Concurrence of symmetrical peripheral gangrene and venous limb gangrene following polytrauma: a case report

Abstract

BackgroundSymmetrical peripheral gangrene is characterized as acral (distal extremity) ischemic limb injury affecting two or more extremities, without large vessel obstruction, typically in a symmetrical fashion. Risk factors include hypotension, disseminated intravascular coagulation, and acute ischemic hepatitis (“shock liver”). In contrast, venous limb gangrene is characterized by acral ischemic injury occurring in a limb with deep vein thrombosis. Both symmetrical peripheral gangrene and venous limb gangrene present as acral limb ischemic necrosis despite presence of arterial pulses. The coexistence of symmetrical peripheral gangrene and venous limb gangrene is rare, with potential to provide pathophysiological insights.Case presentationA 42-year-old Chinese man presented with polytrauma (severe head injury, lung contusions, and right femur fracture). Emergency craniotomy and debridement of right thigh wound were performed on presentation. Intraoperative hypotension secondary to bleeding was complicated by transient need for vasopressors and acute liver enzyme elevation indicating shock liver. Beginning on postoperative day 5, he developed an acute platelet count fall (from 559 to 250 × 109/L over 3 days) associated with left iliofemoral deep vein thrombosis that evolved to bilateral lower limb ischemic necrosis; ultimately, the extent of limb ischemic injury was greater in the left (requiring below-knee amputation) versus the right (transmetatarsal amputation). As the presence of deep vein thrombosis is a key feature known to localize microthrombosis and hence ischemic injury in venous limb gangrene, the concurrence of unilateral lower limb deep vein thrombosis in a typical clinical setting of symmetrical peripheral gangrene (hypotension, proximate shock liver, platelet count fall consistent with disseminated intravascular coagulation) helps to explain asymmetric limb injury – manifesting as a greater degree of ischemic necrosis and extent of amputation in the limb affected by deep vein thrombosis – in a patient whose clinical picture otherwise resembled symmetrical peripheral gangrene.ConclusionsConcurrence of unilateral lower limb deep vein thrombosis in a typical clinical setting of symmetrical peripheral gangrene is a potential explanation for greater extent of acral ischemic injury in the limb affected by deep vein thrombosis.

Influence of Lower Extremity Deep Venous Thrombosis in Cerebral Infarction on Coagulation Index and Thromboelastogram and Its Risk Factors

“…Some patients with LEDVT have no obvious symptoms at the early stage, so they will not attract attention, and the onset of LEDVT is extremely rapid, and the progress is rapid [ 17 ]. Low-molecular-weight heparin can achieve a better therapeutic effect for patients with LEDVT, but if the disease is not diagnosed in time, it may lead to pulmonary embolism and venous gangrene of the lower limbs [ 18 , 19 ].…”

Ischemic limb necrosis in septic shock: What is the role of high‐dose vasopressor therapy?

“…These findings have been extended by more‐recent observations that peripheral limb ischemic necrosis in critical illness is characterized not only by circulatory shock for which vasopressor therapy would usually be administered but also by DIC and acute ischemic hepatitis (i.e., shock liver) . Moreover, there is a characteristic temporal time frame by which onset of shock liver precedes the occurrence of limb ischemic necrosis by a median of 3 days, a period that allows for occurrence of critical depletion of natural anticoagulants including protein C and antithrombin . If vasopressors actually caused critical limb ischemia, this complication logically should occur right away, not a median of 3 days later.…”

“…[29][30][31] Moreover, there is a characteristic temporal time frame by which onset of shock liver precedes the occurrence of limb ischemic necrosis by a median of 3 days, a period that allows for occurrence of critical depletion of natural anticoagulants including protein C and antithrombin. [32][33][34] If vasopressors actually caused critical limb ischemia, this complication logically should occur right away, not a median of 3 days later.…”

Distal Ischemia of the Four Limbs: A Case Report and Literature Review

“…Tan et al described a case of distal ischemia in a 42-yearold male after collision with his motorbike. 14 15 In this case, the authors analyzed the amputated regions with a light microscope observing medium-sized vessels with perivascular infiltrates, endothelium destruction, and thrombosis. No microvascular lesions were seen.…”