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Alhumam T, Alhumam AA, Alhumaidi I, Al Rajeh I, Alduhailan Y. Relationship Between Symmetrical Peripheral Gangrene Patients and Using Vasopressors in the Intensive Care Unit. Cureus 2024; 16:e58117. [PMID: 38741803 PMCID: PMC11088959 DOI: 10.7759/cureus.58117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2024] [Indexed: 05/16/2024] Open
Abstract
Symmetrical peripheral gangrene (SPG) is a rare yet severe condition characterized by peripheral ischemic lesions without significant vascular occlusion. Its clinical presentation includes peripheral cyanosis, mottling, and symmetrical ischemia of distal limbs, often progressing to gangrene. Recent years have seen a rise in SPG cases, with mortality rates ranging from 40% to 90%. The condition is associated with systemic diseases, such as sepsis, vasculitis, and coagulopathy. DIC frequently complicates SPG, reflecting a disturbed procoagulant-anticoagulant balance and depletion of natural anticoagulants. While vasopressor therapy, particularly high-dose administration, has been implicated in SPG pathogenesis due to sustained vasoconstriction or idiosyncratic responses, recent evidence suggests it may not be the underlying cause. Studies indicate a low incidence of ischemic limb necrosis associated with high-dose vasopressors, with DIC and shock liver potentially explaining limb ischemia instead. The characteristic temporal interval between the onset of shock liver and limb ischemic necrosis suggests a more complex pathophysiology. The role of infectious agents, such as bacteria and viruses, in SPG pathogenesis is under investigation, with both direct vascular invasion and immune-mediated mechanisms proposed. Diagnosis involves ruling out other causes of acral gangrene through clinical examination, laboratory tests, imaging studies, and biopsy. Treatment strategies aim to halt disease progression, eliminate causative factors, and prevent complications. While anticoagulants, vasodilators, and adjunctive therapies like hyperbaric oxygen show promise, the efficacy of interventions varies, emphasizing the need for individualized management. Notably, hemoadsorption has emerged as a promising treatment, demonstrating significant improvement in SPG cases. Amputation remains a last resort option in irreversible cases. Early recognition and multidisciplinary management are crucial for improving outcomes. Further research is needed to better understand SPG's etiology and develop effective treatments through collaborative efforts.
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Affiliation(s)
- Turki Alhumam
- College of Medicine, King Faisal University, Al-Hofuf, SAU
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Wang X, Tu Y, Chen Y, Yang H, Luo M, Li Y, Huang L, Luo H. Critical bloodstream infection caused by Chromobacterium violaceum: a case report in a 15-year-old male with sepsis-induced cardiogenic shock and purpura fulminans. Front Med (Lausanne) 2024; 11:1342706. [PMID: 38596787 PMCID: PMC11002164 DOI: 10.3389/fmed.2024.1342706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 03/01/2024] [Indexed: 04/11/2024] Open
Abstract
Chromobacterium violaceum (C. violaceum) is a gram-negative bacillus that is widespread in tropical and subtropical areas. Although C. violaceum rarely infects humans, it can cause critical illness with a mortality rate above 50%. Here, we report the successful treatment of a 15-year-old male who presented with bloodstream infection of C. violaceum along with sepsis, specific skin lesions, and liver abscesses. Cardiogenic shock induced by sepsis was reversed by venoarterial extracorporeal membrane oxygenation (VA ECMO). Moreover, C. violaceum-related purpura fulminans, which is reported herein for the first time, was ameliorated after treatment. This case report demonstrates the virulence of C. violaceum with the aim of raising clinical awareness of this disease.
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Affiliation(s)
- Xueqing Wang
- Department of Intensive Care Unit (ICU), Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Yunliang Tu
- Department of Intensive Care Unit (ICU), Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Yingqun Chen
- Department of Intensive Care Unit (ICU), Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Huilin Yang
- Department of Microbiology Laboratory, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Minghua Luo
- Department of Pathology, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Yanyan Li
- Department of Intensive Care Unit (ICU), Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Lei Huang
- Department of Intensive Care Unit (ICU), Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Hua Luo
- Department of Intensive Care Unit (ICU), Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
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3
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Perry JC, Pindek RL, Sur A, Kc N, Zeibeq J. Alcohol Abuse as a Silent Risk Factor for Purpura Fulminans and the Importance of Pneumococcal Vaccination. Cureus 2023; 15:e39522. [PMID: 37378100 PMCID: PMC10292072 DOI: 10.7759/cureus.39522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2023] [Indexed: 06/29/2023] Open
Abstract
Purpura fulminans (PF) is a rare presentation of disseminated intravascular coagulopathy (DIC) and a life-threatening complication of septic shock. DIC can present with bleeding and thrombosis in acute settings, making its management exceptionally challenging. Common causative organisms include Neisseria meningitidis, Streptococcus pneumoniae, andHaemophilus influenzae. We report a case of a 47-year-old patient with a history of alcohol abuse and marijuana use with a bizarre presentation of copious diarrhea and altered mental status. The patient was subsequently admitted to the intensive care unit (ICU) for acute respiratory failure and septic shock secondary to Streptococcus pneumoniae bacteremia complicated by DIC. Unfortunately, the patient's condition worsened with multiorgan failure and purpura fulminans, leading to extensive necrosis of all his extremities, with the involvement of his lips, nose, and genitals. Unfortunately, despite aggressive interventions, he continued to deteriorate and ultimately was transitioned to comfort care before he expired. In the literature, there is only one reported case of PF in an individual with alcohol abuse. However, the frequency and severity of pneumococcal infections in individuals with a history of alcohol abuse are much higher than in the general population. PF is a devastating complication of Streptococcus pneumoniae, with a mortality of 43%. We hope that this case will continue highlighting the importance of vaccinating patients with a history of alcohol abuse with the pneumococcal vaccine.
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Affiliation(s)
- Jamal C Perry
- Medicine, Brookdale University Hospital Medical Center, Brooklyn, USA
| | - Rachel L Pindek
- Osteopathic Medicine, New York Institute of Technology College of Osteopathic Medicine, Old Westbury, USA
| | - Avtar Sur
- Internal Medicine, Brookdale University Hospital Medical Center, Brooklyn, USA
| | - Nabin Kc
- Critical Care Medicine, One Brooklyn Health System-Interfaith Medical Center, New York, USA
| | - John Zeibeq
- Pulmonary and Critical Care Medicine, Brookdale University Hospital Medical Center, Brooklyn, USA
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Goodall RJ, Roberts J, Correia MD, Frew Q, Barnes D, Dziewulski P, Shelley O, El-Muttardi N. Management of purpura fulminans skin loss at a regional burns centre: Sixteen-year experience. J Plast Reconstr Aesthet Surg 2023; 79:23-29. [PMID: 36842284 DOI: 10.1016/j.bjps.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 01/29/2023] [Indexed: 02/10/2023]
Abstract
INTRODUCTION Purpura fulminans (PF) is a rare syndrome of cutaneous purpura which is the consequence of severe circulatory shock causing intravascular thrombosis, haemorrhagic necrosis, and consequent tissue loss. The aim of this study was to present our 16-year experience of managing PF in a regional burns centre. METHODS We performed a single-centre retrospective case series of all patients admitted to the St Andrews Burns Centre at Broomfield Hospital, Chelmsford, Essex, UK, between June 2006 and July 2022 with a diagnosis of PF. Data were extracted by retrospectively searching hospital case notes. RESULTS Thirteen individuals were identified [five children (mean age 5, range 1-14) and eight adults (mean age 39, range 24-54)]. The total body surface area of cutaneous necrosis ranged from 5% to 80%, with a mean of 27.2%. Patients were treated with an established surgical sequence of total wound debridement and immediate coverage with a cadaveric allograft, followed by staged wound autografting. The mean time from disease onset to wound autografting was 37.3 days (range 20-64 days). Eight individuals (61.6%) required major amputation of at least one limb (proximal to the ankle or wrist joint). Only one mortality (of 80% total body surface area skin loss) was observed in the identified cohort. CONCLUSIONS The large body surface areas often involved in PF cases make management of these wounds well suited for burns centres, wherein established facilities and multidisciplinary teams exist that are familiar with managing large cutaneous burns. We provide a suggested algorithm to aid the management of PF.
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Affiliation(s)
- R J Goodall
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK.
| | - J Roberts
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
| | - M D Correia
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
| | - Q Frew
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
| | - D Barnes
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
| | - P Dziewulski
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
| | - O Shelley
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
| | - N El-Muttardi
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
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Goshua G, Bendapudi PK, Lee AI. Thrombosis questions from the inpatient wards. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:481-490. [PMID: 36485139 PMCID: PMC9819989 DOI: 10.1182/hematology.2022000384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
The multifaceted pathophysiologic processes that comprise thrombosis and thromboembolic diseases take on a particular urgency in the hospitalized setting. In this review, we explore 3 cases of thrombosis from the inpatient wards: purpura fulminans, cancer-associated thrombosis with thrombocytopenia, and coronavirus disease 2019 (COVID-19) and the use of dose-escalated anticoagulation therapy and antiplatelet agents. We discuss the evaluation and management of purpura fulminans and the roles of plasma transfusion, protein C and antithrombin replacement, and anticoagulation in treating this disease. We present a framework for evaluating the etiologies of thrombocytopenia in cancer and review 2 strategies for anticoagulation management in patients with cancer-associated thrombosis and thrombocytopenia, including recent prospective data supporting the use of dose-modified anticoagulation based on platelet count. Last, we dissect the major clinical trials of therapeutic- and intermediate-dose anticoagulation and antiplatelet therapy in hospitalized patients with COVID-19, reviewing key recommendations from consensus guidelines while highlighting ways in which institutional and patient-tailored practices regarding antithrombotic therapies in COVID-19 may differ. Together, the cases highlight the diverse and dramatic presentations of macro- and microvascular thrombosis as encountered on the inpatient wards.
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Affiliation(s)
- George Goshua
- Section of Hematology, Yale School of Medicine, New Haven, CT
| | - Pavan K Bendapudi
- Division of Hematology, Blood Transfusion Service, Massachusetts General Hospital; Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center; and Harvard Medical School, Boston, MA
| | - Alfred Ian Lee
- Section of Hematology, Yale School of Medicine, New Haven, CT
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Bentivegna K, Grant-Kels JM, Livingston N. Cutaneous Mimics of Child Abuse & Neglect: Part II. J Am Acad Dermatol 2022; 87:519-531. [PMID: 35339589 DOI: 10.1016/j.jaad.2021.12.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 12/06/2021] [Accepted: 12/22/2021] [Indexed: 11/17/2022]
Abstract
Given that some cutaneous mimics of child abuse result from rare disease, they may be more prone to misdiagnosis. For possible child abuse cases in which diagnosis remains uncertain at time of initial dermatologic evaluation, it is important that dermatologists are prepared to distinguish true dermatologic conditions in cases of ambiguous skin findings. Additionally, this review will aid clinicians in recognizing the possibility of concurrent true dermatologic disease and skin findings related to abuse with the acknowledgement that they are not mutually exclusive. Proper recognition of mimics of abuse may prevent unnecessary stress and child protective service investigation.
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Affiliation(s)
| | - Jane M Grant-Kels
- Department of Dermatology, University of Connecticut School of Medicine, Farmington, Connecticut; Department of Dermatology, University of Florida, Gainesville, Florida.
| | - Nina Livingston
- Department of Pediatrics, University of Connecticut School of Medicine, Connecticut Children's Medical Center, Hartford, Connecticut
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Mala S, Ahmed B. Symmetrical peripheral gangrene triggered by Escherichia coli sepsis. JOURNAL OF ACUTE DISEASE 2022. [DOI: 10.4103/2221-6189.357461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Sil A, Chakraborty U, Chandra A, Biswas SK. COVID-19 associated symmetrical peripheral gangrene: A case series. Diabetes Metab Syndr 2022; 16:102356. [PMID: 34920197 PMCID: PMC8626894 DOI: 10.1016/j.dsx.2021.102356] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/16/2021] [Accepted: 11/25/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND AIMS The novel coronavirus disease (COVID-19) caused by SARS-CoV-2 has turned the world topsy-turvy since its onset in 2019. The thromboinflammatory complications of this disease are common in critically ill patients and associated with poor prognosis. Symmetrical peripheral gangrene (SPG) is characterized by symmetrical distal gangrene in absence of any large vessel occlusion or vasculitis and it is usually associated with critical illness. Our aim was to report the clinical profile and outcome of patients diagnosed with SPG associated with COVID-19. To the best of our knowledge, no such similar cases have been reported till date. METHODS In this case series, we have discussed the clinical presentation, laboratory parameters and outcome in a series of two patients of SPG associated with COVID-19 and also compared those findings. Due to paucity of data, we also reviewed the literature on this under-diagnosed and rarely reported condition and association. RESULTS Two consecutive patients (both males, age range: 37-42 years, mean: 39.5 years) were admitted with the diagnosis of COVID-19 associated SPG. Both patients had clinical and laboratory evidence of disseminated intravascular coagulation (DIC). Leucopenia was noted in both patients. Despite vigorous therapy, both patients succumbed to their illness within a fortnight of admission. CONCLUSION SPG in the background of COVID-19 portends a fatal outcome. Physicians should be aware of its grim prognosis.
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Affiliation(s)
- Abheek Sil
- Department of Dermatology, Venereology, and Leprosy, RG Kar Medical College and Hospital, 1, Khudiram Bose Sarani, Kolkata, 700004, India
| | - Uddalak Chakraborty
- Department of Neurology, Bangur Institute of Neurosciences, IPGMER and SSKM Hospital, Annex 1, 52/1 Shambhunath Pandit Street, Kolkata, 700020, India
| | - Atanu Chandra
- Department of Internal Medicine, RG Kar Medical College and Hospital, 1, Khudiram Bose Sarani, Kolkata, 700004, India.
| | - Surajit Kumar Biswas
- Department of Dermatology, Venereology, and Leprosy, RG Kar Medical College and Hospital, 1, Khudiram Bose Sarani, Kolkata, 700004, India
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The Epidemiology of Extremity Threat and Amputation Following Vasopressor-dependent Sepsis. Ann Am Thorac Soc 2021; 19:625-632. [PMID: 34644242 DOI: 10.1513/annalsats.202105-547oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Extremity threat and amputation following sepsis is a well-publicized and devastating event. However, there is a paucity of data exists surrounding theabout the epidemiology of extmreityextremity threat following sepsis onset. OBJECTIVES We aim toTo estimate the incidence of extremity threat with or without surgical amputation in community sepsis. METHODS Multihospital Rretrospective cohort study of adults with Sepsis-3 hospitalized at XX14 academic and community sites from 2013 to 2017. Vasopressor-dependent sepsis was identified by administration epinephrine, norepinephrine, phenylephrine, vasopressin, or dopamine for >1 hour during the 48 hours before to 24 hours following sepsis onset. Outcomes included the incidence of extremity threat, defined as acute onset ischemia, with or without amputation in the 90 days following sepsis onset. The association between extremity threat, and demographics, comorbid conditions, and, and time-varying sepsis treatment factorss were evaluated using a Cox-proportional hazards model. RESULTS Among 24,365 adults with sepsis, 12,060 (54%) were vasopressor-dependent (mean±standard deviation SD age, 64±16 years; male, 6,548 [54%]; sequential organ failure assessment (SOFA), 10±4). Of these, 231 (2%) patients had a threatened extremity with 26 undergoing 37 amputations, a risk of 2.2 (95% CI: 1.4-3.2) per 1,000, and 205 not undergoing amputation, a risk of 17.0 (95% CI: 14.8-19.5) per 1,000. 95% of the total 37Most amputations occurred in lower extremities (95%), a median (interquartile range) of 16 (6.3-4039.9) days after sepsis onset. Compared to patients with no extremity threat, patients with threat had a higher sequential organ failure assessmentSOFA score (11±4 vs 10±4; P < 0.001), serum lactate (4.6 mmol/L [2.4-8.7] vs 3.1 [1.7-6.0]; P < 0.001), and more bacteremia (n = 37 [37%??] vs n = 2,087 [26%]; P < 0.001) at sepsis onset. Peripheral vascular disease, congestive heart failure, sequential organ failure assessmentSOFA score, and norepinephrine equivalents were significantly associated with the risk of extremity threat. CONCLUSIONS The evaluation of a threatened extremity resulting in surgical amputation occurred in 2 per 1,000 patients with vasopressor-dependent sepsis.
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Change of the Pattern of the Demographic Characteristics of the Patients with Endocarditis: Clinical Case of Infectious Endocarditis in Man with Injectible Drug Dependence, Complicated with Pneumonia and Peripheral Necroses of Feet, Arms, Nose (Own Clinical Observations and Experience of Education in State and English Language). Fam Med 2021. [DOI: 10.30841/2307-5112.2-3.2021.240770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Infectious endocarditis is multisystem disease, which is the result of the infection (usually bacterial) of endocardial heart surface. Despite of the latest medical achievements in diagnostics and treatment, infectious endocarditis is still a disease with high mortality rate and severe complications. During last decades in developed countries there are obvious changes of demographic characteristics of the patients with infectious endocarditis, namely increasing of aged patients with degenerative valvular diseases, of patients with anamnesis of invasive manipulations and procedures. Beside with well known risk factors (artificial valves and implanted heart devices), there are increasing roles of injectible drug-dependence, human immunodeficiency virus and wide contact with health protection system as predisposing factors for infectious endocarditis. The article contains literature data of the main populational risk groups of infectious endocarditis.
Clinical case of severe (fatal) infectious endocarditis in patient with injectible drug dependence is submitted. Special features of the case are peripheral dry necroses of feet, arms, nose, which are very close to the description of symmetrical peripheral gangrene. This rare disorder was first described by Hutchinson in 1891 in 37-year old man, who had gangrene of fingers, hands and ears after shock. Symmetrical peripheral gangrene can be induced by different infection and non-inflection causes. The majority of these cases are connected to the treatment of cardiogenic shock with disseminated intravascular coagulation.
Submitted description of the case of symmetrical peripheral gangrene in patient with infectious endocarditis will be useful for different medical care specialists as a reminder of the necessity of constant monitoring of the skin color of the distal parts of the limbs in severe sick patients.
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Chang JC. COVID-19 Sepsis: Pathogenesis and Endothelial Molecular Mechanisms Based on "Two-Path Unifying Theory" of Hemostasis and Endotheliopathy-Associated Vascular Microthrombotic Disease, and Proposed Therapeutic Approach with Antimicrothrombotic Therapy. Vasc Health Risk Manag 2021; 17:273-298. [PMID: 34103921 PMCID: PMC8179800 DOI: 10.2147/vhrm.s299357] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 03/24/2021] [Indexed: 12/15/2022] Open
Abstract
COVID-19 sepsis is characterized by acute respiratory distress syndrome (ARDS) as a consequence of pulmonary tropism of the virus and endothelial heterogeneity of the host. ARDS is a phenotype among patients with multiorgan dysfunction syndrome (MODS) due to disseminated vascular microthrombotic disease (VMTD). In response to the viral septicemia, the host activates the complement system which produces terminal complement complex C5b-9 to neutralize pathogen. C5b-9 causes pore formation on the membrane of host endothelial cells (ECs) if CD59 is underexpressed. Also, viral S protein attraction to endothelial ACE2 receptor damages ECs. Both affect ECs and provoke endotheliopathy. Disseminated endotheliopathy activates two molecular pathways: inflammatory and microthrombotic. The former releases inflammatory cytokines from ECs, which lead to inflammation. The latter initiates endothelial exocytosis of unusually large von Willebrand factor (ULVWF) multimers and FVIII from Weibel-Palade bodies. If ADAMTS13 is insufficient, ULVWF multimers activate intravascular hemostasis of ULVWF path. In activated ULVWF path, ULVWF multimers anchored to damaged endothelial cells recruit circulating platelets and trigger microthrombogenesis. This process produces "microthrombi strings" composed of platelet-ULVWF complexes, leading to endotheliopathy-associated VMTD (EA-VMTD). In COVID-19, microthrombosis initially affects the lungs per tropism causing ARDS, but EA-VMTD may orchestrate more complex clinical phenotypes, including thrombotic thrombocytopenic purpura (TTP)-like syndrome, hepatic coagulopathy, MODS and combined micro-macrothrombotic syndrome. In this pandemic, ARDS and pulmonary thromboembolism (PTE) have often coexisted. The analysis based on two hemostatic theories supports ARDS caused by activated ULVWF path is EA-VMTD and PTE caused by activated ULVWF and TF paths is macrothrombosis. The thrombotic disorder of COVID-19 sepsis is consistent with the notion that ARDS is virus-induced disseminated EA-VMTD and PTE is in-hospital vascular injury-related macrothrombosis which is not directly related to viral pathogenesis. The pathogenesis-based therapeutic approach is discussed for the treatment of EA-VMTD with antimicrothrombotic regimen and the potential need of anticoagulation therapy for coinciding macrothrombosis in comprehensive COVID-19 care.
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Affiliation(s)
- Jae C Chang
- Department of Medicine, University of California Irvine School of Medicine, Irvine, CA, USA
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12
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Symmetrical Peripheral Gangrene of All Four Limbs of Unknown Etiology: a Rare Case Report. Indian J Surg 2021. [DOI: 10.1007/s12262-020-02366-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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13
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Macheka KT, Masamha T, Mungani H, Kumirayi L. Symmetrical peripheral gangrene: A rare clinical entity. Clin Case Rep 2020; 8:2914-2917. [PMID: 33363850 PMCID: PMC7752447 DOI: 10.1002/ccr3.3300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/08/2020] [Accepted: 08/09/2020] [Indexed: 11/18/2022] Open
Abstract
Symmetrical peripheral gangrene (SPG) may present initially with septicemia. Prompt identification and management of the underlying cause of SPG is central for the best outcome. Good management incorporates delaying early surgical intervention, suitable antibiotic therapy, judicious debridement, and skin grafting.
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Affiliation(s)
- Kudzai T. Macheka
- Department of SurgeryCollege of Health SciencesParirenyatwa HospitalHarareZimbabwe
| | - Tasimbanashe Masamha
- Department of SurgeryCollege of Health SciencesParirenyatwa HospitalHarareZimbabwe
| | - Hopewell Mungani
- Department of SurgeryCollege of Health SciencesParirenyatwa HospitalHarareZimbabwe
| | - Linda Kumirayi
- Department of SurgeryCollege of Health SciencesParirenyatwa HospitalHarareZimbabwe
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14
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Ghosh SK, Bandyopadhyay D, Dutta A, Jane EP, Biswas SK. A Profile of 23 Indian Patients with Purpura Fulminans: A Retrospective, Descriptive Study. Indian J Dermatol 2020; 65:381-387. [PMID: 33165344 PMCID: PMC7640787 DOI: 10.4103/ijd.ijd_8_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: Purpura fulminans (PF) is a potentially fatal uncommon disorder of intravascular thrombosis and is clinically characterized by rapidly progressive hemorrhagic infarction of the skin. Objective: To describe the clinical feature and outcome of a series of patients with PF. Materials and Methods: A descriptive study based on review of case records was carried out at a tertiary care hospital in Kolkata. Results: Twenty three consecutive cases seen over a period of 8 years were studied. The age range was 4 days to 78 years (mean 35.6 years) with a male to female ratio of 1:2.8. Hemorrhagic rash was the universal presenting symptom. Other major presenting features included pneumonia (26.1%), sudden-onset shock syndrome (21.7%), and urinary tract infection (17.4%). All patients presented with retiform purpura and lesional necrosis and 8 (34.8%) patients had associated peripheral gangrene. Nineteen (82.6%) patients had sepsis and 60.9% patients had vesiculo-bullous lesion. Pneumococcus was the most common (26.1%) pathogenic organism detected. The precise cause of PF could not be detected in two (8.7%) patients. One patient (4.3%) with neonatal PF had protein C deficiency. All patients had evidence of disseminated intravascular coagulation (DIC). One patient had to undergo a below knee surgical amputation and one patient had autoamputation of the digits. Ten (43.5%) patients succumbed to their illness. Seven of the 8 patients who had peripheral gangrene had a fatal outcome. Limitations: Relatively small sample size and a referral bias were a few limitations of the present study. Conclusion: The present study emphasizes that PF is a cutaneous marker of DIC. Association of peripheral gangrene, leukopenia and neutropenia may be the reason for the high mortality rate.
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Affiliation(s)
- Sudip Kumar Ghosh
- Department of Dermatology, Venereology, and Leprosy, R.G. Kar Medical College, Kolkata, India
| | | | - Abhijit Dutta
- Department of Pediatric Medicine, North Bengal Medical College, West Bengal, India
| | - Esther P Jane
- Department of Dermatology, Venereology, and Leprosy, R.G. Kar Medical College, Kolkata, India
| | - Surajit Kumar Biswas
- Department of Dermatology, Venereology, and Leprosy, R.G. Kar Medical College, Kolkata, India
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15
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Brozyna JR, Sardiña LA, Sharma A, Theil KS, Bergfeld WF. Acute purpura fulminans-a rare cause of skin necrosis: A single-institution clinicopathological experience. J Cutan Pathol 2020; 47:1003-1009. [PMID: 32356378 DOI: 10.1111/cup.13732] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 04/15/2020] [Accepted: 04/21/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Purpura fulminans, an uncommon syndrome of intravascular thrombosis with hemorrhagic infarction of the skin, is often accompanied by disseminated intravascular coagulation (DIC) and multi-organ failure, and may ultimately lead to death. METHODS Herein, we document 13 skin biopsies from 11 adult patients with the clinical diagnosis of sepsis and confirmed histopathologic diagnosis of intravascular thrombosis and/or DIC, compatible with acute infectious purpura fulminans (AIPF). Detailed history and clinical examination were performed, and the lesions were correlated with histopathologic findings. Any underlying medical disease was taken into consideration. RESULTS There were 5 males and 6 females with lower extremity or peri-incisional purpuric skin lesions. The most important comorbidities identified were a history of surgical procedure or neoplasm, although 4 patients had no relevant underlying history. Most skin biopsies revealed focal epidermal ischemia or necrosis and 3 showed full-thickness epidermal necrosis. In the underlying dermis, there were fibrin thrombi in superficial and deep blood vessels with acute inflammation. Changes of an inflammatory destructive vasculitis were identified in 5 cases. No bacteria or fungi were identified on histopathology. CONCLUSIONS AIPF is a rapidly-progressing medical emergency which may be identified by histopathology in culture-negative cases. Biopsies may show neutrophilic infiltrate without infective organisms.
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Affiliation(s)
- Jeremy R Brozyna
- Department of Dermatology, Cleveland Clinic, Cleveland, Ohio, USA.,Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Luis A Sardiña
- Department of Dermatology, Cleveland Clinic, Cleveland, Ohio, USA.,Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anurag Sharma
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Karl S Theil
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Wilma F Bergfeld
- Department of Dermatology, Cleveland Clinic, Cleveland, Ohio, USA.,Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
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16
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Singh P, Schwartz RA. Disseminated intravascular coagulation: A devastating systemic disorder of special concern with COVID-19. Dermatol Ther 2020; 33:e14053. [PMID: 32700813 PMCID: PMC7404500 DOI: 10.1111/dth.14053] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 07/14/2020] [Accepted: 07/20/2020] [Indexed: 12/13/2022]
Abstract
Disseminated intravascular coagulation (DIC) is linked with severe COVID‐19, prompting considerable concern. DIC can be a devastating systemic disorder. It is often markedly manifest on the skin as acrocyanosis or as petechiae and purpura with progression to hemorrhagic bullae. Subcutaneous hematomas may occur, as may thrombotic findings including necrosis and gangrene. The most common cause is infection, with special emphasis now on COVID‐19. We have reviewed the medical literature under the search terms “Disseminated intravascular coagulation” and “consumption coagulopathy” for the past two decades in the English language using Medline and Google Scholar to update special concerns and considerations, focusing on those with COVID‐19. Skin findings with DIC may be prominent. The severity of cutaneous lesions often correlates with the gravity of systemic disease. DIC is most effectively treated by addressing the underlying cause and resuscitating the patient using supportive measures. It is pivotal to recognize and treat DIC early, before deadly complications, such as multiple organ failure, arise.
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Affiliation(s)
- Parmvir Singh
- Dermatology, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Robert A Schwartz
- Dermatology, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
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17
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Klifto KM, Gurno CF, Grzelak MJ, Seal SM, Asif M, Hultman CS, Caffrey JA. Surgical outcomes in adults with purpura fulminans: a systematic review and patient-level meta-synthesis. BURNS & TRAUMA 2019; 7:30. [PMID: 31641673 PMCID: PMC6798408 DOI: 10.1186/s41038-019-0168-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 08/06/2019] [Indexed: 12/29/2022]
Abstract
Background Cutaneous manifestations of purpura fulminans (PF) present many challenges for clinicians and surgeons. In a state of septic shock complicated by limb ischemia, surgical interventions are necessary to control the pathological cascade and improve patient outcomes. The objective of this article was to report etiologies and surgical outcomes associated with cutaneous manifestations in adults. Methods This systematic review and meta-analysis compared 190 adult patients with etiologies, signs and symptoms, and surgical outcomes associated with cutaneous manifestations of PF. The PubMed, EMBASE, Cochrane Library, Web of Science, and Scopus databases were systematically and independently searched. Patient and clinical characteristics, surgical interventions, outcomes, and complications were recorded. Results Seventy-nine studies were eligible for the systematic review, and 77 were eligible for meta-analysis using Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) and Cochrane guidelines. A total of 71/190 (38%) cases reported surgical debridement. Fasciotomies were reported in 12/190 (6%) cases and 20 procedures. Amputations were reported in 154/190 (81%) cases. Reconstruction was reported in 45 cases. Skin grafts were applied in 31 cases. Flaps were used for reconstruction in 28 cases. Median (IQR) surgical procedures per patient were 4 (4, 5) procedures. Infectious organisms causing PF were 32% Neisseria meningitidis (n = 55) and 32% Streptococcus pneumonia (n = 55). Coagulase-negative Staphylococcus (95% confidence interval (CI)(8.2-177.9), p = 0.032), Haemophilus influenza (95%CI (7.2-133), p = 0.029), Streptococcus pneumonia (95% CI (13.3-75.9), p = 0.006), and West Nile Virus (95%CI (8.2-177.9), p = 0.032) were associated with significantly more extensive amputations compared to other organisms. Conclusion This systematic review and patient-level meta-analysis found the most common presentation of PF was septic shock from an infectious organism. Neisseria meningitidis and Streptococcus pneumonia were equally the most common organisms associated with PF. The majority of cases were not treated in a burn center. The most common surgeries were amputations, with below-the-knee-amputations being the most common procedure. Skin grafting was the most commonly performed reconstructive procedure. The most common complications were secondary infections. Organisms with significantly more extensive amputations were coagulase-negative Staphylococcus, Haemophilus influenza, Streptococcus pneumonia, and West Nile Virus. Interpretation of findings should be cautioned due to limited sample data.
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Affiliation(s)
- Kevin M Klifto
- 1Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD USA.,Johns Hopkins Burn Center, 4940 Eastern Avenue, Baltimore, MD 21224 USA
| | - Caresse F Gurno
- 2The Johns Hopkins University School of Nursing, Baltimore, MD USA
| | - Michael J Grzelak
- 1Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Stella M Seal
- 3Welch Medical Library, The Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Mohammed Asif
- 1Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD USA.,Johns Hopkins Burn Center, 4940 Eastern Avenue, Baltimore, MD 21224 USA
| | - C Scott Hultman
- 1Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD USA.,Johns Hopkins Burn Center, 4940 Eastern Avenue, Baltimore, MD 21224 USA
| | - Julie A Caffrey
- 1Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD USA.,Johns Hopkins Burn Center, 4940 Eastern Avenue, Baltimore, MD 21224 USA
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18
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Basnet S, Rajagopalan P, Dhital R, Qureshi A. Symmetrical Peripheral Gangrene Associated with Low Output Cardiac Failure. MEDICINA (KAUNAS, LITHUANIA) 2019; 55:E383. [PMID: 31319486 PMCID: PMC6681386 DOI: 10.3390/medicina55070383] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 02/22/2019] [Accepted: 07/15/2019] [Indexed: 11/17/2022]
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.
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Affiliation(s)
- Sijan Basnet
- Department of Medicine, Reading Hospital and Medical Center, West Reading, PA 19611, USA.
| | - Priya Rajagopalan
- Thomas Jefferson University Hospital, 1025 Walnut Street, Philadelphia, PA 19107, USA
| | - Rashmi Dhital
- Department of Medicine, Reading Hospital and Medical Center, West Reading, PA 19611, USA
| | - Ataul Qureshi
- Thomas Jefferson University Hospital, 1025 Walnut Street, Philadelphia, PA 19107, USA
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19
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Bhatti UF, Williams AM, Raghavendran K, Georgoff PE. Four-extremity amputation following disseminated intravascular coagulation and purpura fulminans. BMJ Case Rep 2019; 12:12/3/e228028. [PMID: 30898966 DOI: 10.1136/bcr-2018-228028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Purpura fulminans (PF) is a rare but serious complication of septic shock in adults. The complex disease course makes it challenging to manage the condition. Here, we present the case of a healthy young woman who presented with sepsis and new-onset erythematous lesions 4 days after the vaginal delivery of a healthy baby. The infectious source could not be identified, and the patient was started on antibiotics and resuscitated. However, her condition worsened, and she developed disseminated intravascular coagulation and PF. The septic episode slowly decreased in severity, but she sustained extensive ischaemic injuries to her extremities, for which she underwent four-limb amputation.
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Affiliation(s)
- Umar F Bhatti
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Aaron M Williams
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
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20
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Landry GJ, Mostul CJ, Ahn DS, McLafferty BJ, Liem TK, Mitchell EL, Jung E, Abraham CZ, Azarbal AF, McLafferty RB, Moneta GL. Causes and outcomes of finger ischemia in hospitalized patients in the intensive care unit. J Vasc Surg 2019; 68:1499-1504. [PMID: 29685512 DOI: 10.1016/j.jvs.2018.01.050] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Accepted: 01/22/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Vascular surgeons may be consulted to evaluate hospitalized patients with finger ischemia. We sought to characterize causes and outcomes of finger ischemia in intensive care unit (ICU) patients. METHODS All ICU patients who underwent evaluation for finger ischemia from 2008 to 2015 were reviewed. All were evaluated with finger photoplethysmography. The patients' demographics, comorbidities, ICU care (ventilator status, arterial lines, use of vasoactive medications), finger amputations, and survival were also recorded. ICU patients were compared with concurrently evaluated non-ICU inpatients with finger ischemia. RESULTS There were 98 ICU patients (55 male, 43 female) identified. The mean age was 57.1 ± 16.8 years. Of these patients, 42 (43%) were in the surgical ICU and 56 (57%) in the medical ICU. Seventy (72%) had abnormal findings on finger photoplethysmography, 40 (69%) unilateral and 30 (31%) bilateral. Thirty-six (37%) had ischemia associated with an arterial line. Twelve (13%) had concomitant toe ischemia. Eighty (82%) were receiving vasoactive medications at the time of diagnosis, with the most frequent being phenylephrine (55%), norepinephrine (47%), ephedrine (31%), epinephrine (26%), and vasopressin (24%). Treatment was with anticoagulation in 88 (90%; therapeutic, 48%; prophylactic, 42%) and antiplatelet agents in 59 (60%; aspirin, 51%; clopidogrel, 15%). Other frequently associated conditions included mechanical ventilation at time of diagnosis (37%), diabetes (34%), peripheral arterial disease (32%), dialysis dependence (31%), cancer (24%), and sepsis (20%). Only five patients (5%) ultimately required finger amputation. The 30-day, 1-year, and 3-year survival was 84%, 69%, and 59%. By Cox proportional hazards modeling, cancer (hazard ratio, 2.4; 95% confidence interval, 1.1-5.6; P = .035) was an independent predictor of mortality. There were 50 concurrent non-ICU patients with finger ischemia. Non-ICU patients were more likely to have connective tissue disorders (26% vs 13%; P = .05) and hyperlipidemia (42% vs 24%; P = .03) and to undergo finger amputations (16% vs 5%; P = .03). CONCLUSIONS Finger ischemia in the ICU is frequently associated with the presence of arterial lines and the use of vasopressor medications, of which phenylephrine and norepinephrine are most frequent. Anticoagulation or antiplatelet therapy is appropriate treatment. Whereas progression to amputation is rare, patients with finger ischemia in the ICU have a high rate of mortality, particularly in the presence of cancer. Non-ICU patients hospitalized with finger ischemia more frequently require finger amputations, probably because of more frequent connective tissue disorders.
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Affiliation(s)
- Gregory J Landry
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore.
| | - Courtney J Mostul
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Daniel S Ahn
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Bryant J McLafferty
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Timothy K Liem
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Erica L Mitchell
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Enjae Jung
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Cherrie Z Abraham
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Amir F Azarbal
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Robert B McLafferty
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Gregory L Moneta
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
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21
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Ursin Rein P, Jacobsen D, Ormaasen V, Dunlop O. Pneumococcal sepsis requiring mechanical ventilation: Cohort study in 38 patients with rapid progression to septic shock. Acta Anaesthesiol Scand 2018; 62:1428-1435. [PMID: 30132782 DOI: 10.1111/aas.13236] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 07/08/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND The aim was to study the course of severe pneumococcal sepsis in patients who rapidly developed septic shock with multiorgan failure. METHODS Combined retrospective and prospective cohort study of all patients with pneumococcal sepsis requiring mechanical ventilation admitted to our Medical Intensive Care Unit at Oslo University Hospital Ullevaal, during an 8-year period (01 January 2006 to 31 December 2013). The inclusion criteria were growth of Streptococcus pneumoniae in blood culture and respiratory failure treated with invasive mechanical ventilation. RESULTS Thirty-eight patients were included. Median age was 57 years (interquartile range 49-68, range 22-79). For 84% (32/38), it took <24 hours from the first medical evaluation until they were in septic shock. Initial clinical features were variable; none were treated with antibiotics before hospital admission. Median Sequential Organ Failure Assessment (SOFA) score at admission was 11 (range 1-15) and maximum 15 (range 5-22), all patients developed multiorgan failure. Mutilating complications were seen in 47% (18/38) of the patients: six with amputations, 11 had adverse neurological complications and one patient both. In-hospital mortality was 40% (15/38), 20% (8/38) survived with sequelae and 40% (15/38) returned to their habitual state. Poor outcome was associated with meningitis, disseminated intravascular coagulation, and gastrointestinal symptoms. CONCLUSION In this patient cohort with pneumococcal sepsis and respiratory failure rapid development of septic shock was seen in all cases, even in young healthy individuals. Initial clinical features were variable; none were treated with antibiotics before admission. Mortality was high (40%), as was morbidity with limb amputations and neurological complications.
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Affiliation(s)
| | - Dag Jacobsen
- Department of Acute Medicine Oslo University Hospital Ullevaal Oslo Norway
| | - Vidar Ormaasen
- Department of Infectious Diseases Oslo University Hospital Ullevaal Oslo Norway
| | - Oona Dunlop
- Department of Acute Medicine Oslo University Hospital Ullevaal Oslo Norway
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22
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Okuzono S, Ishimura M, Kanno S, Sonoda M, Kaku N, Motomura Y, Nishio H, Oba U, Hanada M, Fukushi JI, Urata M, Kang D, Takada H, Ohga S. Streptococcus pyogenes-purpura fulminans as an invasive form of group A streptococcal infection. Ann Clin Microbiol Antimicrob 2018; 17:31. [PMID: 29986727 PMCID: PMC6036671 DOI: 10.1186/s12941-018-0282-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 06/26/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Streptococcus pyogenes is an uncommon pathogen of purpura fulminans, and the pathogenesis of S. pyogenes-purpura fulminans remains unclear because of paucity of cases. We reported a pediatric case of S. pyogenes-purpura fulminans with literature review of the disease. CASE PRESENTATION A 3-year-old boy showed limping, lethargy and acral gangrene within 24 h. A diagnosis of S. pyogenes-purpura fulminans was made for bacterial isolation from throat and peripheral blood. Intensive therapy led to a survival with amputation of the left distal metatarsal bone, and normal development. The isolated M12 carried no mutation of csrS/R or rgg. Thrombophilia or immunodeficiency was excluded. DISCUSSION Twelve-reported cases (9 pediatric and 3 elderly) of S. pyogenes-purpura fulminans started with shock and coagulopathy. Five patients age < 8 years had no underlying disease and survived. One youngest and two immunocompromised patients died. CONCLUSION Streptococcus pyogenes-acute infectious purpura fulminans is a distinctive rare form of aggressive GAS infections.
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Affiliation(s)
- Sayaka Okuzono
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Masataka Ishimura
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Shunsuke Kanno
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Motoshi Sonoda
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Noriyuki Kaku
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Yoshitomo Motomura
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Hisanori Nishio
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Utako Oba
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
- Division of Pediatrics, Oita Prefectural Hospital, Oita, Japan
| | - Masuo Hanada
- Department of Plastic Surgery, Kyushu University Hospital, Fukuoka, Japan
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Jun-ichi Fukushi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Michiyo Urata
- Department of Clinical Chemistry and Laboratory Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Dongchon Kang
- Department of Clinical Chemistry and Laboratory Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Hidetoshi Takada
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
| | - Shouichi Ohga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
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Lower Extremity Salvage with Thoracodorsal Artery Perforator Free Flap in Condition of Symmetrical Peripheral Gangrene. BIOMED RESEARCH INTERNATIONAL 2018; 2018:6508607. [PMID: 29854775 PMCID: PMC5964422 DOI: 10.1155/2018/6508607] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 02/28/2018] [Accepted: 03/27/2018] [Indexed: 11/18/2022]
Abstract
Symmetrical peripheral gangrene (SPG) is rare but devastating complication which is characterized by symmetrical ischemic change of the distal extremities. In this report, we describe our management protocol for SPG, focusing on surgical approaches. Between January 2007 and February 2016, 10 thoracodorsal artery perforator (TDAP) free flaps were performed in 6 patients with SPG. Three patients were male and mean age was 56 (range, 44-69) years. All the patients were in shock. The causes of shock were sepsis in 4 cases, respiratory arrest in 1 case, and hypovolemia in 1 case. Eight transmetatarsal amputations and 2 Lisfranc amputations were performed. Flap sizes ranged from 7 × 11 cm to 25 × 15 cm. There were 3 cases of partial necrosis of the flap: two healed conservatively with dressings and one required skin graft. Three of the patients were later able to walk independently at Functional Ambulation Classification (FAC) level 6, one patient could walk independently on level surfaces at FAC level 5, and 2 could walk independently using walking aids, classified at FAC level 4. The average follow-up period was 18 (range, 6-54) months. In patients with SPG, minimal bone amputation and foot salvage with TDAP flaps were successful. Separate reconstruction of bone and soft tissue had good outcomes.
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24
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Symmetrical Peripheral Gangrene: Mechanisms for Limb Loss in the ICU in Patients With Retained Pulses. ACTA ACUST UNITED AC 2018. [DOI: 10.1097/cpm.0000000000000253] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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Ruffin N, Vasa CV, Breakstone S, Axman W. Symmetrical peripheral gangrene of bilateral feet and unilateral hand after administration of vasopressors during septic shock. BMJ Case Rep 2018; 2018:bcr-2017-223602. [PMID: 29437714 PMCID: PMC5836706 DOI: 10.1136/bcr-2017-223602] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
We report a case of a 75-year-old Hispanic man treated for septic shock after undergoing surgery for impacted renal stones. He was given vasopressors and later developed symmetrical peripheral gangrene (SPG) on both his feet and left hand. SPG is a serious and rare condition presenting clinically as an acute onset of ischaemia with no vessel occlusion. Vasopressors are identified as a contributing factor in SPG development. The patient ultimately underwent transmetatarsal amputations of both feet and amputation of three digits on his left hand. Early monitoring and swift management of peripheral ischaemia are essential when using vasopressors for the treatment of septic shock.
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Affiliation(s)
- Naeemah Ruffin
- Orthopedics, Division of Podiatry, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Chirag V Vasa
- Infectious Diseases, Mount Sinai Queens Hospital, Astoria, New York, USA
| | - Sarah Breakstone
- Orthopedics, Division of Podiatry, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Wayne Axman
- Orthopedics, Division of Podiatry, Mount Sinai Queens Hospital, Astoria, New York, USA
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26
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Jung KJ, Nho JH, Cho HK, Hong S, Won SH, Chun DI, Kim B. Amputation of multiple limbs caused by use of inotropics: Case report, a report of 4 cases. Medicine (Baltimore) 2018; 97:e9800. [PMID: 29384879 PMCID: PMC5805451 DOI: 10.1097/md.0000000000009800] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE We present 4 cases of symmetrical peripheral gangrene (SPG) associated with use of inotropic agent to elevate blood pressure. SPG is a relatively rare phenomenon characterized by symmetrical distal ischemic damage that leads to gangrene of 2 or more sites in the absence of large blood vessel obstruction, where vasoconstriction rather than thrombosis is implicated as the underlying pathophysiology. We present 4 SPG cases of the multiple limbs amputation, associated with inevitable use of inotropic agents. PATIENT CONCERNS Inotropic agents including dopamine and norepinephrine are used frequently in the treatment of hypotension, and its effectiveness in treating shock is firmly established. However, it can be caused peripheral gangrene by prolonged administration of high dose inotropics, inducing the constant contraction of the peripheral blood vessels. DIAGNOSIS These 4 patients had different clinical histories and background factors, but each experienced sepsis. The level of amputation is determined by the line of demarcation in concert with considerations of the biomechanics of stump stability, weight bearing, and ambulation. INTERVENTIONS After recovering of general conditions and completion of demarcation, these 4 patients underwent the amputation of multiple limbs.(bilateral amputations of upper extremities or bilateral amputations of lower extremities). OUTCOMES In each patient, there was no additional amputation caused by extension of SPG, and the rehabilitation with appropriate orthosis was performed. Treatment of underlying disease were continued too. LESSONS It is important to alert the possibility of amputations, according to the use of inevitable inotropics. We recommended the careful use of the inotropic agents to the physicians in treating septic shock.
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Affiliation(s)
- Ki Jin Jung
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, Cheonan-si
| | - Jae-Hwi Nho
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Seoul, Yongsan-gu, Seoul, South Korea
| | - Hyeung-Kyu Cho
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Seoul, Yongsan-gu, Seoul, South Korea
| | - Sijohn Hong
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, Cheonan-si
| | - Sung Hun Won
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Seoul, Yongsan-gu, Seoul, South Korea
| | - Dong-Il Chun
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Seoul, Yongsan-gu, Seoul, South Korea
| | - Byungsung Kim
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Seoul, Yongsan-gu, Seoul, South Korea
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27
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Foead AI, Mathialagan A, Varadarajan R, Larvin M. Management of Symmetrical Peripheral Gangrene. Indian J Crit Care Med 2018; 22:870-874. [PMID: 30662227 PMCID: PMC6311972 DOI: 10.4103/ijccm.ijccm_379_18] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Symmetrical peripheral gangrene (SPG) is a rare, debilitating disease that deserves more widespread concern among the medical fraternities. The objective of this review is to outline the etiology, pathology findings, and management practices of SPG. About 18%–40% mortality rate was reported, and survivors have high frequency of multiple limb amputations. SPG is the hallmark of disseminated intravascular coagulation (DIC). The main pathogenesis theory, to date, is microthrombosis associated with disturbed procoagulant–anticoagulant balance. The treatment of SPG is largely anecdotal and theoretically involves heparin-based anticoagulation and substitution of natural anticoagulants. Early recognition, prompt management of DIC, and underlying conditions may halt the progression of the disease. The multicenter randomized controlled trial should be set up to formulate the proper treatment guidelines.
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Affiliation(s)
- Agus Iwan Foead
- Department of Orthopedics, School of Medicine, Perdana University-Royal College of Surgeons Ireland Selangor, Malaysia
| | - Amuthaganesh Mathialagan
- Department of Pharmacology, School of Medicine, Perdana University-Royal College of Surgeons Ireland Selangor, Malaysia
| | - Raghu Varadarajan
- Department of Surgery, School of Medicine, Perdana University-Royal College of Surgeons Ireland Selangor, Malaysia
| | - Michael Larvin
- Department of Surgery, School of Medicine, Perdana University-Royal College of Surgeons Ireland Selangor, Malaysia
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Tsang DC, Carrillo RG. A case of symmetrical peripheral gangrene associated with transvenous lead extraction. HeartRhythm Case Rep 2017; 3:436-439. [PMID: 28948150 PMCID: PMC5602803 DOI: 10.1016/j.hrcr.2017.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Darren C Tsang
- Department of Surgery, Division of Cardiothoracic Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Roger G Carrillo
- Department of Surgery, Division of Cardiothoracic Surgery, University of Miami Miller School of Medicine, Miami, Florida
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Ghosh SK, Majumder B, Ghosh S, Chatterjee S, Agarwal M. Symmetrical peripheral gangrene complicating ventricular pseudoaneurysm: a report of an unusual case and a brief review of the literature. An Bras Dermatol 2017; 91:169-171. [PMID: 28300932 PMCID: PMC5325031 DOI: 10.1590/abd1806-4841.20165061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 10/10/2015] [Indexed: 11/29/2022] Open
Abstract
Symmetrical peripheral gangrene is an ischemic necrosis simultaneously involving
the distal portions of two or more extremities without any proximal arterial
obstruction or vasculitis. It may occur as a result of a large number of
infectious and non-infectious causes. A few cases of symmetrical peripheral
gangrene associated with cardiac disease have been described in the literature.
We describe a case of symmetrical peripheral gangrene complicating ventricular
pseudoaneurysm, probably a hitherto unreported occurrence. In this report, we
sought to emphasize the importance of cardiac evaluation while dealing with a
case of symmetrical peripheral gangrene.
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Pino PA, Román JA, Fernández F. Delayed Surgical Debridement and Use of Semiocclusive Dressings for Salvage of Fingers After Purpura Fulminans. Hand (N Y) 2016; 11:NP34-NP37. [PMID: 28149224 PMCID: PMC5256663 DOI: 10.1177/1558944716661996] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background: Purpura fulminans is a condition characterized by rapidly evolving skin necrosis and disseminated intravascular coagulation. Early recognition and aggressive supportive management has led to a decrease in its mortality rate, but most of these patients must undergo extensive soft tissue debridement and partial or total limb amputation. There is controversial evidence about the timing of surgery, suggesting that some patients may benefit from delayed debridement with limb preservation. Methods: We present a case of an 86-year-old patient who developed skin necrosis of his four limbs after infectious purpura fulminans. He was treated in the ICU with supportive measures and antibiotic treatment. Surgical debridement was delayed for 4 weeks until necrosis delimitation. Results: Only upper extremity debridement was necessary. Four fingers, including one thumb, were salvaged and successfully treated with semi-occlusive dressing without complications. Conclusion: Early recognition of infectious PF and timely supportive management are important pillars of its treatment. Delayed surgical debridement allows for less aggressive resection and good functional outcome.
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Affiliation(s)
- Paula A. Pino
- Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Javier A. Román
- Pontificia Universidad Católica de Chile, Santiago, Chile,Javier A. Román, Hand Surgeon, Department of Orthopedic Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Marcoleta 352, Santiago, Chile.
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31
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Patel ML, Sachan R, Verma A, Shyam R. Symmetrical peripheral gangrene: Unusual complication of dengue fever. Adv Biomed Res 2016; 5:154. [PMID: 27713875 PMCID: PMC5046798 DOI: 10.4103/2277-9175.188940] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 07/16/2015] [Indexed: 12/02/2022] Open
Abstract
Symmetrical peripheral gangrene (SPG) is a rare clinical entity, infective, and noninfective both types of etiologies are responsible. The basic underlying pathology in SPG is being disseminated intravascular coagulation and carries a high mortality. Here, we describe a 52-year-old male with dengue fever, who developed bilateral symmetrical dry gangrene of both hand and feet. His dengue IgM antibody was positive. All the peripheral pulses of the affected limbs were palpable. Color Doppler study of upper and lower limb vessels showed normal flow. The patient was managed with intravenous fluids, low molecular weight heparin, and fresh frozen plasma. His general condition was improved within 72 h with no further progression of gangrene. Clinician should suspect the possibility of SPG while dealing a case of dengue fever presenting as peripheral gangrene.
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Affiliation(s)
- M L Patel
- Department of Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Rekha Sachan
- Department of Obstetrics and Gynaecology, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Amita Verma
- Department of Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Radhey Shyam
- Department of Geriatric ICU, King George's Medical University, Lucknow, Uttar Pradesh, India
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Konda MK, Chang S, Zaccheo M. Purpura fulminans and severe sepsis due to Pasteurella multocida infection in an immunocompetent patient. BMJ Case Rep 2016; 2016:bcr-2016-214891. [PMID: 27298290 DOI: 10.1136/bcr-2016-214891] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 75-year-old woman was admitted into the intensive care unit, with severe sepsis and renal failure. She developed purpura fulminans (PF) of bilateral upper and lower extremities along with gangrene on the tips of her fingers and toes. Blood cultures confirmed Pasteurella multocida as the causative organism. Despite aggressive supportive measures, the patient remained dependent on high doses of vasopressors and the gangrene progressed. She ultimately succumbed to her underlying severe sepsis. PF is a rare and fatal dermatological emergency commonly seen in children, but it also occurs in adults. Acute infectious PF occurs secondary to severe sepsis and P. multocida is a rare cause of PF. To the best of our knowledge, this is only the second reported case of PF due to P. multocida in an adult.
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Affiliation(s)
- Monoj Kumar Konda
- Department of Internal Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
| | - Stephanie Chang
- Department of Internal Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
| | - Mathew Zaccheo
- Department of Critical Care, Bronson Methodist Hospital, Kalamazoo, Michigan, USA
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Theilacker C, Ludewig K, Serr A, Schimpf J, Held J, Bögelein M, Bahr V, Rusch S, Pohl A, Kogelmann K, Frieseke S, Bogdanski R, Brunkhorst FM, Kern WV. Overwhelming Postsplenectomy Infection: A Prospective Multicenter Cohort Study. Clin Infect Dis 2015; 62:871-878. [PMID: 26703862 DOI: 10.1093/cid/civ1195] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 12/14/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Recent population-based cohort studies have questioned the role of pneumococci as the most frequent pathogen causing severe infection in patients after splenectomy. The aim of the study was to define the causative pathogens and clinical presentation of patients with overwhelming postsplenectomy infection (OPSI). METHODS In a prospective cohort study in 173 German intensive care units, we searched for patients with and without asplenia and community-acquired severe sepsis/septic shock. Clinical and laboratory variables and survival of patients were assessed. RESULTS Fifty-two patients with severe sepsis or septic shock with asplenia and 52 without asplenia were included. OPSI patients more often had a history of malignancy (38% vs 17%; P = .016) and had a lower body mass index (24 kg/m(2) vs 28 kg/m(2); P = .004). Streptococcus pneumoniae was detected more frequently in OPSI patients (42% vs 12% without asplenia; P < .001) and more frequently manifested as bloodstream infection (31% vs 6%; P = .002). Gram-negative infection was similar in both groups (12% vs 19%; P = .157). Pneumococcal vaccine coverage of OPSI patients was low overall (42% vs 8% among patients without asplenia; P < .001). Purpura fulminans was a frequent complication, developing in 19% of OPSI patients vs 5% of patients without asplenia (P = .038). The interval between splenectomy and OPSI was 6 years (range, 1 month-50 years). On multivariable Poisson regression, asplenia was the only predictive variable independently associated with pneumococcal sepsis (adjusted relative risk, 2.53 [95% confidence interval, 1.06-6.08]). CONCLUSIONS Pneumococcal infections remain the most important cause of severe sepsis and septic shock following splenectomy.
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Affiliation(s)
- Christian Theilacker
- Center for Chronic Immunodeficiency.,Division of Infectious Diseases, Department of Medicine
| | | | | | | | - Jürgen Held
- Institute for Microbiology and Hygiene.,Mikrobiologisches Institut, Universitätsklinikum Erlangen und Friedrich-Alexander-Universität Erlangen-Nürnberg
| | - Martin Bögelein
- Center for Chronic Immunodeficiency.,Division of Infectious Diseases, Department of Medicine.,Clinical Research Unit, Freiburg University Medical Center
| | | | - Stephan Rusch
- Clinical Research Unit,Freiburg University Medical Center
| | - Annette Pohl
- Center for Chronic Immunodeficiency.,Clinical Research Unit, Freiburg University Medical Center
| | | | | | - Ralph Bogdanski
- Klinikum rechts der Isar, Technical University, Munich, Germany
| | - Frank M Brunkhorst
- Center for Sepsis Control and Care.,Paul Martini Sepsis Research Group, Jena University Hospital
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Shah S, Fite LP, Lane N, Parekh P. Purpura fulminans associated with acute West Nile virus encephalitis. J Clin Virol 2015; 75:1-4. [PMID: 26686320 DOI: 10.1016/j.jcv.2015.11.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Revised: 11/17/2015] [Accepted: 11/26/2015] [Indexed: 12/01/2022]
Abstract
Purpura fulminans is a progressive thrombotic disorder that presents with widespread purpura due to deficiency or dysfunction of protein C or protein S. Lesions present as well-demarcated erythematous macules that progress to irregular areas of hemorrhagic necrosis.West Nile virus is a member of the Flaviviridae family transmitted to humans through the bite of various mosquito species. It manifests as West Nile fever in 25% of those infected and less commonly as neuroinvasive disease. An African American man in his fortiespresented with altered mental status and was noted to have evidence of disseminated intravascular coagulation according to his lab data. He then developed dusky skin discoloration and systemic flaccid bullae with desquamation. Biopsy was consistent with purpura fulminans and the patient eventually developed symmetric peripheral gangrene, requiring amputations of all four extremities. Infectious work up revealed positive testing for IgM and IgG antibodies in serum and cerebrospinal fluid leading to the diagnosis of acute West Nile Virus encephalitis. We present this case to describe the rarely reported association of purpura fulminans with West Nile Virus infection.
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Affiliation(s)
- Sheevam Shah
- Texas A&M Health Science Center College of Medicine, Temple, TX, United States
| | - Laura Paul Fite
- Department of Dermatology, Scott & White Memorial Hospital, Temple, TX, United States.
| | - Natalie Lane
- Department of Dermatology, Scott & White Memorial Hospital, Temple, TX, United States
| | - Palak Parekh
- Department of Dermatology, Scott & White Memorial Hospital, Temple, TX, United States
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Liao CY, Huang SC, Lin CH, Wang CC, Liu MY, Ben RJ, Kuo WH, Lee CC. Successful resolution of symmetrical peripheral gangrene after severe acute pancreatitis: a case report. J Med Case Rep 2015; 9:213. [PMID: 26376919 PMCID: PMC4573942 DOI: 10.1186/s13256-015-0688-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 08/21/2015] [Indexed: 12/28/2022] Open
Abstract
Introduction Symmetrical peripheral gangrene is an uncommon but devastating complication in critically ill patients, and it has a high mortality. It is seen in a wide variety of medical conditions, presenting as symmetrical gangrene of two or more extremities without large blood vessel obstruction. Case presentation We report a case of a 44-year-old Chinese man who was diagnosed with alcohol-related severe acute pancreatitis and presented with systemic inflammatory response syndrome and intractable vomiting. On the fourth day of admission, the patient developed cyanosis and gangrene of the fingers bilaterally. His cyanosis and gangrene did not resolve despite tapering of the vasopressor treatment. Gradually, his digital gangrene improved after administration of anti-platelet medication and pentoxifylline. Conclusions To the best of our knowledge, this is the first case report of symmetrical peripheral gangrene occurring after acute pancreatitis with successful resolution. We highlight the importance of prompt and aggressive fluid resuscitation and consideration of multiple treatment options to prevent a hypovolemic state caused by acute pancreatitis.
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Affiliation(s)
- Chen-Yi Liao
- Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan.
| | - Shih-Chung Huang
- Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan.
| | - Cheng-Hui Lin
- Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan.
| | - Chih-Chiang Wang
- Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan.
| | - Mei-Yu Liu
- Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan.
| | - Ren-Jy Ben
- Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan.
| | - Wu-Hsien Kuo
- Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan.
| | - Ching-Chang Lee
- Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan.
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Dong J, Zhang L, Rao G, Zhao X. Complicating Symmetric Peripheral Gangrene after Dopamine Therapy to Patients with Septic Shock. J Forensic Sci 2015. [PMID: 26223832 DOI: 10.1111/1556-4029.12844] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Dopamine is commonly used as a first-line agent in the treatment of patients with septic shock. The use of dopamine rarely causes symmetric peripheral dry gangrene. If the symmetric peripheral dry gangrene occurs in the patient after dopamine injection, it easily leads to disagreement between doctors and patients. A 60-year-old woman who had sudden septic shock was sent to intensive care unit (ICU). She was received dopamine injection according to the routine during treatment. Over the next 3 months, her limbs developed to dry gangrene and required amputation. The result shows that the occurrence of dry gangrene could only be associated with the long-term excessive use of dopamine according to the medical records. Although dopamine is a conventional drug for the treatment of septic shock, the forensic workers and clinicians must realize that vasopressors such as dopamine have been implicated directly or as a contributory cause in dry gangrene cases.
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Affiliation(s)
- Juan Dong
- Department of Forensic Medicine, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Lingli Zhang
- Department of Forensic Medicine, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Guangxun Rao
- Department of Forensic Medicine, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xiaohong Zhao
- Department of Forensic Medicine, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, 430030, China
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Four limb amputations due to peripheral gangrene from inotrope use - Case report and review of the literature. Int J Surg Case Rep 2015; 14:63-5. [PMID: 26232740 PMCID: PMC4573421 DOI: 10.1016/j.ijscr.2015.07.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 07/17/2015] [Accepted: 07/17/2015] [Indexed: 12/03/2022] Open
Abstract
Rare case of 4 limb amputations due to peripheral gangrene from inotrope use. Contributing factors include disseminated intravascular coagulation and septic shock. Differential diagnoses include symmetrical peripheral gangrene and purpura fulminans. Some therapeutic agents are beneficial for peripheral ischemia with dopamine use. Single-stage elective amputations led to satisfactory rehabilitation with prosthesis.
INTRODUCTION We present a rare case of 4 limb amputations due to peripheral gangrene which resulted from the use of inotropes for septic shock. PRESENTATION OF CASE A 72-year-old woman with no past medical history presented with fever and pain in bilateral big toes. She was diagnosed with Streptococcal pneumoniae septicaemia and was started on broad spectrum antibiotics, dopamine and noradrenaline in the medical intensive care unit. She developed peripheral gangrene of all 4 extremities due to microvascular spasm from inotrope use and 4 limb amputations were performed electively in a single stage. DISCUSSION The gangrene was contributed by the presence of disseminated intravascular coagulation and septic shock. There was no evidence of an autoimmune disorder or vasculitis on laboratory investigations and tissue histology. CONCLUSION Microvascular spasm is a rare complication of inotrope use which may lead to extensive peripheral gangrene. Anecdotal reports of reversal agents have been discussed. Four limb amputations are a reasonable option especially if done in an elective setting after the gangrene has demarcated itself. Rehabilitation with prosthesis after 4 limb amputations can result in good functional outcome.
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Chatterjee K, Sen C. Symmetrical Peripheral Gangrene Complicating Vivax Malaria. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2015. [DOI: 10.4103/0972-0820.180128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023] Open
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Pastushenko I, Gracia-Cazaña T, Casado-Arroyo R. [Purpura and necrosis of sudden onset in a patient with fever]. Enferm Infecc Microbiol Clin 2014; 33:129-30. [PMID: 25542339 DOI: 10.1016/j.eimc.2014.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Revised: 07/06/2014] [Accepted: 07/10/2014] [Indexed: 11/25/2022]
Affiliation(s)
- Ievgenia Pastushenko
- Departamento de Dermatología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - Tamara Gracia-Cazaña
- Departamento de Dermatología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España.
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Tanosaki M, Shimizu N, Lian CG, Jurchak M, Patel V. Purpura fulminans managed with multi-limb amputation: substituted judgment and surrogate decision-making in the surgical management of necrotizing soft tissue infections. Surg Infect (Larchmt) 2014; 15:853-6. [PMID: 25494230 DOI: 10.1089/sur.2013.223] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Purpura fulminans (PF) is a rare but lethal complication of severe infection. Aggressive surgical debridement of irreversibly devitalized tissue improves survival frequently at the cost of disfigurement. The ethical dilemma of surrogate decision-making for these often incapacitated patients presents a unique challenge for acute care surgeons managing necrotizing soft tissue infections (NSTI). METHODS Case presentation and scholarly discussion of substituted judgment. RESULTS A previously healthy 72-y-old fisherman developed PF as a consequence of Neisseria meningiditis severe sepsis requiring bilateral partial finger amputations and bilateral below-knee amputations of the affected gangrenous extremities. Skin biopsy confirmed the clinical impression of disseminated intra-vascular coagulation (DIC). During his 55-d hospitalization, medical decisions were made by a surrogate because the patient's mental status failed to recover to his pre-morbid baseline. A literature review revealed a paucity of data on the accuracy of a health care agent's ability to represent a patient's preferences accurately in elective as well as emergency surgery. CONCLUSIONS Patients with NSTI and the surgeons who care for them are often confronted with the need to make prompt decisions of radical debridement or amputation. These patients are frequently incapable of making these decisions because of the severity of systemic illness. In such cases, physicians must help patient surrogates or health care agents (when identified) navigate a complex process of acute interventions balancing known or inferred patient's wishes. We urge surgeons to become familiar with the concept of substituted judgment and the challenges of surrogate decision-making.
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Abstract
Burn units provide a unique set of resources to patients with complex wounds, sepsis, and organ failures. This resource set is useful in a number of traumatic, infectious, and medical conditions as well. Further, many burn patients have sustained simultaneous non-burn trauma which will be managed in burn programs.
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Affiliation(s)
- Robert L Sheridan
- Boston Shriners Hospital for Children, 51 Blossom Street, Boston, MA 02114, USA.
| | - David Greenhalgh
- Department of Surgery, Shriners Hospitals for Children Northern California, University of California, Davis, 2425 Stockton Boulevard, Sacramento, CA 95817, USA
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Yoshimoto K, Okuma Y, Nakamura T, Mita T, Mitsumoto A, Yamasaki N, Tobimatsu Y, Akai M. Limb fitting for quadruple amputees: report of two cases of symmetrical peripheral gangrene caused by pneumococcal purpura fulminans. Prosthet Orthot Int 2013; 37:489-94. [PMID: 23558402 DOI: 10.1177/0309364613481797] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND We report our experiences of prosthetic fitting in quadruple amputees. Two patients underwent quadruple amputation after suffering from disseminated intravascular coagulation in conjunction with pneumococcemia with purpura fulminans. CASE DESCRIPTION AND METHODS The first patient, a 52-year-old man, underwent bilateral transradial, left transtibial, and right transfemoral amputation, and the second patient, a 62-year-old man, underwent bilateral transradial and bilateral transfemoral amputation, both for symmetrical peripheral gangrene subsequent to septic shock. FINDINGS AND OUTCOMES The amputations were accompanied by skin damage due to ischemic tissue changes both on the stumps and on the nose and/or lips. The combination of the intensive prosthetic rehabilitation program and supportive medical care led to completely independent functioning, including driving a car, with the use of four prosthetic limbs and a wheelchair in both cases. CONCLUSION Early initiation of a multidisciplinary approach can properly address impairments and minimize future disability.
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Affiliation(s)
- Kenji Yoshimoto
- 1Department of Rehabilitation Medicine, Hospital for National Rehabilitation Center, Tokorozawa, Japan
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Lerolle N, Carlotti A, Melican K, Aubey F, Pierrot M, Diehl JL, Caille V, Hékimian G, Gandrille S, Mandet C, Bruneval P, Dumenil G, Borgel D. Assessment of the interplay between blood and skin vascular abnormalities in adult purpura fulminans. Am J Respir Crit Care Med 2013; 188:684-92. [PMID: 23924269 DOI: 10.1164/rccm.201302-0228oc] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Purpura fulminans in adults is a rare but devastating disease. Its pathophysiology is not well known. OBJECTIVES To understand the pathophysiology of skin lesions in purpura fulminans, the interplay between circulating blood and vascular alterations was assessed. METHODS Prospective multicenter study in four intensive care units. Patients with severe sepsis without skin lesions were recruited as control subjects. MEASUREMENTS AND MAIN RESULTS Twenty patients with severe sepsis and purpura fulminans were recruited for blood sampling, and skin biopsy was performed in deceased patients. High severity of disease and mortality rates (80%) was observed. Skin biopsies in purpura fulminans lesions revealed thrombosis and extensive vascular damage: vascular congestion and dilation, endothelial necrosis, alteration of markers of endothelial integrity (CD31) and of the protein C pathway receptors (endothelial protein C receptor, thrombomodulin). Elevated plasminogen activating inhibitor-1 mRNA was also observed. Comparison with control patients showed that these lesions were specific to purpura fulminans. By contrast, no difference was observed for blood hemostasis parameters, including soluble thrombomodulin, activated protein C, and disseminated intravascular coagulation markers. Bacterial presence at the vascular wall was observed specifically in areas of vascular damage in eight of nine patients tested (including patients with Streptococcus pneumoniae, Neisseria meningitidis, Escherichia coli, and Pseudomonas aeruginosa infection). CONCLUSIONS Thrombi and extensive vascular damage with multifaceted prothrombotic local imbalance are characteristics of purpura fulminans. A "vascular wall infection" hypothesis, responsible for endothelial damage and subsequent skin lesions, can be put forward.
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Affiliation(s)
- Nicolas Lerolle
- 1 Département de Réanimation Médicale et Médicine Hyperbare, Centre Hospitalier Universitaire Angers, and Faculté de Médecine, Université d'Angers, Angers, France
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Purpura Fulminans Associated With a Cardiac Implantable Electronic Device Infection. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2013. [DOI: 10.1097/ipc.0b013e31826991f4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Ohga S, Ishiguro A, Takahashi Y, Shima M, Taki M, Kaneko M, Fukushima K, Kang D, Hara T. Protein C deficiency as the major cause of thrombophilias in childhood. Pediatr Int 2013; 55:267-71. [PMID: 23521084 DOI: 10.1111/ped.12102] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 03/07/2013] [Accepted: 03/18/2013] [Indexed: 12/12/2022]
Abstract
Genetic predisposition of thromboembolism depends on the racial background. Factor V Leiden (G1691A) and factor II mutation (G20210A) are the leading causes of inherited thrombophilias in Caucasians, but are not found in Asian ancestries. Protein S (PS), protein C (PC) and antithrombin (AT) activity are reportedly low in 65% of adult Japanese patients with deep vein thrombosis. Approximately half of the patients with each deficiency carry the heterozygous mutation of PS (PROS1; 20%), PC (PROC; 10%), and AT genes (SERPINC1: 5%). Recently, several studies have revealed an outline of inherited thrombophilias in Japanese children. Congenital thrombophilias in 48 patients less than age 20 years consisted of 45% PC deficiency, 15% PS deficiency and 10% AT deficiency, along with other causes. All PS- and AT-deficient patients had a heterozygous mutation of the respective gene. On the other hand, PC-deficient patients were considered to carry the homozygous or compound heterozygous mutation in 50%, the heterozygous mutation in 25%, and unknown causes in the remaining 25% of patients. Half of unrelated patients with homozygous or compound heterozygous PROC mutations carried PC-nagoya (1362delG), while their parents with its heterozygous mutation were asymptomatic. Most of the PC-deficient patients developed intracranial lesion and/or purpura fulminans within 2 weeks after birth. Non-inherited PC deficiency also conveyed thromboembolic events in early infancy. The molecular epidemiology of thrombosis in Asian children would provide a clue to establish the early intervention and optimal anticoagulant therapy in pediatric PC deficiency.
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Affiliation(s)
- Shouichi Ohga
- Department of Perinatal and Pediatric Medicine, Kyushu University, Fukuoka, Japan.
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47
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Gupta A, Dwivedi Y, Saxena AK, Joshi K. Symmetrical peripheral gangrene with Plasmodium falciparum malaria. J Nat Sci Biol Med 2013; 4:262-4. [PMID: 23633880 PMCID: PMC3633296 DOI: 10.4103/0976-9668.107323] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Symmetric peripheral gangrene is rare and relatively uncommon complication of malaria. We report a case of a 50-year-old male who survived Plasmodium falciparum infection with disseminated intravascular coagulation. Symmetric peripheral gangrene in our case, which ultimately required amputation of the toes, was most likely due to interaction between parasitic factors and host factors.
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Affiliation(s)
- Amrita Gupta
- Department of Anaesthesia and Critical Care, SN Medical College, Agra, Uttar Pradesh, India
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48
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Stewart S. Symmetrical peripheral gangrene and the use of systemic hyperbaric oxygen therapy. J Wound Care 2013; 21:615-6, 618-9. [PMID: 23299273 DOI: 10.12968/jowc.2012.21.12.615] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Symmetrical peripheral gangrene (SPG) is a rare but devastating condition when two or more distal sites become gangrenous, as the result of severe illness and treatment in critical care. The striking factor in SPG is that there is no occlusion of the major blood vessels to the affected limbs; the pathogenesis of the condition is not well understood and there are high reported mortality and amputation rates. Here we report the chronological progress report of a case of SPG, which affected both forefeet. This case report supports the view that early amputation should be avoided allowing for stabilisation of the gangrene so that no viable tissue is sacrificed. Further research is necessary to establish the pathogenesis and suitable treatment pathways.
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Affiliation(s)
- S Stewart
- Department of Podiatry and Foot Health, Newton Abbot Hospital, Newton Abbot, Devon, UK.
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Ohga S, Kang D, Kinjo T, Ochiai M, Doi T, Ishimura M, Kayamori Y, Urata M, Yamamoto J, Suenobu SI, Kanegane H, Ikenoue T, Shirahata A, Hara T. Paediatric presentation and outcome of congenital protein C deficiency in Japan. Haemophilia 2013; 19:378-84. [DOI: 10.1111/hae.12097] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2012] [Indexed: 12/13/2022]
Affiliation(s)
| | - D. Kang
- Department of Clinical Chemistry and Laboratory Medicine; Kyushu University Hospital; Fukuoka; Japan
| | - T. Kinjo
- Department of Pediatrics; Graduate School of Medical Sciences; Kyushu University; Fukuoka; Japan
| | - M. Ochiai
- Department of Pediatrics; Graduate School of Medical Sciences; Kyushu University; Fukuoka; Japan
| | - T. Doi
- Department of Pediatrics; Graduate School of Medical Sciences; Kyushu University; Fukuoka; Japan
| | - M. Ishimura
- Department of Pediatrics; Graduate School of Medical Sciences; Kyushu University; Fukuoka; Japan
| | - Y. Kayamori
- Department of Clinical Chemistry and Laboratory Medicine; Kyushu University Hospital; Fukuoka; Japan
| | - M. Urata
- Department of Clinical Chemistry and Laboratory Medicine; Kyushu University Hospital; Fukuoka; Japan
| | | | - S.-I. Suenobu
- Department of Pediatrics and Child Neurology; Oita University Faculty of Medicine; Oita; Japan
| | - H. Kanegane
- Department of Pediatrics; Graduate School of Medicine; University of Toyama; Toyama; Japan
| | - T. Ikenoue
- Department of Obstetrics and Gynecology; Faculty of Medicine; University of Miyazaki; Miyazaki; Japan
| | - A. Shirahata
- Department of Pediatrics; Kitakyushu Yahata Higashi Hospital; Kitakyushu; Japan
| | - T. Hara
- Department of Pediatrics; Graduate School of Medical Sciences; Kyushu University; Fukuoka; Japan
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Aroor S, Varma C, Mundkur SC. Purpura fulminans in a child: a case report. J Clin Diagn Res 2013; 6:1812-3. [PMID: 23373061 DOI: 10.7860/jcdr/2012/4339.2618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Accepted: 09/15/2012] [Indexed: 11/24/2022]
Abstract
Purpura Fulminans is a life threatening condition characterised by cutaneous haemorrhage and gangrenous necrosis. We present such a case in an eight year old child.
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Affiliation(s)
- Shrikiran Aroor
- Professor, Department of Paediatrics, Kasturba Medical College , Manipal, Karnataka, India
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