Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 6  |  Page : 162-164

Four limb gangrene - A rare presentation


1 Department of General Surgery, Gadag Institute of Medical Sciences, Gadag, Karnataka, India
2 Department of Forensic Medicine and Toxicology, ESIC Medical College and PGIMSR, Bengaluru, Karnataka, India

Date of Submission29-Jan-2021
Date of Acceptance06-Jun-2021
Date of Web Publication20-Jan-2022

Correspondence Address:
V Vijayanath
Department of Forensic Medicine and Toxicology, ESIC Medical College and PGIMSR, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_18_21

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  Abstract 


We report a case of a 73-year-old male, who presented with acute gangrene of the left thumb which then progressed to symmetrical peripheral gangrene of digits of all four limbs, with no comorbid diseases. On investigation, there was high D-dimer, normal lipid profile, and two-dimensional Echo. Computed tomography and magnetic resonance angiogram of all limbs revealed atherosclerotic changes. The patient underwent disarticulation of digits under the wrist block. Symmetrical peripheral gangrene, seen in a wide variety of medical conditions presents as symmetrical gangrene of two or more extremities without large vessel obstruction or vasculitis. The fingers and toes (rarely nose, ear lobes, or genitalia) are affected. It may manifest unpredictably in conditions associated with sepsis, diabetes mellitus, low-output states, vasospastic conditions, myeloproliferative disorders, or hyperviscosity syndrome. It carries a high mortality rate with a very high frequency of multiple limb amputations in survivors.

Keywords: Ischemic, pathology, vascular


How to cite this article:
Niveda B R, Karegoudar JS, Vijayanath V. Four limb gangrene - A rare presentation. Indian J Vasc Endovasc Surg 2021;8, Suppl S2:162-4

How to cite this URL:
Niveda B R, Karegoudar JS, Vijayanath V. Four limb gangrene - A rare presentation. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2022 Jul 4];8, Suppl S2:162-4. Available from: https://www.indjvascsurg.org/text.asp?2021/8/6/162/336016




  Introduction Top


Symmetrical peripheral gangrene is defined as distal ischemic damage in two or more extremities, without large vessel obstruction or vasculitis. It is associated with various underlying medical conditions and is a rare but significant complication of septicemia, with up to 40% mortality. The aggravating factors include asplenia, immunosuppression, previous cold injury to extremities, diabetes mellitus, renal failure, increased sympathetic tone, and the use of vasopressors.[1]

Symmetrical peripheral gangrene is a rare, debilitating disease that deserves more widespread concern. About 18%–40% mortality rate was reported, and survivors had a high frequency of multiple limb amputations. Up to 85% of patients with superficial peripheral gangrene have associated disseminated intravascular coagulation. The main theory of pathogenesis, to date, is micro thrombosis associated with disturbed procoagulant-anticoagulant imbalance.[2]

Symmetrical peripheral gangrene in children is rare and the etiology may be unknown or vascular or related to Henoch-Schonlein purpura or sepsis.[3]

We report a rare case of peripheral vascular disease with gangrenous changes in all four limbs with no associated comorbid conditions which are having a rapid course of about 1 month.


  Presentation of the Case Top


A 73-year-old male patient presented with pain and blackish discoloration of the left thumb, which later extended to the rest of the fingers, and simultaneously in the opposite hand and both the lower limbs which is restricted only to the digits. The patient is not having any predisposing factors to developing gangrene. The predisposing conditions such as diabetes mellitus, vasculitis, and renal failure were ruled out with concerning investigations [Figure 1].
Figure 1: Preoperative photos

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The patient was anemic, with a high D-Dimer (798 mg/dl) value, and varied lipid profile, two dimensional Echo was normal.

Computed tomography angiography of both upper limbs shows near-total stenosis of radial and ulnar arteries due to atherosclerosis. Magnetic resonance angiography of both lower limbs shows occlusion of anterior and posterior tibial arteries.

The patient was started on prophylactic antibiotics, aspirin, cilostazol and was advised limb care. The patient under general anesthesia underwent disarticulation of digits once the line of demarcation was formed [Figure 2].
Figure 2: Postoperative photos

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  Discussion Top


Gangrene is a clinical condition presenting with necrotic tissue, often circumferential around a digit or extremity. Dry gangrene is most commonly secondary to atherosclerosis and progressive occlusion of peripheral arterial blood supply.[4]

A wide array of infective and noninfective etiological factors having linked with the development of symmetrical peripheral gangrene. The exact mechanism is uncertain. A low flow state along with disseminated intravascular coagulation is usually present.[4],[5]

Symmetrical peripheral gangrene due to diabetes mellitus, purpura fulminans, sepsis, following neurosurgery procedure, autoimmune diseases, are known but secondary atherosclerosis is not documented. The involvement of one limb due to atherosclerosis is documented but not all four limbs.[6] The dry gangrene of the lower limb is known but not upper limb due to atherosclerosis as per literature, but in our case, the involvement of upper limbs first followed by lower limbs which is very unusual.

Superficial peripheral gangrene can be suspected as the first sign of extreme coldness, pallor, cyanosis, or pallor in the extremity which progresses in a short time to acrocyanosis and if not reversed to frank gangrene. The ischemic changes will begin distally and will involve the entire extremity. In our patient, he had gangrene of both the upper limbs at presentation, the lower limb gangrene was set in within 48 h.[7]


  Conclusion Top


The gangrene of the upper limb to be considered and investigated in the atherosclerotic patient. Peripheral vascular disease present with gangrene of all four limbs should be evaluated properly at the earliest as possible. Early recognition, proper management of disseminated intravascular coagulation, and underlying conditions may halt the progression of the disease. The multicentric randomized controlled trial should be set up to formulate the proper treatment guidelines.[8]

There is no definitive treatment for complete effectiveness. Early diagnosis is only the key factor in the management of superficial peripheral gangrene. Discontinuation or reduction of the vasopressor therapy, aggressive fluid resuscitation is indicated as the initial management along with its treatment of sepsis and disseminated intravascular coagulation with intravenous antibiotics and low-dose aspirin should be started. Other modes of treatment such as intravenous vasodilators, infusion of alpha blockers, and intravenous prostaglandins are tried.[9]

Amputation of the gangrenous area may be inevitable, but it is rarely required urgently. An initial non-surgical approach allows time for the patient's condition to stabilize and the gangrene to become localized.[9],[10]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Phan PN, Acharya V, Parikh D, Shad A. A rare case of symmetrical four limb gangrene following emergency neurosurgery. Int J Surg Case Rep 2015;16:15-8.  Back to cited text no. 1
    
2.
Foead AI, Mathialagan A, Varadarajan R, Larvin M. Management of symmetrical peripheral gangrene. Indian J Crit Care Med 2018;22:870-4.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Ghosh SK, Bandyopadhyay D, Dutta A. Purpura fulminans: A cutaneous marker of disseminated intravascular coagulation. West J Emerg Med 2009;10:41.  Back to cited text no. 3
    
4.
Maheshwari PN, Okwi N, Anant P. Pore symmetrical peripheral gangrene of all four limbs: An unusual complication of ureteroscopy. Indian J Urol 2019;35:78-80.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Yelamanchi R,Agarwal H, Kambalimath C. Symmetrical peripheral gangrene of all four limbs of unknown etiology: A rare case report. Indian J Surg 2021;83:336-7.  Back to cited text no. 5
    
6.
Neki NS, Jain A, Bajaj R, Jindal MM, Chavan V, Kumar H. Symmetrical peripheral gangrene: An unusual presentation of dengue fever. JK Sci 2015;17:104-5.  Back to cited text no. 6
    
7.
Roh SS, Gertner E. Digital necrosis in acquired immune deficiency syndrome vasculopathy treated with recombinant tissue plasminogen activator. J Rheumatol 1997;24:2258-61.  Back to cited text no. 7
    
8.
Vaiphei K, Vaidya PC, Vignesh P, Barwad P, Gupta A. Recurrent ventricular tachycardia and peripheral gangrene in a young child. Indian Pediatr 2016;53:815-21.  Back to cited text no. 8
    
9.
Molos MA, Hall JC. Symmetrical peripheral gangrene and disseminated intravascular coagulation. Arch Dermatol 1985;121:1057-61.  Back to cited text no. 9
    
10.
Klein L, Galvez A, Klein O, Chediak J. Warfarin-induced limb gangrene in the setting of lung adenocarcinoma. Am J Hematol 2004;76:176-9.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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