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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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Bhandari A, Razmi M, Mahajan R. Symmetrical Peripheral Gangrene: A Rare Complication of Severe Illness. Indian Dermatol Online J 2023; 14:922. [PMID: 38099024 PMCID: PMC10718089 DOI: 10.4103/idoj.idoj_32_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/28/2023] [Accepted: 03/11/2023] [Indexed: 12/17/2023] Open
Affiliation(s)
- Adhyatm Bhandari
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Muhammed Razmi
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rahul Mahajan
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Rijal P, Kaur G, Yadav B, Raina R, Pathania M. Bilateral Upper Limb Symmetrical Digital Gangrene: A Rare Presentation of Anti-Phospholipid Syndrome. Cureus 2022; 14:e29516. [PMID: 36312664 PMCID: PMC9595255 DOI: 10.7759/cureus.29516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2022] [Indexed: 11/21/2022] Open
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disease present most commonly in young women, characterized by the presence of antibodies against various phospholipids and culminating in alteration of the flow of blood, leading to arterial and venous thrombosis. Although it can present with a wide range of manifestations, digital gangrene is one of the important ones. We present a case of a young female with antiphospholipid syndrome who presented with acute onset bilateral upper limb symmetrical digital gangrene with prior history of multiple fetal losses. Acute onset, symmetrical gangrene, limited to the bilateral upper limbs without venous system involvement, that too in association with systemic lupus erythematosus (SLE) which does not usually manifest as such make this case a unique and interesting one.
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Achieving Functional Outcomes after Surgical Management of Catastrophic Vasopressor-induced Limb Ischemia. Plast Reconstr Surg Glob Open 2022; 10:e4175. [PMID: 35265449 PMCID: PMC8901208 DOI: 10.1097/gox.0000000000004175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 01/06/2022] [Indexed: 12/02/2022]
Abstract
Vasopressor-induced limb ischemia is an unfortunate complication that can occur in patients treated for septic shock. Current literature lacks surgical treatment recommendations for this condition, besides amputation. We describe various reconstructive surgeries and functional outcomes in patients treated surgically for vasopressor-induced limb ischemia.
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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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Chu YT, Hsu A, Wu CC, Tsai HD, Tsung-Che Hsieh C, Hsiao YH. Acute chorioamnionitis complicated with symmetrical peripheral gangrene. Taiwan J Obstet Gynecol 2021; 59:972-974. [PMID: 33218425 DOI: 10.1016/j.tjog.2020.09.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2020] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE Symmetrical peripheral gangrene (SPG) is an uncommon but important clinical syndrome. We present a case of acute chorioamnionitis complicated with SPG. CASE REPORT A 33-year-old female (gravida 5, para 2) was admitted with preterm premature rupture of membranes (PPROM) at 20 weeks and four days of gestation. She received cervical cerclage four days ago. Seven days after the diagnosis of PPROM, she developed fever, tachypnea and tachycardia. Termination of pregnancy was decided for clinical diagnosis of sepsis. After the abortus was born, gangrene change on the nose was noticed. Afterwards, this patient developed acrocyanosis of extremities. SPG developed following sepsis with intravascular disseminated coagulation (DIC). After intensive care, the patient underwent hyperbaric oxygen therapy and fasciectomy of the left forearm. CONCLUSION We suggest awareness of SPG associated with acute chorioamnionitis. Early recognition of SPG, multidisciplinary care, and treatment of its underlying conditions are the mainstays of management.
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Affiliation(s)
- Yi-Tzu Chu
- Women's Health Research Laboratory, Changhua Christian Hospital, Changhua, Taiwan; Department of Obstetrics and Gynecology, Changhua Christian Hospital, Changhua, Taiwan
| | - Alan Hsu
- Women's Health Research Laboratory, Changhua Christian Hospital, Changhua, Taiwan; Department of Obstetrics and Gynecology, Changhua Christian Hospital, Changhua, Taiwan; Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Chia-Chieh Wu
- Hyperbaric Oxygen Therapy Center, Changhua Christian Hospital, Changhua, Taiwan; Department of Orthopedic Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Horng-Der Tsai
- Women's Health Research Laboratory, Changhua Christian Hospital, Changhua, Taiwan; Department of Obstetrics and Gynecology, Changhua Christian Hospital, Changhua, Taiwan
| | | | - Yi-Hsuan Hsiao
- Women's Health Research Laboratory, Changhua Christian Hospital, Changhua, Taiwan; Department of Obstetrics and Gynecology, Changhua Christian Hospital, Changhua, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan; College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
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Botulinum Toxin in the Treatment of Vasopressor-associated Symmetric Peripheral Gangrene. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3582. [PMID: 34036024 PMCID: PMC8140772 DOI: 10.1097/gox.0000000000003582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/23/2021] [Indexed: 11/26/2022]
Abstract
Symmetric peripheral gangrene (SPG) affects peripheral tissues of critically ill patients and can have severe disfiguring and debilitating effects. It can occur in the setting of multiple conditions, and it is associated with the use of vasopressors. There are no evidence-based treatments available for patients who develop SPG. Botulinum toxin has emerged as a potential therapy in vasospastic disorders, and we hypothesized that it may be used in the treatment of tissue ischemia in critically ill patients on vasopressors. We present a case of a patient who developed vasopressor-associated SPG and who experienced complete resolution after local injection with botulinum toxin. While the action of botulinum toxin on skeletal muscle is best understood, it has also been demonstrated to attenuate the release of multiple vasoconstrictive factors that impact vascular smooth muscle and modulate calcium and nitric oxide. These effects may result in vasodilation and improvement of cutaneous ischemia when injected locally. Clinicians may consider this local therapy in the treatment of vasopressor-associated symmetric peripheral gangrene.
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Alfraij A, Elseadawy M, Alghounaim M. The effect of topical nitroglycerin on symmetrical peripheral gangrene in a pediatric patient. Clin Case Rep 2021; 9:e04213. [PMID: 34026189 PMCID: PMC8123546 DOI: 10.1002/ccr3.4213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/02/2021] [Accepted: 04/06/2021] [Indexed: 11/17/2022] Open
Abstract
Symmetrical peripheral gangrene is a rare condition associated with significant morbidity and mortality. The use of topical nitroglycerin may have a role in improving patient outcomes and opens a new area for future research regarding the use of topical nitroglycerin in SPG.
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Affiliation(s)
- Abdulla Alfraij
- Department of PediatricsPediatric Intensive Care UnitFarwaniya HospitalFarwaniyaKuwait
| | - Mohammad Elseadawy
- Department of PediatricsPediatric Intensive Care UnitFarwaniya HospitalFarwaniyaKuwait
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Gaba S, Syal A, Arya Y, Gupta M, Kaur A. Idiopathic Symmetrical Peripheral Gangrene: A Rare Clinical Entity. Cureus 2021; 13:e14447. [PMID: 33996310 PMCID: PMC8114964 DOI: 10.7759/cureus.14447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Symmetrical peripheral gangrene (SPG) is a rare disorder leading to ischemic necrosis of extremities. We present a rare case of idiopathic SPG in a 58-year-old male who did not seek any medical care, and history was elucidated only after he presented one year later for treatment of pneumonia. Extensive investigations revealed no etiology. SPG can result from a variety of conditions that cause disseminated intravascular coagulation and lead to distal hypoperfusion. The treatment is aimed at the control of the underlying disease and wound management.
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Affiliation(s)
- Saurabh Gaba
- General Medicine, Government Medical College and Hospital, Chandigarh, IND
| | - Arshi Syal
- General Medicine, Government Medical College and Hospital, Chandigarh, IND
| | - Yajur Arya
- General Medicine, Government Medical College and Hospital, Chandigarh, IND
| | - Monica Gupta
- General Medicine, Government Medical College and Hospital, Chandigarh, IND
| | - Amanjot Kaur
- General Medicine, Government Medical College and Hospital, Chandigarh, IND
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11
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Mahajan R, Bishnoi A, Raj D. Atypical manifestations of cutaneous staphylococcal infection in infants – Generalized bullous impetigo and asymmetrical peripheral gangrene. INDIAN JOURNAL OF PAEDIATRIC DERMATOLOGY 2021. [DOI: 10.4103/ijpd.ijpd_54_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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12
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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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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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Ibrahim U, Aliyu I, Lawal N, Bala A. Gangrene and sepsis in sickle cell disease. SAUDI JOURNAL FOR HEALTH SCIENCES 2020. [DOI: 10.4103/sjhs.sjhs_75_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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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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Casey K, Dickinson A. Suspected symmetrical peripheral gangrene in a cat. JFMS Open Rep 2019; 5:2055116919855539. [PMID: 31245021 PMCID: PMC6582298 DOI: 10.1177/2055116919855539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Case summary An 8-year-old female spayed domestic shorthair cat was presented for evaluation of non-specific lethargy and pain. It was diagnosed with septic shock secondary to wounds on the dorsum and required treatment with multiple vasopressors for circulatory support. During the course of hospitalization, it was weaned from vasopressors but subsequently developed symmetric skin necrosis and sloughing of the paws on the right thoracic and right pelvic limbs leading to a presumptive diagnosis of suspected symmetrical peripheral gangrene (SPG). Relevance and novel information This report documents the first case of suspected SPG in a cat that received multiple vasopressors for treatment of septic shock. Early recognition, cessation of vasopressor therapy and surgical management are necessary for treatment of this condition.
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Affiliation(s)
- Kelsey Casey
- Department of Emergency and Critical Care, Pittsburgh Veterinary Specialty and Emergency Center, Pittsburgh, PA, USA
| | - Amy Dickinson
- Department of Emergency and Critical Care, Pittsburgh Veterinary Specialty and Emergency Center, Pittsburgh, PA, USA
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Abstract
Background Symmetrical peripheral gangrene (SPG) is an uncommon syndrome showing symmetrical gangrene in acral regions without evidence of large-vessel occlusion or vasculitis. Intravenous vasopressors are frequently used to manage hemodynamically unstable patients. There have been few reports about SPG after using inotropics. However, risk factors for SPG have not been extensively studied. Therefore, the objective of this study was to analyze several cases of SPG and identify risk factors for SPG. Methods From October 2013 to October 2016, 36 patients with SPG after using vasopressors were included in this study. SPG is an extremely rare disease entity. Therefore, this work was designed as a matched case-control study. For the control group, 42 patients (25 men and 17 women) with similar age, admission department, sex, and vasopressor usage in intensive care unit patients during the same period were selected. Retrospective chart review was performed to identify risk factors within the following categories: medical conditions, vasopressor-related factors, and Sequential Organ Failure Assessment scores. Results Differences between the 2 groups concerning medical condition-related variables did not exist. Statistically significant differences were found in intensive care unit duration (P = 0.0011) and survival. All vasopressor-related factors were adjusted according to weights of patients. Weight-compensated mean dose of dopamin significantly (P = 0.028) affected the occurrence of SPG. Weight-compensated peak dose of norpin, dopamin, and epinephrine also significantly contributed to SPG. Conclusions Symmetrical peripheral gangrene is a rare clinical syndrome related with a high mortality and up to 70% of patients who survive require amputation. Several studies have mentioned that there are several factors affecting the result of SPG. Few studies on SPG have been reported and most of them are case reports. In this study, we revealed the influence of vasopressors to the occurrence of SPG, and this was the first matched case-control study based on the analysis of multiple risk factors.
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Dry Gangrene in Children with Typhoid Intestinal Perforation: A Report of Two Cases. Case Rep Surg 2018; 2018:7097014. [PMID: 30402323 PMCID: PMC6196789 DOI: 10.1155/2018/7097014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 09/23/2018] [Indexed: 11/17/2022] Open
Abstract
Intestinal perforation is a life-threatening complication of typhoid fever commonly seen in developing countries, but extraintestinal complications are infrequently reported. We report herein two cases of gangrene seen in children managed for typhoid intestinal perforation, highlighting the challenges faced in their management.
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Nakagawa S, Kawarada O, Yagyu T, Noguchi T, Yasuda S. Extensive Calcification of the Radial and Ulnar Arteries Associated With Vasculitis. Circ J 2018; 82:1714-1715. [PMID: 28966287 DOI: 10.1253/circj.cj-17-0864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Shoko Nakagawa
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Osami Kawarada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Takeshi Yagyu
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
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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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21
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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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22
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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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23
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Affiliation(s)
- Rajinder Singh Rawat
- Department of Cardiac Anaesthesiology, Max Devki Devi Heart and vascular institute, Saket, Delhi, India
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24
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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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25
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Shiba M, Ieko M, Kawarada O. Symmetric peripheral gangrene in antiphospholipid syndrome. HEART ASIA 2016; 8:8. [PMID: 27326242 DOI: 10.1136/heartasia-2016-010768] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Mikio Shiba
- Department of Cardiovascular Medicine , National Cerebral and Cardiovascular Center , Suita, Osaka , Japan
| | - Masahiro Ieko
- Department of Internal Medicine , School of Dentistry, Health Sciences University of Hokkaido , Ishikari-Tobetsu, Hokkaido , Japan
| | - Osami Kawarada
- Department of Cardiovascular Medicine , National Cerebral and Cardiovascular Center , Suita, Osaka , Japan
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26
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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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27
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Shastri M, Parikh M, Patel D, Chudasma K, Patell R. Symmetrical peripheral gangrene following snake bite. J Clin Diagn Res 2014; 8:MD03-4. [PMID: 25386476 DOI: 10.7860/jcdr/2014/8573.4822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Accepted: 05/21/2014] [Indexed: 11/24/2022]
Abstract
SPG (Symmetrical peripheral gangrene) is defined as symmetrical distal ischemic damage at two or more sites in the absence of large vessels obstruction. It has been ascribed to a number of infectious and non infectious conditions including connective tissue, cardiovascular, neoplastic and iatrogenic causes. We report a unique case of SPG in a 35-year-old Indian female who developed spontaneous gangrene of the distal phalanges of the right and left index, middle, ring and little fingers and the distal phalanges of all toes of the right and left foot following a snake bite. There have been very few cases of peripheral gangrene and acute renal failure associated with snake bite in literature.
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Affiliation(s)
- Minal Shastri
- Associate Professor, Department of Medicine, Medical College Baroda, Gujarat, India
| | - Mital Parikh
- Senior Resident, Department of Medicine, Medical College Baroda, Gujarat, India
| | - Dwijal Patel
- Senior Resident, Department of Medicine, Medical College Baroda, Gujarat, India
| | - Ketan Chudasma
- Senior Resident, Department of Medicine, Medical College Baroda, Gujarat, India
| | - Rushad Patell
- Resident, Department of Internal Medicine, Cleveland Clinic , Cleveland, Ohio, USA
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28
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Abdali N, Malik AM, Kamal A, Ahmad M. Symmetrical peripheral gangrene due to Plasmodium falciparum malaria. BMJ Case Rep 2014; 2014:bcr-2014-204268. [PMID: 24862424 DOI: 10.1136/bcr-2014-204268] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 45-year-old man presented with a 4-day history of high-grade fever with rigours and a 2-day history of painful bluish black discolouration of extremities (acrocyanosis). He was haemodynamically stable and all peripheral pulses palpable, but the extremities were cold with gangrene involving bilateral fingers and toes. Mild splenomegaly was present on abdominal examination but rest of the physical examinations were normal. On investigating he was found to have anaemia, thrombocytopaenia with gametocytes of Plasmodium falciparum on peripheral blood smear. His blood was uncoagulable during performance of prothrombin time with a raised D-dimer. Oxygen saturation was normal and the arterial Doppler test showed reduced blood flow to the extremities. A diagnosis of complicated P. falciparum malaria with disseminated intravascular coagulation (DIC) leading to symmetrical peripheral gangrene was performed. Artemisinin combination therapy was started and heparin was given for DIC. A final line of demarcation of gangrene started forming by 12th day.
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Affiliation(s)
- Nasar Abdali
- Department of Medicine, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
| | - Azharuddin Mohammed Malik
- Department of Medicine, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
| | - Athar Kamal
- Department of Medicine, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
| | - Mehtab Ahmad
- Department of Radiodiagnosis, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
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29
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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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Raghunandan J, Rajeshwari K, Dubey AP, Singh T. Peripheral gangrene in an 18-month-old boy with Plasmodium vivax malaria. Paediatr Int Child Health 2012; 32:164-6. [PMID: 22824666 DOI: 10.1179/2046905512y.0000000006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
An 18-month-old boy presented with a high-grade fever, generalised petechiae and rapidly progressive, blackish discolouration of the fingers of the hands for the past 3 days. At presentation, he was haemodynamically stable. There were gangrenous changes in the index and middle fingers of both hands. Plasmodium vivax was demonstrated in the peripheral blood smear but there was no evidence of disseminated intravascular coagulopathy. The platelet count fell to 10×10(9)/L. Bone marrow aspiration to rule out leukaemia demonstrated schizonts of P. vivax with some atypical lymphocytes. The fingers recovered completely. As far as we are aware, this is the first report of peripheral gangrene associated with P. vivax malaria.
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Affiliation(s)
- J Raghunandan
- Department of Pediatrics, Maulana Azad Medical College, New Delhi, India
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31
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Gandhi V, Sharma R, Raizada A, Dhawan A. Peripheral symmetrical gangrene treated with sildenafil citrate. J Cutan Aesthet Surg 2012; 5:57-8. [PMID: 22557864 PMCID: PMC3339137 DOI: 10.4103/0974-2077.94333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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32
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Reed RC. Symmetrical peripheral gangrene in four pediatric cardiac surgery patients receiving extracorporeal membrane oxygenation. Pediatr Dev Pathol 2012; 15:217-25. [PMID: 22400489 DOI: 10.2350/11-10-1102-oa.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Symmetrical peripheral gangrene (multilimb ischemia without large artery occlusion) is a rare condition usually associated with disseminated intravascular coagulation, hemodynamic compromise, and/or sepsis. However, it has not been described in patients on extracorporal membrane oxygenation (ECMO). Over a 5 year period, four pediatric patients developed symmetrical peripheral gangrene on ECMO after cardiac surgery. They subsequently died and came to autopsy. History, physical examination, and laboratory studies were examined. Gross and microscopic autopsy material was reviewed. Patients were 11 days to 13 years old. Extracorporal membrane oxygenation duration was 11-22 days, and limb ischemia began 2-4 days before death. Three patients had rapid onset, with ischemia developing in <48 hours. In the fourth, ischemic changes began as focal lesions and gradually spread. Two patients were septic. Three had evidence of other end-organ damage. Pressors were used in 3 patients before the limb ischemia. Autopsies disclosed ischemic changes involving all limbs, with confluent ecchymoses. In a detailed examination in 1 case, large arteries of the extremities were patent. Involved skin and soft tissue showed bland fibrin thrombi in the microcirculation, with tissue necrosis and hemorrhage. This report describes the first 4 cases of symmetrical peripheral gangrene complicating ECMO. The 4 pediatric patients all had recent surgery for congenital cardiac disease, and all had significant exposure to ECMO prior to developing limb ischemia. Symmetrical peripheral gangrene is an unusual complication of ECMO that may arise in the setting of disseminated intravascular coagulation, sepsis, or other hemostatic and/or hemodynamic imbalance.
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Affiliation(s)
- Robyn C Reed
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN 55455, USA.
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