Acute kidney injury due to rhabdomyolysis-associated gangrenous myositis

Rhabdomyolysis is associated with infectious diseases in approximately 5% of cases and acute kidney injury occurs in 33-50% of cases. Gangrenous myositis is a deep seated infection of the subcutaneous and muscular tissues. We report the case of an 18 year-old man who was admitted to the emergency room with leg pain, fever, nausea, vomiting and oliguria. Physical examination showed moderate dehydration, peripheral cyanosis and skin necrosis with severe myalgia and no subcutaneous gas. Laboratory findings at admission were: serum urea 111 mg/dL, creatinine 1.3 mg/dL, potassium 6.3 mEq/L, creatine kinase (CK) 112,452 IU/L, aspartate amino transaminase (AST) 1116 IU/L, alanine amino transaminase (ALT) 1841 IU/L, pH 7.31, bicarbonate (HCO3) 11 mEq/L and lactate 4.3 mmol/L. Emergency hemodyalisis was started, and antibiotics were given due to high suspicion for bacterial infection. The patient developed respiratory insufficiency and septic shock needing mechanical ventilation and vasoactive drugs. He presented spontaneous gangrenous myositis in both legs and in his left arm. After 26 sessions of hemodialysis, partial recovery of renal function was observed. He was discharged from the ICU after 38 days, still with leg pain. Acute kidney injury due to rhabdomyolysis should be considered as a possible complication of gangrenous myositis.

Severe primary antiphospholipid syndrome

Antiphospholipid syndrome (APS) is characterised by recurrent venous or arterial thrombosis and/or fetal losses. In APS, the homeostatic regulation of blood coagulation is altered, however, the mechanism of thrombosis is not yet defined and it has varied manifestations. Deep vein thrombosis with or without pulmonary embolism is the most common manifestation followed by arterial occlusion of cerebral, coronary and other arteries including subclavian, retinal, renal and pedal arteries. We report a case of a 42 years old female, with severe primary APS, who presented with symmetrical peripheral gangrene, an uncommon presentation and was treated successfully.

[Optimization of surgical treatment of patients with complicated forms of the diabetic foot]

An analysis of results of complex treatment of 160 patients with purulent complications of the diabetic foot has allowed optimization of the decision on surgical strategy using the proposed formula depending on the severity of the general state of the patients. The decision on the surgical strategy of treatment taking into account the indices of the severity of the disease led to 2.5 times less number of "great" amputations and 29% shorter duration of the patients' staying at the hospital.

Clinical burden of digital vasculopathy in limited and diffuse cutaneous systemic sclerosis

BACKGROUND

Vascular damage is a key pathological process in systemic sclerosis (SSc) and accounts for significant disease-related morbidity. To determine the clinical burden of severe digital vasculopathy (SDV), we have reviewed hospital-based treatment for this important complication of SSc in a large single centre cohort.

METHODS

Cases were identified from a cohort of 1168 patients with a diagnosis of SSc who were reviewed during an 18-month period. Patients with recorded episodes of SDV-related complications (digital ulceration, critical digital ischaemia or digital gangrene), requiring surgical amputation, digital sympathectomy or admissions for intravenous prostacyclin or calcitonin gene related peptide (CGRP) and/or intravenous antibiotic treatment were identified.

RESULTS

From this large SSc cohort, 17.4% had SDV-related complications. Contrary to expectation, their frequency was significantly higher among the patients with the diffuse cutaneous subset of SSc (27.5%) compared with 13% among the patients with limited cutaneous SSc (p<0.0001). 16.6% had at least one recorded episode of digital ulcers, and 12% required at least one hospitalisation during the 18 months for treatment with intravenous prostacyclin/CGRP. Overall, there were 242 admissions with a mean duration of 6 days.

CONCLUSIONS

Digital vasculopathy is a serious complication of SSc contributing significant morbidity and often requiring hospital-based management.

Gangrenous cystitis

Gangrenous cystitis is an extremely rare condition. During the last 70 years, only 30 cases have been reported in the literature. We report a case of gangrenous cystitis in a 70-year-old woman presented with symptoms of acute abdomen. Main causative factor was overdistension of the bladder due to catheter obstruction. She underwent debridement and drainage of the cystic remnant. The pathogenesis, diagnosis, and management of gangrenous cystitis are discussed.

Intrauterine gangrene of the lower extremity in the newborn: a report of two cases

We describe 2 cases of intrauterine gangrene involving the lower extremity in 2 unrelated neonates. Both cases were complicated by prematurity, and 1 case was complicated by an intrauterine distal femur fracture and twin-twin transfusion syndrome. Both cases resulted in profound ischemic necrosis from the knee to the foot, requiring knee disarticulation. In both cases, a follow-up period of 7 years is now completed, and no further medical or surgical complications have arisen.

Intestinal gangrene due to mesenteric vascular occlusion masquerading as strangulated inguinal hernia

Strangulated inguinal hernia may present with intestinal gangrene. However, mesenteric arterial thrombosis producing massive gangrene of the bowel as content in inguinal hernia is an entity probably not reported in the medical literature. We report a case of inguinal hernia presenting with features of strangulation, which on exploration was found to be a case of massive bowel gangrene due to superior mesenteric artery thrombosis affecting the terminal ileum, cecum, ascending colon and proximal three-fourths of the transverse colon. We think this is the first case report of superior mesenteric artery thrombosis masquerading as strangulated inguinal hernia and present it with a message that while dealing with an inguinal hernia with gangrenous bowel as the content, one should keep in mind a rare possibility of mesenteric thrombo-embolism as the cause.

Pulmonary aspergillosis and ischemic distal limb necrosis associated with enteric salmonellosis in a foal

A 5-month-old mixed-breed filly presented with diarrhea due to Salmonella typhimurium infection and subsequently developed pneumonia in addition to ischemic necrosis of distal limbs. Pulmonary lesions were characterized by numerous discrete, disseminated pyogranulomas with intralesional fungal hyphae. The morphologic characteristics of fungal hyphae were consistent with Aspergillus spp., and large numbers of A fumigatus were isolated from lung tissue via fungal culture. Lesions in all 4 limbs were similar in distribution, duration, and severity and were characterized by coagulation necrosis accompanied by occasional thrombi in small vessels without evidence of thrombosis of larger limb arteries. Thus, limb lesions are consistent with symmetrical peripheral gangrene, a potential complication of sepsis.

Disseminated intravascular coagulation complicated by peripheral gangrene in a rhesus macaque (Macaca mulatta) experimentally infected with Plasmodium coatneyi

We report the first case of disseminated intravascular coagulation (DIC) complicated by peripheral gangrene induced by Plasmodium coatneyi in rhesus monkeys. Ten days after experimental challenge, numerous petechiae were noted over the trunk and extremities, with polychromasia, severe anemia, thrombocytopenia, and moderate parasitemia. These changes were accompanied by elevated serum activity of blood urea nitrogen, creatinine, transaminases, and creatinine phosphokinase. The animal received intravenous fluid support, artemether, and blood transfusion. Three days after treatment, the platelet counts returned to normal, and parasitemia was abated. However, several areas of skin discoloration with gangrenous tissue in the hands and the tail were observed. Coagulation profile showed elevated D-dimers and elevated levels of fibrinogen/fibrin degradation products with low levels of protein S functional activity. DIC with peripheral gangrene is very rare in Plasmodium-infected individuals. Our results indicate that the experimental model of P. coatneyi infection of rhesus monkeys is important for studies of malarial anemia and coagulopathy.

Four-Extremity Gangrene Associated With Crack Cocaine Abuse

A 43-year-old woman with a history of cocaine abuse presented with decreased mental responsiveness and cyanosis of the extremities several hours after repeated use of "crack" cocaine. She developed bilateral hand compartment syndrome requiring emergency fasciotomy and gangrene of both hands and legs despite anticoagulant and antithrombotic therapy. Digital and above-knee amputations were performed. There was no evidence of an autoimmune disorder or vasculitis on laboratory evaluation and tissue histology. Peripheral vasospasm may have been the mechanism of toxicity in this case, and the use of intravenous vasodilators should be considered as potential additional therapy.

Limb amputation in hemoglobin SC disease after application of ice and elevation

A 31-year-old man with hemoglobin SC disease was admitted with acute chest syndrome, treated with antibiotics and ventilator support. His restrained right wrist and hand became swollen and cool, thought due to infiltration of an intravenous line. The hand was elevated, ice packs applied around the clock, and prophylactic low molecular weight heparin given. The arm quickly turned gangrenous. In spite of attempted thrombectomy and red blood cell exchange transfusion, amputation was required. Cold, elevation, and measures that reduce blood flow are known precipitators of sickling and crises. Vasoocclusion of the extremities to the point of gangrene is rarely reported in sickle cell disorders, and this case highlights the dangers of measures limiting blood flow in such patients.

Conservative debridement of postoperative Meleney's gangrene following a caesarean section

Meleney's gangrene is almost exclusively postoperative and is caused by multiple bacteria. This case review describes the conservative management of Meleney's gangrene in a young patient following a Caesarean section.

Prognostic parameters for the prediction of acute gangrenous cholecystitis

BACKGROUND/PURPOSE

The aim of this study was to identify preoperative prognostic parameters for gangrenous cholecystitis to differentiate this subgroup of patients with acute cholecystitis in order to provide immediate surgical therapy.

METHODS

The medical records of patients who had an emergency cholecystectomy with the diagnosis of acute cholecystitis between January 2002 and June 2005 were reviewed retrospectively. Univariate and multivariate analysis were performed on the data.

RESULTS

Out of 203 individuals with the clinical diagnosis of acute cholecystitis, 21 (10.3%) patients had a histological diagnosis of gangrenous cholecystitis. Multivariate analysis demonstrated an independent association of male sex, diabetes mellitus and white blood cell (WBC) count with the development of acute gangrenous cholecystitis.

CONCLUSIONS

The risk for gangrenous cholecystitis is increased in male patients who have diabetes and a greater WBC count than 14 900/mm(3). Urgent surgical intervention should be considered for these patients because of the high morbidity and mortality rate of the condition.

Retroarterial colon with right-sided obstructive gangrenous colitis

Retroarterial colon is a rare entity in which the colon is located behind the superior mesenteric vessels. Transmesenteric internal hernias result in portions of the bowel protruding through a defect in the mesentery and are often acquired but may be congenital. We report a 10-year-old female with trisomy 13 who lacked retroperitoneal fixation of the intestines and had a retroarterial transverse colon possibly resulting from a congenital transmesenteric internal hernia, that eventually lead to obstructive gangrenous colitis.

Successful treatment of diabetic gangrene with topical application of a mixture of peripheral blood mononuclear cells and basic fibroblast growth factor

Diabetic gangrene is a non-healing skin ulcer that is often resistant to most common treatments. It is caused by microvascular disorders and an immunocompromised state which are induced by diabetes mellitus. We report a 65-year-old man with an aggressive, refractory diabetic gangrene on his left foot. Treatment of his diabetic gangrene with topical application of a mixture of peripheral blood mononuclear cells (PBMC) and basic fibroblast growth factor (bFGF) resulted in a dramatic improvement in a short time. The ulcer was completely closed and, in the past 6 months, no new ulceration has been observed. The patient is able to stand and walk by himself. Topical application of a mixture of PBMC and bFGF appears to be a useful, non-invasive and convenient method for the treatment of diabetic gangrene.

Dry gangrene of the extremities in calves associated with Salmonella dublin infection; a possible immune-mediated reaction

Dry gangrene of the extremities in calves is a circulatory error that may occur after infection with Salmonella dublin. This report describes an examination of three affected, 12 in-contact and five control calves, a main objective being to investigate the possible role of cold agglutination in pathogenesis. The lesions included dry gangrene of the hind legs, ears and tail. A cold agglutination test gave positive results in all animals examined except the controls. The three affected calves had high titres of S. dublin antibodies, as also did four of the in-contact animals. The results suggested a relationship between cold agglutination and the occurrence of the disease.