Warfarin-induced limb gangrene in the setting of lung adenocarcinoma

A 53-year-old man with lung adenocarcinoma developed pulmonary embolism and bilateral popliteal venous thrombosis. Treated with intravenous unfractionated heparin and discharged home on warfarin, he returned a week later with extending thrombosis. Treatment with heparin followed by warfarin was reinitiated. Twenty-four hours following the re-administration of warfarin, the patient's INR increased to 14.5. The platelet count dropped by more than 50%, and he developed venous limb gangrene of the left leg and skin necrosis of the right leg. Heparin-induced thrombocytopenia was ruled out, and coagulation studies showed a severe depletion of protein C as well as increased thrombin generation. The patient was transfused with fresh frozen plasma, and vitamin K was given. Heparin was continued, and after 4 weeks, the patient improved markedly showing only minimal necrosis of the toes. Venous limb gangrene is a major complication associated with warfarin therapy. Its pathogenesis is explained by a transient hypercoagulable state produced by protein C depletion that leads to microvascular thrombi progressing to venous limb gangrene. The present case emphasizes the importance of careful anticoagulation with heparin followed by slow initiation of low-dose warfarin, in order to minimize thrombotic complications.

[Ecthyma gangrenosum caused by Pseudomonas stutzeri with bacteraemia and systemic vascularitis]

INTRODUCTION

Ecthyma gangrenosum is a cutaneous manifestation of Pseudomonas infections. This condition may be associated with bacteraemia but can also occur in the absence of bacteraemia.

EXEGESIS

The authors report the case of a 66-year-old woman presented with necrotic ulcerations on the face associated with fever, arthralgia, myalgia, fatigue and neutropenia. Blood cultures and skin cultures were positive for Pseudomonas stutzeri. Her condition improved under appropriate antibiotic therapy. However, the patient further developed clinical and biological symptoms of systemic vasculitis and mixed cryoglubulinemia. Complete healing was finally obtained after a course of corticosteroids.

CONCLUSION

Ecthyma gangrenosum should be suspected in people who have typical clinical presentation. This disease could sometimes be associated with systemic vasculitis.

Digital gangrene associated with idiopathic hypereosinophilia: treatment with allogeneic cultured dermal substitute (CDS)

In the present case study, the patient was a 65-year-old man who suddenly developed purpuric and necrotic lesions with severe pain in his fingers and toes. Laboratory investigations revealed marked eosinophilia (77.9%), but there was no evidence to support a diagnosis of parasitic infections, allergic disease, neoplasm or connective tissue disorder. The histopathological findings did not show any distinct vasculitis, but there were obliterative changes of the arterioles. The digital gangrene gradually progressed and was unresponsive to corticosteroid therapy. The patient eventually underwent amputation of the distal phalanges. We applied allogeneic cultured dermal substitute (CDS) to the skin defect. The allogeneic CDS was prepared by culturing fibroblasts on a two-layered sponge of hyaluronic acid and atelo-collagen. This CDS is able to release a number of cytokines including VEGF. The present case had a good clinical result.

Gangrene of Meckel's diverticulum

Gangrene of Meckel's diverticulum is uncommon and its pre-operative diagnosis is difficult. We report three cases with different presentations--simulating acute appendicitis, intestinal obstruction, and strangulation of the bowel.

Gangrenous sigmoid volvulus: a clinical study of 76 patients

BACKGROUND AND AIMS

This study investigated the clinical picture of gangrenous sigmoid volvulus presented by Indian patients to describe the various patterns of gangrene and to identify the risk factors leading to the very high mortality from this disease.

PATIENTS AND METHODS

A structured protocol including nine parameters was used to study risk factors in 76 patients treated at two major teaching hospitals in India. The clinical picture of patients at the two hospitals did not differ significantly.

RESULTS

Contrary to expectations, we found gangrene in 26% of cases extending beyond the area of constriction into the rectum/descending colon. This extension was sometimes patchy and had an ill defined line of demarcation, which may lead to an error in judgment and cause a failure of anastomosis, which can be fatal. Risk factors were age over 60 years, the presence of shock on admission and a history of previous episodes of volvulus.

CONCLUSION

This study identified three risks for survival. It is suggested that all patients with nongangrenous sigmoid volvulus undergo a recurrence-prevention procedure immediately or electively. We also found that extension of gangrene beyond the confines of the constriction is not uncommon, calling for caution on the part of the treating surgeon.

[The association of Pneumatosis intestinalis and portal venous gas]

INTRODUCTION

Pneumatosis intestinalis is the presence of air in a wall of a section of the digestive tract. Portal venous gas is a radiological sign that corresponds to the presence of air in the portal vein. Their association, observed among others in certain pathologies such as the blunt abdominal trauma, endoscopic procedures or anaerobic infections, is a factor of severity.

OBSERVATION

We report a case of Pneumatosis intestinalis and portal venous gas secondary to uterine gangrene after caesarean operation in a 16 year-old woman.

CONCLUSION

Diagnosis of Pneumatosis intestinalis in association with portal venous gas is an emergency indication for surgery in the case of septicaemia, although exhibiting a high rate of complications and mortality.

The interrupted rim sign in acute cholecystitis: a method to identify the gangrenous form with MRI

We present the imaging findings on MR of a patient with acute gangrenous cholecystitis that demonstrated patchy enhancement of the gallbladder mucosa on gadolinium-enhanced fat-saturated T1-weighted gradient echo images. This interrupted rim of mucosal enhancement correlated with patchy areas of necrosis and inflammation of the gallbladder mucosa on the histopathological examination.

Marked reduction in serum high-density lipoprotein cholesterol concentrations in a woman with acute inflammation due to diabetic gangrene

BACKGROUND

C-reactive protein (CRP) is a well-established, sensitive marker of systemic inflammation and the risk of cardiovascular disease. High-density lipoprotein (HDL) is an anti-atherogenic lipoprotein known to be regulated by genetic and acquired factors.

METHODS

The patient was a 77-year-old Japanese woman, who was diagnosed with type 2 diabetes mellitus (DM), with a body height of 152 cm and a weight of 65 kg (body mass index 28.1 kg/m2). She suffered from diabetic foot gangrene in her right foot with high-grade fever when she visited our hospital. Her plasma glucose (PG) concentration and serum CRP were markedly elevated being 21.6 mmol/l and 370 mg/l, respectively, while her serum HDL-C concentrations were markedly low being 0.13 mmol/l. She was immediately admitted to our hospital and received intensive insulin treatment, along with intravenous-administration of antibiotics. Her general conditions were gradually improved and the high-grade fever disappeared, with concentrations of plasma PG and serum CRP being reduced, and concurrent reciprocal increase in her serum HDL-C concentrations.

RESULTS

To determine the potential causative factors responsible for the drastic change in serum HDL-C concentrations, we investigated the relationship of serum HDL-C to serum CRP, serum total protein (TP) and PG. Serum CRP and PG showed inverse relationships with serum HDL-C, while serum TP concentrations showed a positive association with HDL-C. After multivariate analyses with CRP, TP and PG as independent variables and serum HDL-C as dependent variable, CRP maintained its independent association with serum HDL-C. CRP also showed inverse correlations with lipoprotein lipase (LPL) mass and cholesteryl ester transfer protein mass.

CONCLUSIONS

In acute inflammation and poorly controlled diabetes, CRP is suggested to be inversely associated with serum HDL-C, independent of PG and TP.

Progression to wet gangrene in penile necrosis and calciphylaxis

We report a patient who presented with gangrene of the penis due to renal failure and calciphylaxis. In view of his advanced underlying conditions we pursued an expectant approach. Superinfection set in necessitating extensive debridement, demasculinisation and a perineal urethrostomy. Of the 34 reported cases in the literature, 12 (35%) were treated conservatively, 18 (53%) had been treated expectantly with delayed surgery following the development of complications and 4 (12%) underwent early surgery (penectomy). 20 (59%) of the patients subsequently died--8/12 (58%) treated conservatively, 11/18 (61%) treated with expectant surgery and 1/4 (25%) treated with early surgery. Progression to wet gangrene developed in the majority of patients--23/34 patients (68%). Penile gangrene is a symptom of severe systemic disease, where two thirds of affected patients decease within six months of onset of symptoms. Expectant treatment results in superinfection and wet gangrene in the majority of cases who ultimately require extensive surgery and debridement.

Pulmonary gangrene complicating bacterial pneumonia

Two cases of pulmonary gangrene involving left lower lobe in an 18-month and 4-year-old female children are reported. The patients looked like having empyema following Klebsiella pneumonia. The diagnosis was made following computerized tomography scan and during decortication respectively.

Symmetrical peripheral gangrene and dopamine

We describe a case of a 55-year-old man with hypovolemic shock who developed a symmetrical peripheral gangrene (SPG) on hands and feet. The SPG syndrome consists of sudden onset of symmetrical gangrene of the fingers, toes and rarely, the nose, upper lip, ear lobes or genitals without large vessel obstruction or vasculitis. Vasopressors have been implicated directly or as a contributory cause in many cases. In this case, dopamine was used with high dose (> 20 microg/kg/min) which is inappropriate in hypovolemic shock states. SPG might be a severe and rare complication of dopamine. Care should be taken with the use of dopamine in patients with shock.

Peripheral gangrene complicating hemolytic uremic syndrome in a child

A patient with hemolytic uremic syndrome (HUS) developed peripheral gangrene involving all fingers and toes. There was no history of bloody diarrhea. Hypocomplementemia was present, with a serum C3 concentration of 41 mg/dl. Acute renal failure was treated with peritoneal dialysis for 4 months. He received daily fresh-frozen plasma infusions and plasmapheresis on alternate days for ten sessions, followed by once-weekly sessions. He was anuric for 9 weeks. All medial and distal phalanxes became necrotic and were removed surgically. The renal biopsy findings were consistent with HUS. This is the second report of peripheral gangrene during the course of HUS in childhood.

[Juvenile gangrenous vasculitis of the scrotum]

OBJECTIVE

To describe clinical and pathological findings of a new case of juvenile gangrenous vasculitis of the scrotum, a peculiar and unusual (only 7 cases, approximately, have been previously reported) type of scrotal gangrene described by Piñol in 1973.

METHODS

A 24 year-old male presented at the emergency room with a right scrotal necrotising cutaneous lesion and fever. Physical examination, complete blood count, biochemical test, roentgenographic abdominal and thoracic findings, microbiological test and biopsy were performed.

RESULTS

Clinical aspects (symptoms and sings) and results of complete blood count (leukocytosis), normal ultrasound exploration and biochemical and roentgenographic abdominothoracic findings, microbiological test (negative) and biopsy (necrotising vasculitis) are compatible with juvenile gangrenous vasculitis of the scrotum.

CONCLUSIONS

Juvenile gangrenous vasculitis of the scrotum is a rare entity which should be diagnosed by strict clinicopathological diagnostic criteria because treatment and prognosis are distinct of other numerous ulcerative scrotal diseases.

[Necrotizing soft tissue infections: nomenclature and classification]

Terminology used to refer to necrotizing infections is extensive because of the absence of clear definitions and the use of classification systems based on a variety of criteria, including etiologic, microbiologic, anatomic, and clinical aspects. This situation has led to some confusion. In the attempt to unify terminology, it might be more appropriate to use only the terms necrotizing fasciitis and myonecrosis, in which differentiation is mainly anatomical. Another option would be to use only the expression necrotizing soft tissue infections, a non-specific term, since these constitute a group of clinical processes having similar pathophysiologic characteristics and therapeutic principles.

Small bowel herniation and gangrene from peritoneal dialysis catheter exit site

Peritoneal dialysis is one of the standard methods for blood purification. It is particularly well suited for treating children with acute renal failure. Here we report a rare case of small bowel herniation at the peritoneal catheter exit site following removal, leading to gangrenous infarction.

Vasculitis with digital gangrene in a patient with HIV infection

A case of polyarteritis nodosa (PAN) like systemic necrotizing vasculitis in an HIV infected individual, who presented with digital ischaemia is reported. The pathogenesis of PAN in HIV infected patients is not well understood and whether HIV or other agents are directly involved in the vascular injury remains to be established.

Idiopathic purpura fulminans and varicella gangrenosa of both hands, toes and integument in a child

Chicken pox is a common childhood illness and, though a vaccine is readily available, it is not routinely included in the vaccination schedule of most countries owing to its mild clinical nature. However, varicella gangrenosa is a rare complication of this disease, infrequently reported in the literature. We report the case of a child who developed purpura fulminans in the convalescent phase of chicken pox and subsequently presented with peripheral gangrene of both hands and the toes of the right foot, and skin gangrene. To our knowledge, bilateral gangrene of the hands has rarely been reported, and we present this case to highlight the serious nature of complications following varicella infection.