,3,5,6,7]

Symmetrical Peripheral Gangrene Complicating Vivax Malaria

We present a case of Plasmodium vivax malaria who presented with distal lower limb gangrene. Large vessels of the lower limb were normal. After ruling out other causes, a diagnosis of symmetrical peripheral gangrene was made. The dry gangrene was treated conservatively, and amputation planned after the line of demarcation was seen.

Malaria-associated peripheral gangrene

Abstract Malaria is a common parasitic disease endemic in tropical and subtropical areas, including Mozambique. Symmetrical peripheral gangrene is a rare complication of malaria. The purpose of this study was to review cases of malaria-associated peripheral gangrene that were evaluated by the pediatric surgical service at Hospital Central. Four patients ranging in age from 11 months to 7 years with documented Plasmodium falciparum infection and peripheral gangrene were identified. Amputation was required in cases of wet-gangrene. The majority of cases were allowed to self-demarcate, and one was allowed to auto-amputate.

Poster #S217 COMPARISON OF CHARACTERISTICS OF PSYHOSIS PATIENTS WITH AND WITHOUT HOSPITALIZATION AT FIRST EPISODE

Symmetrical peripheral gangrene (SPG) is an uncommon but devastating complication in critically ill patients with a high mortality. It is seldom seen in pregnancy and postpartum period.We hereby report a 27-year-old woman diagnosed of having postpartum hemorrhagic shock. The patient developed symmetrical peripheral gangrene triggered possibly by sepsis and inotropes. The patient presented with consciousness disturbance and hemodynamically unstable condition. Owing to the unstable hemodynamic status, inotropic agents with maximum dose of dopamine at 17 mcg/kg/min and norepinephrine of 8 mcg/kg/min were used. On the 4th day of admission, the patient developed gangrene and compartmental syndrome in the limbs. However, even with the dose of inotropic agents tapered, the gangrene did not resolve. So, multiple amputations and fasciotomy were done. Patient also developed acute kidney injury with anuria, thus necessitating hemodialysis treatment.Although postpartum hemorrhagic shock is of high risk for sepsis and use of inotropes is common, occurrence of peripheral gangrene is rare. A high index of suspicion for the diagnosis and timely intervention will prevent irreparable damage and loss of limb.

Symmetrical peripheral gangrene and extremity amputations

Symmetrical peripheral gangrene (SPG) is a rare syndrome. It is characterized by bilateral distal ischemia leading to gangrene, in the absence of major vascular occlusive disease. It is considered a cutaneous marker of disseminated intravascular coagulation, and more than half of the patients who survive require amputation of the affected limb(s). The etio-pathogenesis of SPG is not well understood, but the hallmark is the occurrence of microcirculatory failure. We present two patients with SPG. The aim of this report is to sensitize and to help make the diagnosis easier for the clinician. Patients who are identified to be at risk require frequent observation and examination of the appearance of their distal extremities, nose, and ears. No treatment is universally effective. It should be individualized according to the underlying disease and patient's general condition. The guiding principle is prompt identification and reduction or removal of aggravating factors.

Plasmodium falciparum Malaria Complicated by Symmetrical Peripheral Gangrene, Bowel Ischemia, Repeated Candidemia, and Bacteraemia.

A 63-year-old Caucasian woman developed severe Plasmodium falciparum malaria when travelling back from Cameroun. No antimalarial chemoprophylaxis had been observed. The patient was immediately admitted to the intensive care unit after evidence of multiple organ failure (coma, shock, acute respiratory distress syndrome, acute renal failure, etc.). However, initial parasitemia was less than 1%. The patient was managed by intravenous quinine and norepinephrine infusion due to refractory shock. The patient developed as an early complication ischemic lesions of both arms and feet. In addition to laboratory changes consistent with disseminated intravascular coagulation, there was also evidence for a low activity of the von Willebrand factor (VWF) cleaving protease ADAMTS13. Later complications included repeated candidemia and bacteraemia despite appropriate therapy; the origin appeared to be diffuse ischemic injury of the gastrointestinal tract. The patient ultimately recovered, but quadriamputation was necessary to treat symmetrical peripheral gangrene (SPG). In severe Plasmodium falciparum malaria, ischemic changes may be due to microvascular obstruction, but, in patients with low parasitemia, other endothelial factors may also be involved as observed in other groups of thrombotic microangiopathies.

Symmetrical Peripheral Gangrene ComplicatingEscherichia coliSepsis Associated with Antiphospholipid Antibodies in Lupus Nephritis

Antiphospholipid syndrome (APS) is an autoimmune disease that involves vascular thrombosis and pregnancy morbidity associated with elevated titers of antiphospholipid antibodies. APS can affect any organ and has a variety of clinical manifestations. Infections can be associated with thrombotic events in APS, including the potentially fatal subset catastrophic APS. We report a case of extensive symmetrical peripheral gangrene complicating Escherichia coli sepsis associated with antiphospholipid antibodies in a patient with lupus nephritis. (Korean J Med 2014;87:379-382)

Sepsis-Induced Disseminated Intravascular Coagulation, Symmetrical Peripheral Gangrene, and Amputations

Sepsis-Induced Disseminated Intravascular Coagulation, Symmetrical Peripheral Gangrene, and Amputations

Limb fitting for quadruple amputees

We report our experiences of prosthetic fitting in quadruple amputees. Two patients underwent quadruple amputation after suffering from disseminated intravascular coagulation in conjunction with pneumococcemia with purpura fulminans. The first patient, a 52-year-old man, underwent bilateral transradial, left transtibial, and right transfemoral amputation, and the second patient, a 62-year-old man, underwent bilateral transradial and bilateral transfemoral amputation, both for symmetrical peripheral gangrene subsequent to septic shock. The amputations were accompanied by skin damage due to ischemic tissue changes both on the stumps and on the nose and/or lips. The combination of the intensive prosthetic rehabilitation program and supportive medical care led to completely independent functioning, including driving a car, with the use of four prosthetic limbs and a wheelchair in both cases. Early initiation of a multidisciplinary approach can properly address impairments and minimize future disability.

Symmetrical peripheral gangrene of all fingers and toes: creating a thumb by on-top plasty in a difficult situation

Symmetrical peripheral gangrene of all fingers and toes: creating a thumb by on-top plasty in a difficult situation

Symmetrical peripheral gangrene associated with peripartum cardiomyopathy

Symmetrical peripheral gangrene (SPG) is a rare clinical entity. It was first described in late 19th century and since then has been reported with array of medical conditions mainly those complicated with shock, sepsis, and disseminated intravascular coagulation (DIC). Here in, we describe a parturient with peripartum cardiomyopathy (PPCM) and SPG. Clinicians should be aware of this entity as early recognition can help in reducing morbidity and mortality.

Negative pressure wound therapy incorporating early exercise therapy in hand surgery: bag-type negative pressure wound therapy.

In the postoperative treatment of hand surgery, it is important to start exercise therapy as early as possible. In conventional negative pressure wound therapy, the fingers are immobilized by the film dressing covering the wound and hand, thereby preventing sufficient rehabilitation. Here, we devised a bag-type negative pressure wound therapy that makes it possible to start finger exercises almost immediately, and we applied it to 4 patients:one each with hand burns, symmetrical peripheral gangrene, a crush injury accompanied by extensive skin defects and a fingertip degloving injury. The duration of the bag-type negative pressure wound therapy ranged from three to eight weeks, and good granulation was achieved, so that a skin graft was not required. In addition, particularly in the case of the fingertip degloving injury, good nail regeneration was achieved. Except for the case of symmetrical peripheral gangrene, a good range of joint motion with a percent total active motion (%TAM) of 94.7% or more was achieved. Our therapy was performed by inserting the hand into a sealing bag;sufficient exercise therapy was made possible by expanding the bag during rehabilitation.

Peripheral gangrene in Plasmodium vivax malaria: a rare manifestation

Symmetrical peripheral gangrene (SPG) is an extremely rare complication of malaria that has been well described in multiple case reports of Plasmodium falciparum and mixed infection. We present a case of malaria with isolated Pl. vivax infection complicated by SPG. This index case is the first reported case of peripheral gangrene involving bilateral hands and feet in Pl. vivax infection in an adult.

Symmetrical peripheral gangrene and the use of systemic hyperbaric oxygen therapy

Symmetrical peripheral gangrene (SPG) is a rare but devastating condition when two or more distal sites become gangrenous, as the result of severe illness and treatment in critical care. The striking factor in SPG is that there is no occlusion of the major blood vessels to the affected limbs; the pathogenesis of the condition is not well understood and there are high reported mortality and amputation rates. Here we report the chronological progress report of a case of SPG, which affected both forefeet. This case report supports the view that early amputation should be avoided allowing for stabilisation of the gangrene so that no viable tissue is sacrificed. Further research is necessary to establish the pathogenesis and suitable treatment pathways.

Symmetrical Peripheral Gangrene—A Case Report and Brief Review

A 30year-old gentleman presented to casualty with history of pain abdomen for six days, fever and decreased urine output since two days. He was in a state of septic shock and was diagnosed to have intestinal perforation. His peripheral pulses were not palpable except for the femoral and brachial vessels. Despite fluid resuscitation, he needed infusion of high doses of dopamine and noradrenaline to maintain his blood pressure. He was operated for repair of perforation. On the first postoperative day, in the intensive care unit, vasopressin infusion was added in view of persistent hypotension. Appropriate fluid resuscitation and antibiotic therapy helped to wean him off inotropes and vasopressors by the second postoperative day. On the 3rd postoperative day, however, the patient developed discolouration and blebs on the fingers of left hand, followed by the right hand and then both the lower limbs. Subsequently, over a period of 10days, this progressed to gangrene formation in the hands despite the patient being haemodynamically stable without any inotropes or vasopressors in this period. We conclude that the septic shock is a systemic derangement affecting all organ systems including coagulation and microcirculation. Early recognition and prompt management of sepsis, optimisation of fluid status to wean off the inotropes and vasopressors at the earliest is necessary to avoid catastrophes such as symmetrical peripheral gangrene.

Symmetrical Peripheral Gangrene in Four Pediatric Cardiac Surgery Patients Receiving Extracorporeal Membrane Oxygenation

Symmetrical peripheral gangrene (multilimb ischemia without large artery occlusion) is a rare condition usually associated with disseminated intravascular coagulation, hemodynamic compromise, and/or sepsis. However, it has not been described in patients on extracorporal membrane oxygenation (ECMO). Over a 5 year period, four pediatric patients developed symmetrical peripheral gangrene on ECMO after cardiac surgery. They subsequently died and came to autopsy. History, physical examination, and laboratory studies were examined. Gross and microscopic autopsy material was reviewed. Patients were 11 days to 13 years old. Extracorporal membrane oxygenation duration was 11-22 days, and limb ischemia began 2-4 days before death. Three patients had rapid onset, with ischemia developing in <48 hours. In the fourth, ischemic changes began as focal lesions and gradually spread. Two patients were septic. Three had evidence of other end-organ damage. Pressors were used in 3 patients before the limb ischemia. Autopsies disclosed ischemic changes involving all limbs, with confluent ecchymoses. In a detailed examination in 1 case, large arteries of the extremities were patent. Involved skin and soft tissue showed bland fibrin thrombi in the microcirculation, with tissue necrosis and hemorrhage. This report describes the first 4 cases of symmetrical peripheral gangrene complicating ECMO. The 4 pediatric patients all had recent surgery for congenital cardiac disease, and all had significant exposure to ECMO prior to developing limb ischemia. Symmetrical peripheral gangrene is an unusual complication of ECMO that may arise in the setting of disseminated intravascular coagulation, sepsis, or other hemostatic and/or hemodynamic imbalance.

HIV status should also be documented in patients with tuberculosis-associated symmetrical peripheral gangrene

Sir, A major difference between the reporting of tuberculosis-associated ‘simultaneous quadrilateral gangrene’ in the era antedating awareness of the association of tuberculosis and human immune deficiency virus (HIV) infection,1 and the reporting of …

Symmetrical Peripheral Gangrene in an Octagenerian Asian male with Multiple Morbidities: A Case Report

Introduction: Symmetrical peripheral gangrene (SPG, or peripheral symmetrical gangrene, PSG) is defined as acute onset of symmetrical ischemic gangrene over multiple sites of acral area, mostly extremities and sometimes nose, ear or scalp, without vascular occlusion or vasculitis. The pathogenesis is still unknown but related to local ischemia due to disseminated intravascular coagulation, infection, or medications. Case presentation: A 87 year-old Asian man was admitted to the intensive care unit under the impression of septic shock. Vasopressors were administered due to hypotension. However, bilateral cyanosis over limbs was noted gradually few days after the medications given. Dry gangrene over distal limbs developed even after we stopped the medication as early as possible. Discussion: Symmetrical peripheral gangrene may be an indicator for disseminated intravascular coagulation and poor prognosis. Quick reversal of underlying disease and elimination of precipitating factors are both significant managements once symmetrical peripheral gangrene is diagnosed.