1
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
2
|
Liu Z, Zhang W, Zhang B, Ma L, Zhou F, Hu Z, Jie X, Gao H, Zhu X. Toxic shock syndrome complicated with symmetrical peripheral gangrene after liposuction and fat transfer: a case report and literature review. BMC Infect Dis 2021; 21:1137. [PMID: 34742247 PMCID: PMC8571909 DOI: 10.1186/s12879-021-06777-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 10/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Liposuction is one of the most commonly performed aesthetic procedures. Toxic shock syndrome(TSS) is a rare, life-threatening complication. The incidence rate of TSS is very low in the plastic surgery field, especially after liposuction and fat transfer. CASE PRESENTATION A 23-year-old female patient was transferred to our emergency department from an aesthetic clinic with sepsis shock features after received liposuction and fat transfer. The patient underwent TSS, disseminated intravascular coagulation(DIC), multiple organ dysfunction syndrome (MODS), symmetrical peripheral gangrene (SPG), and necrotizing soft tissue infection of the buttocks in the next 10 days. Authors used a series of debridement and reconstructive surgery including vacuum sealing drainage (VSD) treatment, artificial dermis grafts,split-thickness skin grafts, amputation surgeries when her vital signs were stable. The patient experienced desquamation of the hand on the 26th day. The skin grafts survived and the function of both fingers and toes recovered. She was discharged 2 months after admission and was in good health. CONCLUSION TSS is extremely rare in the field of liposuction and autologous fat transfer. The mortality rate of TSS is very high. Early diagnosis and operative treatment, as well as correction of systemic abnormalities, are the important keys to save a patient's life.
Collapse
Affiliation(s)
- Zhiwan Liu
- Department of Plastic Surgery, Shanghai Changzheng Hospital, No.415 Fengyang Road, Huangpu District, Shanghai, 200003, China
| | - Wenjun Zhang
- Department of Plastic Surgery, Shanghai Changzheng Hospital, No.415 Fengyang Road, Huangpu District, Shanghai, 200003, China
| | - Boyu Zhang
- Department of Emergency, Shanghai Changzheng Hospital, Shanghai, China
| | - Linhao Ma
- Department of Emergency, Shanghai Changzheng Hospital, Shanghai, China
| | - Feng Zhou
- Department of Plastic Surgery, Shanghai Tongji Hospital, Shanghai, China
| | - Zheyuan Hu
- Department of Plastic Surgery, Shanghai Changzheng Hospital, No.415 Fengyang Road, Huangpu District, Shanghai, 200003, China
| | - Xiang Jie
- Department of Plastic Surgery, Shanghai Changzheng Hospital, No.415 Fengyang Road, Huangpu District, Shanghai, 200003, China
| | - Hong Gao
- Department of Plastic Surgery, Shanghai Changzheng Hospital, No.415 Fengyang Road, Huangpu District, Shanghai, 200003, China
| | - Xiaohai Zhu
- Department of Plastic Surgery, Shanghai Changzheng Hospital, No.415 Fengyang Road, Huangpu District, Shanghai, 200003, China.
| |
Collapse
|
3
|
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: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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.
| |
Collapse
|
4
|
Abstract
Symmetrical peripheral gangrene (SPG) is a disabling complication that affects a small proportion of patients who survive critical illness. Its pathogenesis reflects profoundly disturbed procoagulant-anticoagulant balance in susceptible tissue beds secondary to circulatory shock (cardiogenic, septic). There is a characteristic SPG triad: (a) shock (hypotension, lactic acidemia, normoblastemia, multiple organ dysfunction), (b) disseminated intravascular coagulation (DIC), and (c) natural anticoagulant depletion (protein C, antithrombin). In recent years, risk factors for natural anticoagulant depletion have been identified, most notably acute ischemic hepatitis ("shock liver"), which is seen in at least 90% of patients who develop SPG. Moreover, there is a characteristic time interval (2-5 days, median 3 days) between the onset of shock/shock liver and the beginning of ischemic injury secondary to peripheral microthrombosis ("limb ischemia with pulses"), reflecting the time required to develop severe depletion in hepatically-synthesized natural anticoagulants. Other risk factors for natural anticoagulant depletion include chronic liver disease (e.g., cirrhosis) and, possibly, transfusion of colloids (albumin, high-dose immunoglobulin) lacking coagulation factors. A causal role for vasopressor therapy is unproven and is unlikely; this is because critically ill patients who develop SPG do so usually after at least 36-48 hours of vasopressor therapy, implicating a time-dependent pathophysiological mechanism. The most plausible explanation is a progressive time-dependent decline in key natural anticoagulant factors, reflecting ongoing DIC ("consumption"), proximate liver disease whether acute or chronic ("impaired production"), and colloid administration ("hemodilution"). Given these evolving concepts of pathogenesis, a rationale approach to prevention/treatment of SPG can be developed.
Collapse
Affiliation(s)
- Theodore E Warkentin
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Pathology and Molecular Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; McMaster Centre for Transfusion Research, Canada; Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada; Service of Clinical Hematology, Hamilton General Hospital, Hamilton Health Sciences, Hamilton, Ontario, Canada.
| | - Shuoyan Ning
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Pathology and Molecular Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; McMaster Centre for Transfusion Research, Canada; Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada; St. Joseph's Healthcare, Hamilton, Ontario, Canada
| |
Collapse
|
5
|
Cho SH, Park JS, Lee WK, Shin MK, Jung M, Lee KM, Hwang KJ, Moon DK. The first case of hand infection caused by Dermabacter jinjuensis in a symmetrical peripheral gangrene patient. Ann Med Surg (Lond) 2018; 36:63-66. [PMID: 30402221 PMCID: PMC6206325 DOI: 10.1016/j.amsu.2018.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 10/04/2018] [Accepted: 10/06/2018] [Indexed: 11/28/2022] Open
Abstract
Introduction Strains of the genus Dermabacter is a recently established species, recognized as relatively rare opportunistic human pathogen, and is infrequently isolated from clinical specimens, including blood cultures, abscesses, wounds, bone, eye, and skin. Presentation of case We present a 78-year old female with chronic symmetrical peripheral gangrene and hand infection. The patient underwent surgical debridement with amputation on gangrene with infection of both fingers. At 2 weeks postoperatively, pus discharge was newly observed and the patient underwent reoperation. In the subsequent reinfection, unknown organism has been repeatedly identified, may be the most likely causative agent. On the basis of phenotypic and genotypic distinctness and DNA–DNA hybridization results, new strain should be placed in the genus Dermabacter as representing a novel species, for which the name Dermabacter jinjuensis sp. nov. is proposed. Discussion We judged the novel species as the causative bacteria. Because of, a novel species called D. jinjuensis was repeatedly identified more than common bacteria. It can be considered as a postoperative nosocomial infection or opportunistic infection. It is not clear how the infection of D. jinjensis occurred. Conclusion This is the first reported case of a human D. jinjuensis infection. We were able to treat patients without any complications by operative treatment and administering appropriate antimicrobial agents according to antibiotics susceptibility test. Strain of the genus Dermabacter is a recently established species. Strain of the genus Dermabacter recognized as relatively rare opportunistic human pathogen. Dermabacter jinjuensis is newly described Dermabacter species. Dermabacter jinjuensis can be human pathogen.
Collapse
Affiliation(s)
- Seong Hee Cho
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jin Sung Park
- Department of Orthopaedic Surgery and Institute of Health Sciences, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Woo-Kon Lee
- Department of Microbiology, School of Medicine, Gyeongsang National University, Jinju, South Korea
| | - Min-Kyoung Shin
- Department of Microbiology, School of Medicine, Gyeongsang National University, Jinju, South Korea
| | - Myunghwan Jung
- Department of Microbiology, School of Medicine, Gyeongsang National University, Jinju, South Korea
| | - Kyeong Min Lee
- Pathogen Resource TF, Center for Infectious Diseases, Korea National Institute of Health, Korea Center for Disease Control and Prevention, Cheongju, Republic of Korea
| | - Kyu Jam Hwang
- Pathogen Resource TF, Center for Infectious Diseases, Korea National Institute of Health, Korea Center for Disease Control and Prevention, Cheongju, Republic of Korea
| | - Dong Kyu Moon
- Department of Orthopaedic Surgery and Institute of Health Sciences, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea
| |
Collapse
|
6
|
Albano MN, Brazão SG, Caroço TV, Louro JM, Coelho MI, Costa Almeida CE, Reis LS, Costa Almeida CM. Rare case of symmetrical peripheral gangrene due to septic shock, disseminated intravascular coagulation and inotropic use. Ann Med Surg (Lond) 2018; 35:103-107. [PMID: 30294440 PMCID: PMC6168929 DOI: 10.1016/j.amsu.2018.09.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 09/13/2018] [Accepted: 09/18/2018] [Indexed: 11/18/2022] Open
Abstract
Introduction Symmetrical peripheral gangrene (SPG) is a rare syndrome defined by the peripheral ischemic lesion of two or more extremities in the absence of major vascular obstructive disease. Presentation of case A 45yo woman, admitted in intensive care unit due to urinary septic shock, in need of high doses of amines, developed cold extremities with acrocyanosis that rapidly progressed to gangrene. Laboratory analysis revealed increased inflammatory parameters, liver shock, thrombocytopenia, prolonged coagulation times, increased D-Dimers and isolation of Acinetobacter baumanni in urine culture. An intravenous vasodilator was initiated with clinical benefits. After improvement and delimitation of the lesions, the patient underwent the amputation of the distal phalanges of the 2nd, 3rd and 4th fingers of the right hand and the toes of both feet. Discussion/conclusion Even though there is no consensus regarding SPG treatment, consequences should be mitigated, particularly when vasodilators are used, in order to avoid major amputation. Symmetrical Peripheral Gangrene (SPG), although rare, must be immediately recognized because of its harmful consequences. SPG has a high mortality rate and a high percentage of the survivors have at least one limb amputated. The necessary measures should be taken in a timely manner to mitigate consequences. Treatment of the infection, the avoidance of vasopressors, and the use of LMWH and vasodilators, seem to be important to reduce major amputation.
Collapse
|
7
|
Tan JH, Mohamad Y, Tan CLH, Kassim M, Warkentin TE. Concurrence of symmetrical peripheral gangrene and venous limb gangrene following polytrauma: a case report. J Med Case Rep 2018; 12:131. [PMID: 29776439 DOI: 10.1186/s13256-018-1684-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 04/09/2018] [Indexed: 11/12/2022] Open
Abstract
Background Symmetrical peripheral gangrene is characterized as acral (distal extremity) ischemic limb injury affecting two or more extremities, without large vessel obstruction, typically in a symmetrical fashion. Risk factors include hypotension, disseminated intravascular coagulation, and acute ischemic hepatitis (“shock liver”). In contrast, venous limb gangrene is characterized by acral ischemic injury occurring in a limb with deep vein thrombosis. Both symmetrical peripheral gangrene and venous limb gangrene present as acral limb ischemic necrosis despite presence of arterial pulses. The coexistence of symmetrical peripheral gangrene and venous limb gangrene is rare, with potential to provide pathophysiological insights. Case presentation A 42-year-old Chinese man presented with polytrauma (severe head injury, lung contusions, and right femur fracture). Emergency craniotomy and debridement of right thigh wound were performed on presentation. Intraoperative hypotension secondary to bleeding was complicated by transient need for vasopressors and acute liver enzyme elevation indicating shock liver. Beginning on postoperative day 5, he developed an acute platelet count fall (from 559 to 250 × 109/L over 3 days) associated with left iliofemoral deep vein thrombosis that evolved to bilateral lower limb ischemic necrosis; ultimately, the extent of limb ischemic injury was greater in the left (requiring below-knee amputation) versus the right (transmetatarsal amputation). As the presence of deep vein thrombosis is a key feature known to localize microthrombosis and hence ischemic injury in venous limb gangrene, the concurrence of unilateral lower limb deep vein thrombosis in a typical clinical setting of symmetrical peripheral gangrene (hypotension, proximate shock liver, platelet count fall consistent with disseminated intravascular coagulation) helps to explain asymmetric limb injury – manifesting as a greater degree of ischemic necrosis and extent of amputation in the limb affected by deep vein thrombosis – in a patient whose clinical picture otherwise resembled symmetrical peripheral gangrene. Conclusions Concurrence of unilateral lower limb deep vein thrombosis in a typical clinical setting of symmetrical peripheral gangrene is a potential explanation for greater extent of acral ischemic injury in the limb affected by deep vein thrombosis.
Collapse
|
8
|
Smaoui F, Koubaa M, Rekik K, Mejdoub Y, Mezghani S, Maaloul I, Hammami A, Marrakchi C, Ben Jemaa M. [ Symmetrical peripheral gangrene: 4 cases]. Ann Dermatol Venereol 2017; 145:95-99. [PMID: 29169658 DOI: 10.1016/j.annder.2017.09.592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 06/28/2017] [Accepted: 09/26/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Symmetric peripheral gangrene (SPG) is a symmetrical distal ischemic lesion on at least 2 or more extremities in the absence of proximal arterial obstruction and vasculitis. It is a rare and severe clinical entity. The aim of this study was to describe clinical symptoms, etiological agents and the management of SPG through a series of 4 cases. PATIENTS AND METHODS We included all cases of SPG hospitalized between 2000 and 2014. The inclusion criterion was the presence of distal ischemic damage at two or more sites in the absence of large vessel obstruction. RESULTS Four patients (2 men and 2 women) were included. The mean age was 43.2±12 years. Two patients had a history of splenectomy. All patients had blackening of the tips of the fingers and toes. Three patients presented with septic shock. The etiology was bacteremia involving Streptococcus pneumoniae in two cases and a malignant form of Mediterranean spotted fever (MSF). In addition to specific antibiotics, we used a potent vasodilator (iloprost) in two cases and curative heparin therapy in two cases. The outcome was favorable in 3 cases, with regression of necrotic lesions. One case required the amputation of non-perfused necrotic fingers and toes. CONCLUSION SPG can complicate MSF in some rare cases. Thorough and repeated skin examinations are essential to ensure timely diagnosis and treatment of GPS in order to improve the prognosis.
Collapse
Affiliation(s)
- F Smaoui
- Service des maladies infectieuses, université de Sfax, CHU Hédi Chaker, 3029 Sfax, Tunisie
| | - M Koubaa
- Service des maladies infectieuses, université de Sfax, CHU Hédi Chaker, 3029 Sfax, Tunisie.
| | - K Rekik
- Service des maladies infectieuses, université de Sfax, CHU Hédi Chaker, 3029 Sfax, Tunisie
| | - Y Mejdoub
- Service des maladies infectieuses, université de Sfax, CHU Hédi Chaker, 3029 Sfax, Tunisie
| | - S Mezghani
- Laboratoire de microbiologie, université de Sfax, CHU Habib Bourguiba, 3029 Sfax, Tunisie
| | - I Maaloul
- Service des maladies infectieuses, université de Sfax, CHU Hédi Chaker, 3029 Sfax, Tunisie
| | - A Hammami
- Laboratoire de microbiologie, université de Sfax, CHU Habib Bourguiba, 3029 Sfax, Tunisie
| | - C Marrakchi
- Service des maladies infectieuses, université de Sfax, CHU Hédi Chaker, 3029 Sfax, Tunisie
| | - M Ben Jemaa
- Service des maladies infectieuses, université de Sfax, CHU Hédi Chaker, 3029 Sfax, Tunisie
| |
Collapse
|
9
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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
| |
Collapse
|
10
|
Phan PN, Acharya V, Parikh D, Shad A. A rare case of symmetrical four limb gangrene following emergency neurosurgery. Int J Surg Case Rep 2015; 16:15-8. [PMID: 26406313 PMCID: PMC4643340 DOI: 10.1016/j.ijscr.2015.09.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 09/08/2015] [Accepted: 09/11/2015] [Indexed: 11/24/2022] Open
Abstract
Postoperative sepsis and limb gangrene are uncommon but important complications of neurosurgery. Peripheral gangrene should be suspected at the first signs of distal ischaemia. Early diagnosis and intervention is crucial. Early specialist and multi-disciplinary team input with close monitoring ensures better outcomes.
Introduction The authors report a case of symmetrical peripheral gangrene (SPG) following emergency neurosurgery. Presentation of case A 35-year-old female presented to hospital in Thailand with nausea, headache, and subsequent seizures. She was found to have a large intracranial space-occupying lesion with mass effect. Following emergency surgical debulking and decompression, she suffered from severe sepsis with multiple organ failure, treated with high dose intravenous vasopressors and developed secondary gangrene in all four limbs. She was repatriated to the UK with a baseline GCS of 8 and multiple postoperative medical complications. With initial conservative management, the patient made a prolonged but satisfactory progression to recovery prior to semi-elective debridement and selected digit amputation of the gangrene. Discussion This is the first reported case of four limb symmetrical peripheral gangrene following an emergency craniotomy. Conclusion Although rare, SPG is a substantial complication with high mortality and morbidity and therefore should be especially taken into account for emergency intracranial pathologies in neurosurgical patients, particularly if they require emergency surgery.
Collapse
Affiliation(s)
- Pho Nh Phan
- University of Warwick Medical School, Gibbet Hill Road, Coventry, West Midlands CV4 7AL, United Kingdom.
| | - Vikas Acharya
- Department of Neurosurgery, University Hospital of Coventry and Warwickshire, Clifford Bridge Road, Coventry, West Midlands CV2 2DX, United Kingdom.
| | - Dhruv Parikh
- Department of Neurosurgery, University Hospital of Coventry and Warwickshire, Clifford Bridge Road, Coventry, West Midlands CV2 2DX, United Kingdom.
| | - Amjad Shad
- Department of Neurosurgery, University Hospital of Coventry and Warwickshire, Clifford Bridge Road, Coventry, West Midlands CV2 2DX, United Kingdom.
| |
Collapse
|
11
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
12
|
Shenoy R, Agarwal N, Goneppanavar U, Shenoy A, Sharma A. Symmetrical peripheral gangrene-a case report and brief review. Indian J Surg 2012; 75:163-5. [PMID: 24426551 DOI: 10.1007/s12262-012-0576-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Accepted: 06/04/2012] [Indexed: 10/28/2022] Open
Abstract
A 30 year-old gentleman presented to casualty with history of pain abdomen for six days, fever and decreased urine output since two days. He was in a state of septic shock and was diagnosed to have intestinal perforation. His peripheral pulses were not palpable except for the femoral and brachial vessels. Despite fluid resuscitation, he needed infusion of high doses of dopamine and noradrenaline to maintain his blood pressure. He was operated for repair of perforation. On the first postoperative day, in the intensive care unit, vasopressin infusion was added in view of persistent hypotension. Appropriate fluid resuscitation and antibiotic therapy helped to wean him off inotropes and vasopressors by the second postoperative day. On the 3rd postoperative day, however, the patient developed discolouration and blebs on the fingers of left hand, followed by the right hand and then both the lower limbs. Subsequently, over a period of 10 days, this progressed to gangrene formation in the hands despite the patient being haemodynamically stable without any inotropes or vasopressors in this period. We conclude that the septic shock is a systemic derangement affecting all organ systems including coagulation and microcirculation. Early recognition and prompt management of sepsis, optimisation of fluid status to wean off the inotropes and vasopressors at the earliest is necessary to avoid catastrophes such as symmetrical peripheral gangrene.
Collapse
Affiliation(s)
- Rajgopal Shenoy
- Department of Surgery, Kasturba Hospital, Manipal, India ; Department of general surgery, Kasturba medical college, Manipal, 576104 Karnataka India
| | | | | | - Anitha Shenoy
- Department of Anaesthesiology, Kasturba Hospital, Manipal, India
| | - Ankur Sharma
- Department of Surgery, Kasturba Hospital, Manipal, India
| |
Collapse
|
13
|
Rai SP, Neog LS, Bhattacharyya D, Ganguli M. Symmetrical Peripheral Gangrene complicating Staphylococcal Toxic Shock Syndrome. Med J Armed Forces India 2008; 64:181-2. [PMID: 27408131 DOI: 10.1016/s0377-1237(08)80076-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2007] [Accepted: 03/27/2007] [Indexed: 10/18/2022] Open
Affiliation(s)
- S P Rai
- Senior Advisor (Medicine & Respiratory Medicine), Military Hospital (CTC) Pune - 4
| | - L S Neog
- Consultant Dermatologist, Apollo Hospital, Delhi
| | - D Bhattacharyya
- Senior Advisor (Medicine & Respiratory Medicine), Army Hospital R&R, Delhi Cantt - 10
| | - M Ganguli
- Classified Specialist (Pathology), Military Hospital Namkum, Ranchi - 10
| |
Collapse
|