Symmetrical Peripheral Gangrene Associated with Low Output Cardiac Failure

Abstract

Symmetrical peripheral gangrene (SPG) is a rare entity characterized by ischemic changes of the distal extremities with maintained vascular integrity. We present the case of a 64-year-old man with bilateral necrotic toes and deranged liver function tests. This was thought to be related to severely depressed ejection fraction from non-ischemic etiology, presumably chronic alcohol ingestion. We hope that awareness of SPG and association with a low output state will aid in early detection and prevention.

Idiopathic Symmetrical Peripheral Gangrene: A Rare Clinical Entity

“…In most cases, it is a result of DIC causing thrombotic occlusion of capillaries and downstream hypoperfusion. The etiology is diverse and includes sepsis, heart failure, shock, malignancies, hypercoagulable conditions (commonly protein C and S deficiency), myeloproliferative neoplasms which lead to hyperviscosity of the blood, various autoimmune conditions including systemic lupus erythematosus, antiphospholipid antibody syndrome, and cryoglobulinemia [4,5].…”

Symmetrical and Peripheral Gangrene Complicating a Third-Degree Atrioventricular Block: A New Presentation of a Known Disease

“…This condition may result from acute bacteremia or vasopressor drug use, which results in the occlusion of microcirculation of the affected part. Many cardiac conditions were associated with SPG such as myocardial infarction [7][8][9][10], ventricular pseudoaneurysm [11], pulmonary embolism [12], paroxysmal ventricular tachycardia [13], post-cardiac surgery [14][15], severe heart failure [3], and postpartum cardiomyopathy ( Table 1) [16]. It may be also encountered in some chronic conditions such as essential thrombocythemia, polycythemia rubra vera, Raynaud's syndrome, diabetes, small vessel obstruction, and disseminated intravascular coagulation (DIC) [7].…”

“…A low-flow state can lead to ischemic changes. Aggravating factors include the use of vasoconstrictor drugs [2][3], diabetes mellitus, and renal failure [2].…”

“…It was first illustrated by Hutchinson in 1891 [1]. It is defined by a sudden onset of symmetrical ischemia of two or more extremities, leading to gangrene in the absence of large vessel obstruction or vasculitis, increasing the risk of limb amputation and affecting the quality of life [2][3]. The etiology is multifactorial.…”