Digital Thermal Necrosis Resulting in Amputation After Removing a Tungsten Carbide Ring With a High-Speed Metal Burr: A Case Report

CASE

A 41-year-old man removed a tungsten carbide ring from his left index finger by cutting it off with a high-speed metal burr. The patient presented two days later with a pink and perfused left index finger with circumferential dry gangrene along the area of the ring, active flexor and extensor tendon excursion, and decreased sensation distally. Within 24 hours, the wound developed into wet gangrene and diffuse cyanosis requiring amputation.

CONCLUSION

After reviewing previously documented methods to remove tungsten carbide rings, the authors conclude clinicians should be cognizant of the potential complications associated with the use of a high-speed metal burr.

Puerperal septic shock complicated with symmetrical peripheral gangrene: A case report

RATIONALE

Puerperal sepsis is a life-threatening condition caused by infection that can rapidly progress to multisystem infection and toxin-mediated shock. Symmetrical peripheral gangrene is defined as symmetrical distal ischemic damage in two or more sites in the absence of major vascular occlusive disease. The syndrome is devastating and rare. In this study, we introduce a case of puerperal septicemia complicated by symmetrical peripheral gangrene.

PATIENT CONCERNS

A 23-year-old woman delivered a live female infant vaginally after cervical balloon dilatation at 39 weeks of gestation. Persistent hyperthermia developed on the first postpartum day. After experiencing ventricular fibrillation, acute liver failure, and acute pulmonary edema, she developed blackened extremities on the 5th postpartum day.

DIAGNOSES

Puerperal septicemia complicated by symmetrical peripheral gangrene.

INTERVENTIONS

Upon transfer to our hospital, the patient was enrolled in the intensive care unit and underwent anti-infective and amputation surgery.

OUTCOMES

After the surgery, the patient recovered well and was successfully discharged from the hospital.

LESSONS

Early detection and timely treatment is the best way to reduce the mortality and sequelae of puerperal sepsis. Physicians should be alert to the possibility of comorbid symmetrical peripheral gangrene when sepsis patients present with hepatic impairment.

Compound volvulus: ileosigmoid knot

Compound volvulus, also known as ileosigmoid knot, is a rare cause of intestinal obstruction due to twisting of the small bowel around the large bowel or vice-versa. It poses a diagnostic dilemma due to the presence of features of closed-loop obstruction of both the small and large bowel. Being a surgical emergency due to the rapid progression to gangrene of involved segments leading to septicaemia, early suspicion of the disease entity, adequate resuscitation and prompt treatment are the need of the hour. Three cases encountered and managed in our setting are described here with a review of the literature.

Digital Gangrene as a Paraneoplastic Manifestation of Peripheral T-cell Lymphoma Not Otherwise Specified Type

BACKGROUND

Peripheral T cell lymphoma (PTCL), not otherwise specified (NOS) is a heterogenous group of predominantly nodal T cell lymphomas that generally presents with lymphadenopathy with or without extra nodal involvement. Acral vascular syndrome clinically presents as digital ischemia with Raynaud's phenomenon and acral cyanosis. Although, this condition is commonly associated with connective tissue disorder, smoking and vasculitis, its association with lymphoid malignancy is very rare. Here, we present a case report of a patient with digital gangrene of all toes and fingers as a presenting symptom of PTCL-NOS.

CASE DESCRIPTION

A 62 year old male presented with digital ischemia associated with pain, low grade fever, loss of appetite and significant weight loss of 6 kilograms over a period of 3 months. On examination, he was found to have bilateral inguinal and axillary lymph nodes with gangrenous changes over toes and fingers but peripheral pulses were palpable. On evaluation he had anemia, elevated ESR and CRP. CT angiogram revealed thinned out digital arteries with multifocal areas of narrowing. Patient was screened for other causes of digital gangrene and was tested negative for ANCA, ANA, cryoglobulins and viral markers. Lymph node biopsy with IHC was suggestive of peripheral T-cell lymphoma-NOS and was started on CHOP regimen. Lymph nodes size decreased and gangrenous changes resolved.

CONCLUSION

Though digital ischemia is a rare paraneoplastic presentation of lymphoma, it should be considered if there is a rapid progression of gangrene. Early initiation of chemotherapy may result in the reduction of further progression of digital gangrene and thus prevent permanent disability. In our patient, progression of gangrene was prevented even though it was an aggressive variant of T cell lymphoma.

First Global Report of Catastrophic Results Due to Internal Herniation of Roux Limb in the Space Between the Gastric Pouch and Band: a Series of 3 Cases of Banded Roux-en-Y Gastric Bypass (BRYGB)

BACKGROUND

Banded Roux-en-Y gastric bypass (BRYGB) is associated with complications known with the bypass along with specific complications related to the band. Roux-limb gangrene, due to herniation between the gastric pouch and band, however, has no mention in literature.

METHODS

We report this potentially fatal complication of BRYGB and its management in a series of 3 patients.

RESULTS

All 3 patients were women, 35-45 years, with a BRYGB (roux limb-150 cm, biliopancreatic limb-100 cm) using a MiniMizer or a Fobi ring with 2-point fixation to the gastric pouch 2 cm above the gastrojejunostomy. All patients presented 3-4 years post-BRYGB, with an average total body weight loss (TWL%) of 41.28%. To discuss video of a single case, a 35-year-old female presented with abdominal pain, hematemesis and signs of abdominal tenderness and guarding. X-Ray abdomen showed distended small bowel loops and CT-scan revealed ischemic small bowel loops with free fluid. Diagnostic laparoscopy showed alimentary/roux limb (AL) gangrene, from the gastrojejunostomy to the jejunojejunostomy. The entire AL had herniated between the gastric pouch and band which had formed an obstructive ring around the herniated bowel loop and led to compromise of blood supply and gangrene. Resection of gangrenous bowel with reversal of BRYGB was done.

CONCLUSION

Early diagnosis and timely management may save a patient from gangrene. It also raises questions: Is a 2-point fixation of the band to the gastric pouch insufficient? Does a longer roux limb make it prone to herniating in the space between the gastric pouch and band?

Use of prostaglandin and cyclophosphamide for pediatric lupus with digital gangrene: Back to safety before hitting the axe!

Digital gangrene is a rare presenting feature of childhood lupus and only a reported incidence of 1.3%. We describe two cases of pediatric onset systemic lupus erythematosus (SLE), both 16 years old, presenting with digital gangrene and the successful salvage of the digits after using intravenous cyclophosphamide for immunosuppression and use of intravenous prostaglandin E1 infusions for limb reperfusion. Both of the patients responded exceptionally to the infusions with resolution of gangrene and near-total preservation of the functionality of toes.

Symmetrical peripheral gangrene and Roth spots in a patient with infective endocarditis

We present a case of a young man with symmetrical peripheral gangrene (SPG) resulting from Streptococcus viridans-related infective endocarditis, an association which has not previously been reported. SPG is associated with up to 40% mortality and may necessitate amputation; early identification and treatment of the precipitating factors is very important.

Digital Gangrene is a Rare Presentation of Takayasu's Arteritis

Takayasu's arteritis is a chronic large vessel vasculitis that mainly affects the aorta and its major branches such as brachiocephalic, carotid, subclavian, vertebral, renal, coronary and pulmonary arteries. It most commonly occurs in female at child bearing age and female to male ratio is 8:2. Initial presentations of Takayasu's arteritis may be nonspecific like fever, malaise, weakness, fatigue, arthralgia, myalgia and weight loss but in advanced stage there may be features of vascular inflammation like segmental stenosis, occlusion, dilatation and/or aneurysm. It is a sub acute process over months to years and usually with good collateral formation. So, critical limb ischemia due to acute onset of vascular stenosis is very rare. Here we are reporting a case of a 50-year- old male patient who presented with digital gangrene due to critical limb ischemia. Though the age of onset was at 50 years and the patient lacks clinical features like constitutional symptoms, bruit, claudication, asymmetrical blood pressure, the patient was diagnosed as a case of Takayasus's arteritis. The patient dramatically improved with oral glucocorticoid treatment. Although rare, takayasu's arteritis can presents only with digital gangrene without having other clinical features. The physicians should be aware of this unusual but limb threatening presentation and more studies are needed to find out the exact mechanism of this presentation.

Polycythemia as an Underlying Cause of Digital Gangrene: A Rare and Unusual Case Presentation

Digital gangrene is frequently encountered in patients who have diabetes with peripheral vascular compromise, with or without superimposed infection. Preoperative laboratory values and radiographic images are important to determine a proper course of action. Equally important is a thorough history taking to confirm or rule out systemic entities and preexisting conditions that can aggravate or predispose one to the development of digital gangrene. A patient with diabetes presented with a rare and unusual case of digital gangrene, as he clinically had strong pedal pulses. Preoperative workup revealed a suspicion of polycythemia, which was subsequently confirmed. The patient underwent several days of phlebotomy until his hemoglobin and hematocrit levels were brought down to optimized levels before a digital amputation was performed. He went on to heal uneventfully, and he is currently being closely followed by oncology/hematology colleagues with periodic phlebotomy.

[Venous gangrene of small intestine following coronavirus infection (SARS-COVID-19)]

The pandemic of a new coronavirus infection has made certain adjustments to modern emergency medicine. Systemic endothelial dysfunction following COVID-19 largely determines hemostatic disorders. Numerous studies revealed that intense platelet adhesion followed by platelet aggregates in COVID-19 patients and functional disorders of fibrinolysis system are combined with activation and severe endothelial dysfunction. The last one inevitably leads to thrombosis and adverse vascular events. There are a lot of studies devoted to deep vein thrombosis and fatal massive pulmonary embolism under COVID-19 infection. However, there are no descriptions of mesenteric thrombosis followed by intestinal wall necrosis. Our experience is based on the treatment and follow-up of 14 patients with venous gangrene of small intestine under COVID-19-induced severe endothelial dysfunction. We present a 40-year-old man with coronavirus infection complicated by ileum gangrene and subsequent favorable outcome.

Hand gangrene after repetitive IV midazolam injections

In the IV drug user (IVDU) population injection may inadvertently be intra-arterial or in the subcutaneous tissue causing a various range of complication ranging from simple cellulitis to artero-venous embolization. We present here a case of a full hand mummification and necrosis following repeated injection of chopped midazolam at the elbow, forearm and hand. A 36 year-old man presented to the emergency department with a 24 months history of slowly progressive necrosis to his right. Dry necrosis had progressively evolved into gangrene with almost spontaneous amputation at the level of the wrist. Surgical intervention was performed urgently with amputation at the proximal forearm level. No early complications were detected, and the patient did not show up at least follow-up. The present case represents an example of progressive microembolisation initially involving the hand and progressively affecting the whole forearm in an impressive mummification process over a 2-year period. Minimal but repetitive distal drug embolization can give silent and initially negligible symptoms, before clear signs of tissue sufferance are detected. When dealing with patients with IVDU history, anamnestic record of eventual use of chopped/pulverized should be performed. Careful examination of the limb should be always conducted, considering the risk of silent embolization and long term potentially devastating consequences.

Digital gangrene and pulmonary consolidation in a young girl with Takayasu arteritis

Takayasu arteritis (TA) is a large-vessel vasculitis most commonly affecting women of childbearing age. The disease process is usually slow and smoldering, presenting over months to years. Digital gangrene is an uncommon manifestation of TA because of the formation of good collateral circulation. Similarly, although pulmonary artery involvement is well described, pulmonary parenchymal involvement is very rare. We are reporting a case of a young girl with TA presenting with digital gangrene and pulmonary consolidation, which was treated successfully with a combination of aggressive systemic immunosuppression and anti-coagulants. The possible mechanism for gangrene along with the confounding diagnostic possibility of co-existing tuberculosis have been discussed.

COVID-19 associated symmetrical peripheral gangrene: A case series

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.

COVID-19 and peripheral arterial complications in people with diabetes and hypertension: A systematic review

AIMS

Identify the prevalence, risk factors and outcomes of lower extremity ischemic complications.

METHODS

A systematic review was conducted by searching PubMed and SCOPUS databases for SARS-CoV-2, COVID-19 and peripheral arterial complications.

RESULTS

Overall 476 articles were retrieved and 31 articles describing 133 patients were included. The mean age was 65.4 years. Pain and gangrene were the most common presentation. Hypertension (51.3%), diabetes (31.9%) and hypercholesterolemia (17.6%) were associated co-morbidities. Overall, 30.1% of patients died and amputation was required in 11.8% patients.

CONCLUSIONS

COVID-19 patients with diabetes or hypertension are susceptible for lower limb complications and require therapeutic anti-coagulation.

Peripheral Gangrene Associated with Disseminated Tuberculosis - a Rare Manifestation

With global resurgence of M. tuberculosis infection, cases of extra pulmonary TB have also shown an increase. Tuberculosis is a major cause of morbidity and mortality in India. Although disseminated tuberculosis can affect most of the organs, vasculitis presenting as peripheral gangrene as a manifestation of tuberculosis is very rare. We report the case of a 70 years old male who presented with gangrene of left leg complicating disseminated tuberculosis.

Cutaneous calciphylaxis of the glans penis presenting as a gangrenous ulceration

Report _Case Presentation X Photo Vignette _Letter Authors declare that the contents of this article are their own original unpublished findings. Title: Cutaneous calciphylaxis of the glans penis presenting as a gangrenous ulceration Authors: Marie Danset, Cécile Lesort, Denis Jullien, Jean Kanitakis Affiliations: Dermatology Department, Edouard Herriot Hospital, Hospices Civils de Lyon, Claude Bernard Lyon I University, Lyon, France Corresponding Author: Jean Kanitakis, Department of Dermatology, Edouard Herriot Hospital Group, 69437 Lyon Cedex 03, France, Tel: 33-472110301, Email: jean.kanitakis@univ-lyon1.fr Abstract: Calciphylaxis is a rare microvascular disorder causing necrotic skin ulcers. It is characterized by deposits of calcium within vascular walls but its precise pathogenesis remains poorly understood. A major risk factor is end-stage renal disease on dialysis. We report a 67-year-old man with calciphylaxis revealed by an unusual necrotic ulcer of the glans penis. The patient also presented with bilateral panniculitis of the thighs and a calf ulcer. All those lesions were painful, highlighting the value of pain as a diagnostic clue. Penile involvement of calciphylaxis is rare and biopsy is often avoided in this area. However, rapid diagnosis of calciphylaxis is important because early treatment has a better chance of being successful. Our patient's condition deteriorated rapidly with development of bilateral retinal artery occlusion and he died shortly thereafter. This case further highlights the fact that calciphylaxis is a systemic vascular disease with an ominous prognosis.

Nitroglycerin patch use in digital ischemia secondary to sepsis: a case report

Sepsis results in intense disturbances in homoeostasis and is responsible for considerable morbidity and mortality in early infancy. Owing to insufficiency on part of infant to develop adequate inflammatory response to localize the infection, they usually progress to disseminated systemic infection, pneumonia and/or meningitis. We present the case of a 26 weeks preterm boy with acute digital ischemia in right index finger progressing to impending gangrene as a manifestation of septicemia. Use of topical nitroglycerin patch with meticulous monitoring successfully alleviated the impending peripheral gangrene without any adverse effects.

Axillary artery thrombosis resulting in upper limb amputation as a COVID-19 sequela

Novel COVID-19 continues to intrigue medical professionals with its varied presentations. Though it affects the respiratory tract primarily, thrombogenesis has been the Achilles' heel. A 44-year-old man diagnosed with COVID-19 presented with upper limb pain at a local hospital and was found to have thrombosis of the right axillary artery. Despite a successful embolectomy at the local hospital, there was re-occlusion of the axillary artery and the limb became ischaemic. He was referred to our institution by which time the limb became gangrenous above the elbow and had to be amputated. Extensive sloughing of the nerves was also seen in the local area. Hypercoagulability presenting with various manifestations is common in COVID-19 and needs early anticoagulation. We present this asymptomatic patient who lost a limb to this COVID-19 sequelae.

A rare case of gangrenous foot in juvenile systemic lupus erythematosus

This report describes a rare case of Juvenile Systemic Lupus Erythematosus (JSLE). A young 13-year-old girl presented to the Civil Hospital Karachi on February 15, 2019 with gangrene as the only manifestation of this autoimmune disease. JSLE has several clinical manifestations such as butterfly rash, fever, joint pain, cardiac problems like pericardial infusion and neuropsychiatric disorders. However, in this case gangrene was the only presenting symptom; only laboratory investigations - anti-SSA and anti-ribosomal P protein - were suggestive of JSLE, while anti dsDNA, considered to be the most sensitive and reliable diagnostic tool for Systemic Lupus Erythematosus (SLE), was negative. Raynaud's phenomenon and gangrene have been described as rare symptoms, with gangrene occurring in only a small percentage of SLE patients. Moreover, the patient had received a blood transfusion a few months ago in Hyderabad which was suspected to be the cause of the transmission of infection which lead to polyclonal activation of lymphocytes.

A 47-Year-Old Hispanic Man Who Developed Cutaneous Vasculitic Lesions and Gangrene of the Toes Following Admission to Hospital with COVID-19 Pneumonia

BACKGROUND Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which originated in Wuhan, China, in late 2019 and has led to an ongoing pandemic. COVID-19 typically affects the respiratory tract and mucous membranes, leading to pathological involvement of various organ systems. Although patients usually present with fever, cough, and fatigue, less common manifestations have been reported including symptoms arising from thrombosis and thromboembolism. A spectrum of dermatologic changes is becoming recognized in patients with COVID-19 who initially present with respiratory symptoms. The mechanism behind these manifestations remains unclear. This report presents the case of a 47-year-old Hispanic man who developed cutaneous vasculitic lesions and gangrene of the toes following admission to hospital with COVID-19 pneumonia. CASE REPORT COVID-19 has been associated with cardiovascular disease entities including stroke, acute coronary syndrome, venous thromboembolism, and peripheral vascular disease. We present a case in which a 47-year-old Hispanic man arrived at the Emergency Department with COVID-19 and was admitted for respiratory failure. Despite anticoagulation initiated on admission in the presence of an elevated D-dimer, the patient developed gangrene of all his toes, which required bilateral transmetatarsal amputation. CONCLUSIONS This case shows that dermatologic manifestations may develop in patients who initially present with COVID-19 pneumonia. These symptoms may be due to venous thrombosis following SARS-CoV-2 vasculitis, leading to challenging decisions regarding anticoagulation therapy. Randomized controlled trials are needed to evaluate the efficacy of anticoagulation, to choose appropriate anticoagulants and dosing, and to assess bleeding risk.

Intestinal knotting: A case report and brief literature review

Ileo-ileal knotting is a rare cause of intestinal obstruction. In this condition, one bowel loop makes a knot with an adjacent bowel loop, resulting in mechanical obstruction and even gangrene of the bowel. We present a case of a young girl with ileo-ileal knotting resulting in a closed-loop obstruction and gangrene of the small bowel loop. This is a difficult condition to diagnose; a high index of suspicion and early surgical intervention are essential to reduce morbidity and mortality.

Histopathological findings in a COVID-19 patient affected by ischemic gangrenous cholecystitis

BACKGROUND

Since its first documentation, a novel coronavirus (SARS-CoV-2) infection has emerged worldwide, with the consequent declaration of a pandemic disease (COVID-19). Severe forms of acute respiratory failure can develop. In addition, SARS-CoV-2 may affect organs other than the lung, such as the liver, with frequent onset of late cholestasis. We here report the histological findings of a COVID-19 patient, affected by a tardive complication of acute ischemic and gangrenous cholecystitis with a perforated and relaxed gallbladder needing urgent surgery.

CASE PRESENTATION

A 59-year-old Caucasian male, affected by acute respiratory failure secondary to SARS-CoV-2 infection was admitted to our intensive care unit (ICU). Due to the severity of the disease, invasive mechanical ventilation was instituted and SARS-CoV-2 treatment (azithromycin 250 mg once-daily and hydroxychloroquine 200 mg trice-daily) started. Enoxaparin 8000 IU twice-daily was also administered subcutaneously. At day 8 of ICU admission, the clinical condition improved and patient was extubated. At day 32, patient revealed abdominal pain without signs of peritonism at examination, with increased inflammatory and cholestasis indexes at blood tests. At a first abdominal CT scan, perihepatic effusion and a relaxed gallbladder with dense content were detected. The surgeon decided to wait and see the evolution of clinical conditions. The day after, conditions further worsened and a laparotomic cholecystectomy was performed. A relaxed and perforated ischemic gangrenous gallbladder, with a local tissue inflammation and perihepatic fluid, was intraoperatively met. The gallbladder and a sample of omentum, adherent to the gallbladder, were also sent for histological examination. Hematoxylin-eosin-stained slides display inflammatory infiltration and endoluminal obliteration of vessels, with wall breakthrough, hemorrhagic infarction, and nerve hypertrophy of the gallbladder. The mucosa of the gallbladder appears also atrophic. Omentum vessels also appear largely thrombosed. Immunohistochemistry demonstrates an endothelial overexpression of medium-size vessels (anti-CD31), while not in micro-vessels, with a remarkable activity of macrophages (anti-CD68) and T helper lymphocytes (anti-CD4) against gallbladder vessels. All these findings define a histological diagnosis of vasculitis of the gallbladder.

CONCLUSIONS

Ischemic gangrenous cholecystitis can be a tardive complication of COVID-19, and it is characterized by a dysregulated host inflammatory response and thrombosis of medium-size vessels.

Limited cutaneous systemic sclerosis with gangrene: an autopsy case

We describe an autopsy case of a 75-year-old female with limited cutaneous systemic sclerosis (lcSSc) and gangrene due to macrovascular involvement. She was diagnosed with lcSSc complicated with pulmonary arterial hypertension and digital ulcers 9 years before admission. She had recurrent and refractory lower limb ulcers (LLUs), and died because of sepsis caused by gangrene infection. Autopsy findings revealed severely thickened arterial walls of the visceral organs, consistent with vascular involvement of SSc. Systemic vascular involvement in lcSSc may progress in patients with LLUs who harbour several risk factors for vascular involvement.

Peripheral symmetrical gangrene due to severe Plasmodium falciparum malaria: a case report

We present a patient with severe Plasmodium falciparum malaria of seven days' duration who developed an altered sensorium of one day. During hospital admission, peripheral symmetrical gangrene of hands and feet followed, despite normal limb vasculature.

Peripheral Gangrene and Extremity Amputations - Painful Preventable Sequelae of Meningococcal Septicaemia: Case Series Reports

Extremity gangrene is a fairly common pathology, which complicates systemic vascular and endocrine diseases. Most often, it is encountered in diseases like uncontrolled Diabetes Mellitus, presenting as diabetic foot gangrene, severe peripheral arteriosclerosis with gangrene of the extremity complicating severe uncontrolled systemic hypertension and meningococcal septicaemia with peripheral gangrene. It also occurs in some cases of snake bite as well as frost bite (in regions with extreme cold weather conditions). Some of them present as monolateral extremity gangrene. However, others present as bilateral symmetrical peripheral gangrene (SPG) characterized by bilateral extremity ischaemia resulting in gangrene in which there is no major vascular occlusive disease. There is disseminated intravascular coagulation with the gangrene being considered as a cutaneous marker and some of the patients that survive ultimately require amputation of the affected limb(s) in the severe cases. The mild cases end up losing some of the digits or just exfoliation of the dead cutaneous layer. The effects are generally more severe in the lower limbs than in upper limbs. Notable among these are some of those complicating meningococcal sepsis resulting from peripheral intravascular coagulation. We present here, five patients who presented with varying degrees of peripheral gangrene during an epidemic of meningitis and the treatments that were carried out depending on the severity of their cases.

Application of Chitosan and Chondroitin Sulphate Aerogels in a Patient With Diabetes With an Open Forefoot Transmetatarsal Amputation

INTRODUCTION

Diabetic foot ulcers may lead to nontraumatic amputations of the foot, leading to a decrease in patient quality of life. Transmetatarsal amputations (TMAs) represent an effective surgical procedure in cases of severe foot infection, but the tissue reconstruction is complicated and additional procedures should be considered. The present case report evaluates the wound closure of an open TMA in a patient with diabetes treated with a new aerogel composed of chitosan (ChS) and chondroitin sulphate (CS), without needing a skin graft.

CASE REPORT

A 72-year-old man with diabetes and a history of successive amputations was admitted to a hospital in Valdivia, Chile, due to a severe infection of toes 2 and 4 of the right foot. After the diagnosis of gangrene and osteomyelitis, the patient underwent a TMA of his right forefoot. The surgeon proposed the incorporation of ChS and CS aerogels to accelerate wound healing to avoid another surgical procedure. The TMA surgical wound area closed 50% after day 28 from starting treatment with aerogels. Complete closure was achieved at day 94 of treatment with aerogels, with good epithelial tissue and favorable cosmetic results and without residual limb deformities. The patient experienced minimal physical and psychological impairment from the procedure. Other surgical procedures were not necessary.

CONCLUSIONS

Due to the results of this patient, use of ChS and CS aerogels could represent an alternative treatment for forefoot TMA wound closure and prevent further surgical procedures, such as skin grafting. Future works should consider a larger number of cases.

Symmetrical peripheral gangrene reconstruction after lower limb amputation

Symmetrical peripheral gangrene (SPG) is a complication of septicemia, characterized by progressive skin lesions, which can result in wide necrosis of all the extremities. Severe necrosis is often responsible of disfiguring consequences. It is important to limit the amputation and to provide a stable and functional soft tissue coverage of the stumps. Limited amputation and free flap reconstruction may help to prevent tissue loss and to provide an effective prosthetization and a prompt rehabilitation. We present a clinical case of a 60-year-old male admitted in our department for lower limbs necrosis due to SPG after a pneumococcal infection. The patient underwent bilateral forefeet amputation and microsurgical reconstruction with antero-lateral thigh flap was performed on the left stump. Vascular complications determined a progressive necrosis of the flap and the failure of the reconstruction. A careful analysis of the local and systemic inflammatory vascular and coagulative issues following the SPG has been performed to explain the failure of the microsurgery. Although the opinion of several authors is divided about the use of free tissue transfer, we believe that microsurgical reconstruction remains the first choice of treatment due to the reduced morbidity and early rehabilitation it provides. KEY WORDS: Amputation, Free flaps, Free tissue transfer, Limb salvage, Microsurgery salvage, Prosthesis, Sepsis, Septicaemia, Symmetrical peripheral gangrene.

Sepsis-induced digital ischaemia in a professional pianist, in the absence of vasopressors

Peripheral limb ischaemia and gangrene are devastating complications of pneumococcal sepsis. We report a 43-year-old professional pianist who presented with early sepsis and rapid development of this syndrome. No vasopressor medication was ever administered. We urgently reviewed the medical literature on a range of therapies recommended by consulting teams, to ensure he received optimal care. Based on our review and on feedback from the patient himself, we gained valuable insights into this illness and the merits of selected treatment options. His fingers ultimately recovered their function, intact, although several toes were later amputated. More recently published reviews postulate that imbalances in coagulation factors and natural anticoagulants occur as a result of disseminated intravascular coagulopathy and 'shock liver' in the sepsis syndrome, leading to microcirculatory thromboses. We submit this report as we believe it supports this hypothesis and adds further valuable information. We hope our observations will assist other critical care clinicians confronting this serious condition.

A case of peripartum cardiomyopathy presenting as bilateral acute limb ischaemia and gangrene

Peripartum cardiomyopathy (PPCM) is a condition of unknown etiology that presents as heart failure due to left ventricular systolic dysfunction in the last of month of pregnancy and up to six months after giving birth. PPCM predisposes towards thrombo-embolism and an acute limb ischaemia can be a manifestation of this disease. We present a case of a 23-year-old lady presenting an acute lower limb ischaemia four months post-partum. Doppler ultrasound showed bilateral femoral emboli and cardiac ECHO showed a 24% ejection fraction. Amputation was performed on both limbs, below her right knee and above her left knee. The patient was started on heart failure medication and her symptoms improved with diuretic therapy, confirming the diagnoses of PPCM. It is important to recognise acute limb ischaemia as a rare manifestation of PPCM, as a timely diagnosis and effective treatment of the disease can improve the prognosis. We believe this is the first case to be reported in medical literature from Pakistan of a patient presenting PPCM with bilateral acute limb ischaemia and gangrene.

Symmetrical Peripheral Gangrene Associated with Low Output Cardiac Failure

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.

Postoperative nutritional support of the patient with gut gangrene-a case report

BACKGROUND

Bowel necrosis is a commonly observed condition in elderly patients with longstanding diabetes. In such condition, intestinal resection is usually performed for the removal of the gangrenous part. Post-surgical dietary management after bowel resection poses several challenges for the health care team.

CASE PRESENTATION

The case presented in this study is that of an elderly diabetic male who developed acute renal failure as a result of neglect in post-surgical feeding after intestinal resection. After the intervention by a trained dietitian, a transitional diet was planned and successfully executed, resulting in reversal of acute renal failure, dehydration, and post-surgical stress. Several complications including hepatic dysfunction and mouth ulcers were resolved through well-planned transitional diet. The patient was finally discharged in a stable health condition and was regularly followed up for any nutritional or medical issues.

CONCLUSION

Neglects in nutritional care of patients can have severe implications including development of medical complications, resulting in increased length of hospital stay, augmenting the disease stress of the patient and family, and finally the preventable drainage of several human and monetary resources. Therefore, recognition of nutritional intervention as an important part of in-hospital health care may have social as well as economic impacts.

Resolution of Primary Aortic Thrombosis after Dabigatran therapy-A New Hope for the Rare and Old Disease

The primary aortic thrombosis (PAT) is an uncommon noncardiac cause of distal peripheral embolization to lower extremities. Also, this condition develops in the absence of extensive atherosclerosis of aorta or abnormal dilatation like aneurysm of the aorta. In most of the cases, there was either no or minimal atherosclerosis of the aorta. The disease can involve any part of the aorta, but in most of the cases, the thoracic aorta below the origin of the left subclavian artery followed by the infrarenal portion of the abdominal aorta was the most common site of involvement. In our case, there was extensive thrombosis starting from the lower part of the thoracic aorta extending across both the renal arteries up to the aortic bifurcation without any underlying aortic pathology or hypercoagulable disease. There are no guidelines for the management of the PAT, but our experience is based on few case series, case reports, and meta-analysis where there are variable success rate using conservative medical management, endovascular procedure, or surgical thrombectomy. Vitamin K antagonist was the drug of choice in all the cases as a part of conservative medical management or used to prevent recurrence after the endovascular or surgical procedure. We present a case of PAT where the use of dabigatran leads to complete resolution and prevented the recurrence of the disease during two-year follow-up, which is the first and unique case report of the literature.

Operative versus non-operative treatment in diabetic dry toe gangrene

BACKGROUND AND AIM

Diabetic foot is a major comorbidity of diabetes, with 15-25% of diabetic patients developing diabetic foot ulcer during their lifetime. Other major diabetic foot complications include cellulitis, abscess, wet gangrene, dry gangrene, and necrotizing fasciitis. Dry gangrene involves tissue necrosis due to chronic ischemia whereby the tissue becomes numb, dry, wrinkled, and dead. Although diabetic foot complications have been extensively studied in literature, there is limited data on the management of dry gangrene.

METHODS

We report a case series of 12 patients with diabetes-related dry gangrene in the toes, initially planned to be managed conservatively with autoamputation.

RESULTS

One patient had an autoamputation, while eight patients underwent surgical amputations (six major amputations, two minor amputations) for better clinical outcomes. Two patients died, while no change was observed in one patient even after 12 months of follow-up.

CONCLUSION

Managing diabetic dry toe gangrene by waiting for autoamputation may lead to worse clinical outcomes and should be practiced cautiously on a case-by-case basis. Early surgical intervention should be opted to improve patients' quality of life.