Idiopathic gangrene in African children

Prothrombotic profile in children with peripheral gangrene: a single center experience

Peripheral gangrene is rare in children. Protein C, protein S, and antithrombin deficiency, positivity for anticardiolipin antibodies or lupus anticoagulant and factor V Leiden mutation are important causes of thrombosis in the venous system. There is paucity of literature on the contribution of these factors in children with peripheral gangrene. We evaluated the role of aforementioned factors in children with peripheral gangrene. Protein S deficiency was seen in one case and another was transiently positive for lupus anticoagulant. None of the 11 age- and sex-matched normal controls had protein C, protein S, or antithrombin deficiency. Our results indicate that deficiency of protein C, protein S, and antithrombin, and positivity for anticardiolipin antibodies, lupus anticoagulant, and factor V Leiden are uncommon causes of peripheral gangrene in children in north-western India. Fibrinolytic and antiplatelet parameters were not tested. Testing for these may yield further clues to the etiology of this condition.

A review of diagnosis and modes of presentation of tropical idiopathic lower limb gangrene

BACKGROUND

Tropical idiopathic lower limb gangrene (TILLG) is also known as Symmetrical gangrene in the African, Idiopathic gangrene in the African and Idiopathic peripheral gangrene of the tropics. The aetiopathogenesis of this clinical entity is a mystery.

OBJECTIVE

To review methods of diagnosing tropical idiopathic lower limb gangrene (TILLG) and highlight its clinical variants.

METHOD

All Literature on idiopathic gangrene of the extremities was searched from libraries, colleagues and internet but only literature on TILLG (in Africans) from 1947 to date was scrutinised. Each case was studied to find out the basis of diagnosis.

RESULT

TILLG is not fully understood and not easy to recognise. Two sets of criteria are known to be helpful in establishing diagnosis. These criteria can be classified as major and minor criteria. Major criteria are those clinical data that can establish the diagnosis of TILLG. No devices are required to identify them. Minor criteria are pathological changes that are consistent with TILLG. Devices are required to identify them. Three pathomorphological types of TILLG were described in literature and are classified as types A, B and C.

CONCLUSIONS

This review is supposed to sensitise the clinician and make diagnosis easier. This will also encourage more researches. As more information becomes available, aetiopathogenesis of TILLG will be clearer and more clinical variants of the disease may be reported. This additional information will help in the prevention of gangrene, reducing the socioeconomic problems arising from amputation.

Prostacyclin in severe peripheral vascular disease

Prostacyclin (prostaglandin I2, epoprostenol sodium) arrested the progress of gangrene in the feet of a 6 year old boy with familial but otherwise unexplained peripheral vascular disease. Toe regrowth is now occurring at the line of demarcation.

The role of fibrinolysis in the therapy of peripheral vascular disease

In vivo thrombolytic studies in stumptailed monkeys indicated that pentoxifylline potentiates thrombolysis induced by urokinase activated human plasmin. Pentoxifylline as well as prostaglandin E1 released plasminogen activators and activated the fibrinolysin system. From this point of view pentoxifylline and prostaglandin E1 synergized with each other. Pentoxifylline potentiated the thrombolytic effect of prostaglandin E1 in vivo.

Purpura fulminans

Purpura fulminans presents as a catastrophic illness with gangrene of the distal extremities and necrosis of skin. The clinical picture consists of septicemia, shock, and disseminated intravascular coagulation. The Shwartzman and Arthus reactions are thought to be responsible for the pathogenesis of purpura fulminans. The exact mechanisms of these reactions are not completely understood. Immediate resuscitation is the treatment for shock and sepsis. Heparin is recommended to reverse the disseminated intravascular coagulation component of this disease. Surviving patients require treatment of skin necrosis and digital and extremity gangrene. The former are managed in a fashion similar to the management of burns. Amputation should be delayed until maximal collateral circulation has developed. A series of 10 patients is presented and 58 cases from the literature are analyzed.

Bilateral gangrene of the feet associated with Salmonella infection in children with sickle cell anaemia

Two cases of bilateral gangrene of the feet associated with salmonella infection in Nigerian children with sickle cell anaemia are described. Healing was spontaneous and complete in both cases. A search for sickling phenomenon and salmonella infection is advocated in all African children with so-called idiopathic bilateral gangrene of childhood.

Acute ischemia of the limb in a newborn treated successfully by thrombectomy

A seven day old dehydrated male infant was found to have acute ischemia of the leg due to acute thrombotic occlusion of an external iliac, common and superficial femoral, and popliteal arteries. Early thrombectomy and arterioplasty resulted in complete remission of ischemia. Our success with direct vascular surgery prompts us to recommend this form of treatment in preventing neonatal gangrene. To our knowledge, this is the first report of successful thrombectomy in a newborn infant.

Serum fibrin degradation products throughout normal pregnancy

Fibrin/fibrinogen degradation products in the serum of 169 healthy pregnant and 43 healthy non-pregnant subjects of a similar age group showed a significant increase throughout pregnancy, the highest levels being obtained in the third trimester. There was no correlation with plasma fibrinogen levels or euglobulin lysis times. Though these changes may be due to other alterations in pregnancy not primarily associated with fibrinolysis, it is possible that actual fibrinolysis is not decreased in late pregnancy, as has been previously asssumed.