Symmetrical Peripheral Gangrene—A Case Report and Brief Review

Abstract

A 30 year-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 10 days, 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.Keywords Symmetrical peripheral gangrene . Sepsis . Vasopressors . Multiple arterial punctures . Resuscitation. Case ReportA 30-year-old man, an agriculturist by occupation, presented to the casualty ward with abdominal pain for 6 days and fever and reduced urine output for 2 days. He was in a state of intense septic shock with absent peripheral pulsations, and the pulse oximeter could not pick up pulsations. Despite fluid resuscitation, he needed high doses of dopamine (20 μg/kg/min) and noradrenaline (0.2-0.3 μg/kg/ min) to maintain normotension. The patient was also found to have altered coagulation parameters which were corrected with fresh frozen plasma. An emergency laparotomy revealed jejunal perforation which was closed. The patient was found to have cirrhotic liver (he was a known chronic alcoholic). Blood pressure remained persistently low, requiring addition of vasopressin infusion in the postoperative period. After multiple failed attempts at cannulation of the radial arteries in both upper limbs, a femoral arterial line was secured in the intensive care unit. By the second postoperative day, all the vasopressors were weaned off. However, cyanosis of the extremities was noted. On the third postoperative day, small blebs/blisters were noticed first in the left hand and subsequently in other limbs also which progressed to gangrene formation over the next 1 week (Figs. 1, 2, 3). Doppler evaluation revealed presence of diminished pulsations in all the vessels supplying the limbs. Echocardiogram revealed absence of any septic foci. While we were waiting for a clear demarca...

A rare case of symmetrical four limb gangrene following emergency neurosurgery

“…However, prevention is still the best line of management. In addition, caution is necessary when performing arterial punctures, as this may worsen the micro-thrombosis process [9] .…”

Three consecutive cases of dry gangrene in winter

“…La causa de la gangrena del caso 2, una mujer en edad fértil, parece poco probable que esté causada por arteriopatía periférica porque no tiene varios factores de riesgo cardiovascular excepto la hipertensión arterial. Además, presentaba buenos pulsos periféricos (6). El único dato positivo en sus estudios complementarios fue la hipocomplementemia, pero no se detectó la patología subyacente a la misma pues se descartaron las enfermedades autoinmunes y neoplasias (11,12).…”

“…La capacidad del cuerpo humano para adaptarse al frío es mínima. El efecto del frío como factor adyuvante de la gangrena seca fue descrito por diversos autores (2,6,14). Temperaturas menores a 15 °C generan una vasoconstricción prolongada, que a su vez puede causar una lesión directa al endotelio y trombosis de la microcirculación afectando la irrigación de las células nerviosas, adipocitos y miocitos.…”

“…Los pulsos arteriales son palpables en los miembros afectados. Puede acompañarse de petequias, equimosis, hematomas y ampollas hemorragíparas, según la enfermedad predisponente (5,6).…”

February 2017 critical care case of the month

“…Group B Streptococcus has been shown to present with a toxic shock like syndrome (TSLS) from pyrogenic toxin(s) (2)(3)(4). The goal in therapy is to treat the underlying disease but preservation of the extremity is pivotal.…”