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.

The Use of CECT in the Diagnosis of Intestinal Obstruction: A Case of Difficult Diagnosis in a Strangulated Left Femoral Hernia

ABSTRACT

A femoral hernia is an uncommon and acquired hernia in the groin. Its incidence in adults is 2%-8% of all abdominal wall hernias, and it has a female-to-male ratio of 1.8:1. It is usually found in elderly patients and is associated with increased morbidity due to delays in diagnosis leading to a high incidence of incarceration and strangulation. Accurate preoperative diagnosis of femoral hernia is challenging, especially in obese patients in whom a small femoral hernia can be hidden under the groin fat. Unlike an inguinal hernia, it rarely reduces on its own and if asymptomatic and small, is often unnoticed by the elderly obese patient. Femoral hernia is often unsuspected and overlooked in males as it is predominant among females. Delay in diagnosis can lead to intestinal gangrene and high morbidity. We present a case of an incarcerated left femoral hernia in an elderly obese male who presented with acute intestinal obstruction. He was managed with resection of the gangrenous segment and double barrel ileostomy. Although uncommon in males, a femoral hernia has a high incidence of strangulation, and therefore should always be ruled out as a cause of acute intestinal obstruction in elderly patients. Therefore, never forget to examine the groin in case of intestinal obstruction.

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.

Ileo-ileal knot causing acute gangrenous small bowel obstruction: a case report

BACKGROUND

Ileo-ileal knotting is a very rare cause of small bowel obstruction, and only a few reports have been published. Small bowel obstruction (SBO) is one of the most common emergency surgical conditions that require urgent evaluation and treatment and is one of the leading causes of emergency surgical admission. There are many causes of SBO that are known in general surgical practice, and these causes are different in the developing and developed worlds.

CLINICAL PRESENTATION

In this article, we present a case of acute gangrenous SBO secondary to ileo-ileal knotting in a 37-year-old Ethiopian female patient after she presented with severe abdominal cramp, vomiting, and abdominal distension of 4 hours duration. The patient was operated on intraoperatively; she had gangrenous small bowel obstruction caused by ileo-ileal knotting. Later, the patient was discharged and improved after 12 days of hospital stay.

CONCLUSION

Ileo-ileal knotting should always be considered in the differential diagnosis of acute small-bowel obstruction. The diagnostic difficulty and the need for urgent treatment of this condition to yield optimal results are discussed.

Prenatal Torsion of Radial Polydactyly: A Gangrenous Mass at the Base of the Thumb

A patient was born with a mass at the base of the thumb approximately 1.5 cm in diameter on the radial side of the fingers. The mass had globular swelling filled with hemorrhagic fluid and was dark red. X-rays and histology of the excised specimen suggested the diagnosis of gangrene and torsion of polydactyly. Prenatal torsion of polydactyly is not a common occurrence; moreover, prenatal torsion of polydactyly has only been found in ulnar polydactyly. Our case is a novel case of radial polydactyly that was gangrenous at birth owing to prenatal torsion. Diagnosing such a mass at the base of the thumb is important.

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?

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.

Bilateral Digital Ischemia Secondary to Heparin-Induced Thrombocytopenia with Subsequent Limb Salvage: A Case Study

Heparin-induced thrombocytopenia (HIT) is a prothrombotic state caused by the buildup of platelet factor 4 antibodies with decreased platelet count caused by heparin therapeutic or prophylactic therapy. It is important to detect this complication, especially in critically ill patients and cardiac patients. Detection of HIT can be demonstrated by positive antibodies in a HIT panel. Based on clinical and laboratory findings, heparin use should be discontinued with immediate transition to alternative anticoagulation therapies. Thromboembolic events can be an adverse effect of HIT and can cause local tissue necrosis, especially in the lower extremity. This case is a retrospective medical record review of a 52-year-old man who was initially admitted as an outpatient for coronary artery bypass grafting and mitral valve replacement who developed digital gangrene from HIT. This case emphasizes the rare adverse effects of HIT and the need for timely consultation for surgical treatment of limb ischemia/gangrene.

[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.

Clostridium septicum foot gangrene associated with colorectal cancer

INTRODUCTION

Since the second half of the 20th century, an association between the occurrence of Clostridium septicum and Streptococcus gallolyticus infections in patients with colorectal cancer has been described in specialist literature. Infections are manifested by bacteremia, septic embolism, cellulitis, myonecrosis, and gas gangrene of the limbs.

MATERIAL AND METHODS

The authors present a case of a rare association between lower limb gangrene caused by the septic embolization of a Clostridium septicum infection and malignancy of colon ascendens in a polymorbid patient. Gangrene of the lower limb led to septic shock requiring acute amputation treatment. After managing the acute condition, the patient was operated on for a malignant colon tumour.

DISCUSSION

The process of carcinogenesis often takes years and is almost asymptomatic. The occurrence of S. bovis/S. equinus (SBSEC) and C. septicum bacteremia, respectively, is relatively rare, but their presence is often associated with the occurrence of malignancy, most often of the lower gastrointestinal tract. This paraneoplastic symptom may be the first manifestation of a malignant disease. The effect of exotoxins can lead to sepsis or even septic shock with a mortality of 48-56%.

CONCLUSION

Clostridium septicum and Streptococcus gallolyticus infections are rare in clinical practice. However, their presence can be a first paraneoplastic symptom, and therefore the doctor should look for a possible oncological disease when they are detected. The main diagnostic methods include colonoscopy and imaging, especially CT scan.

[Progress in diagnosis and treatment of gangrenous cholecystitis]

Gangrenous cholecystitis is a kind of acute cholecystitis, whose course of disease progresses rapidly, early diagnosis is difficult and mortality is high, and clinicians are prone to misdiagnosis and missed diagnosis in clinical work.However, gangrenous cholecystitis has been ignored in various guidelines.This paper systematically summarized the pathogenesis, pathological manifestations, epidemiology, clinical diagnosis and treatment of gangrenous cholecystitis, hoping to provide a complete and clear diagnosis and treatment process for clinicians.

When amputation is not the end of the challenge: A successful therapy for osteomyelitis and soft tissue infection in a patient with type 1 diabetes

Infection is a common complication in patients with diabetic foot ulcer, leading to lower extremities amputation and healing failure. In this article, we report the case of a 39-year-old man with diabetes who developed a severe soft tissue infection and osteomyelitis after experiencing a major amputation for wet gangrene of both the foot and the ankle.

A Rare Case Presentation

Systemic lupus erythematosus is an autoimmune disorder that affects several organs and systems in the human body. Digital gangrene is known to be a rare and severe complication of systemic lupus erythematosus that could lead to amputation. We report a case of an adolescent who presented with an autoimmune disorder and multiple comorbidities and developed gangrenous toes.

[Treatment of ischemic penile and scrotum gangrene]

Gangrene of the penis is a rare condition manifesting with purulent necrotization of penile tissues and systemic inflammatory response. In more than 90% of cases, the cause of the development of the penile and scrotal gangrene is rapidly progressive necrotizing fasciitis of polymicrobial etiology, which predominantly affected the external genital organs. Isolated cases of penile gangrene development when using the restraining rings of the penis are described in literature (condom urine collection bag, rings for erection, etc.). Cases of penile and scrotum gangrene, when treatment with bilateral orchiectomy and penectomy is required are quite rare. We present the case of penlie and scrotum gangrene in an 86-year-old patient with mental disorders. The cause of gangrene was long-term forced position of the patient with infringement of the penis and scrotum by the thighs. Active intensive therapy, surgical removal of the penis, scrotum and testicles and urine diversion by the imposition of a trocar cystostomy saved the patients life and he was discharged from the hospital in a satisfactory condition.

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.

An uncommon cause of sepsis following dog exposure

ABSTRACT

Capnocytophaga canimorsus is a bacteria commonly found in the normal oral cavity of dogs that can cause bacteremia in immunocompromised patients following a dog bite. This case describes sepsis and disseminated intravascular coagulation associated with C. canimorsus in a patient with a history of alcohol abuse. Clinicians must be alert to the risk factors for this infection and provide appropriate prophylaxis following dog bites.

Fuzzy Models of Choice of Prevention Schemes for the Occurrence and Development of Gangrene of the Lower Extremities

The study focuses on the choice of prevention schemes of the appearance and recurrence of gangrene of the lower extremities, depending on any of the degrees of confidence that the patient will have gangrene or will experience its relapse. The degree of confidence is determined using the fuzzy logic of decision making on the relevant membership functions. For each of the selected classes, an appropriate prevention scheme has been developed, the effectiveness of which was tested using the theory of measuring latent variables and the synthesis of mathematical models of their choice depending on the degree of risk of the occurrence and recurrence of lower extremities gangrene. Model statistical tests showed that compared with traditional prevention schemes the use of the proposed models can increase the rate of positive results in the absence of lower extremities gangrene and reduce the possibility of relapse (recurrent changes by 42%, risk of amputation by 35%).

Susceptibility Factors for Early Reamputation in Diabetic Great Toe Gangrene

INTRODUCTION

The effectiveness of the treatment has long been significant in diabetes and its complications, especially in developing countries. Prolonged hospitalization and repeated surgery should be avoided due to clinical and economic reasons. Wound breakdowns or necrosis can occur after amputation procedures, and subsequently will require reamputation. This study analyzed susceptibility factors in diabetic foot patients undergoing prior high toe amputation that are thought to be related to early reamputation.

METHODS

We performed a retrospective analysis in 107 patients that have undergone amputation for great toe gangrene, during May 2014-April 2019. Demographic data, clinical features, laboratory results and treatment modality, were documented and statistically analyzed by simple and multiple logistic regression methods.

RESULTS

Of all 107 patients, 17 patients had to undergo early reamputation. Limited dorsiflexion, level of amputation, and sepsis condition is shown to be significantly associated with first amputation. Multiple logistic regression analysis confirmed a significant association of early reamputation with amputation or disarticulation at the level of the metatarsophalangeal joint.

CONCLUSION

While limited ankle dorsiflexion and sepsis conditions need to be addressed comprehensively, from the surgical options point of view, we suggest ray amputation to be preferred over metatarsophalangeal joint disarticulation to prevent early reamputation.

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.

Peroneal Artery Adipofascial Flaps for Coverage of Distal Leg and Rearfoot

Chronic wounds of the lower extremity can pose several obstacles for the treating physician as well as the patient. Peroneal artery adipofascial flaps have been shown to be a reliable and durable option for reconstruction of these defects for many reasons, including ease of dissection, minimized donor site mobility, reliability of take to underlying surfaces, and cosmetically more pleasing outcome. This article discusses the current literature regarding the use of peroneal artery adipofascial flaps and our surgical technique for harvest, transfer, and postoperative course for this versatile flap.

Ileo-sigmoid knotting: the Parirenyatwa hospital experience

BACKGROUND

Ileo-sigmoid knotting is a rare cause of intestinal obstruction with a rapidly progressive course, for which expedient surgical intervention is required to prevent mortality. The aim of this study was to determine the characteristics, presentation, morbidity and mortality associated with ileo-sigmoid knotting at Parirenyatwa Group of Hospitals (PGH). To determine the preoperative diagnostic precision and management patterns of ileo-sigmoid knotting cases at PGH.

METHODS

A retrospective analysis was performed on patients operated on at Parirenyatwa Hospital with a diagnosis of ileo-sigmoid knotting between April 2011 and April 2018. Data inclusive of demographics, time to presentation and surgery, preoperative diagnosis, complications and in-hospital mortality was collected. The relationship between the duration of symptoms prior to surgery and incidence of both septic shock and transfusion were analysed.

RESULTS

Twenty-one cases of ileo-sigmoid knotting were identified for analysis. The median age was 37 years (range 18-65 years) with a 6:1 male to female ratio. Two of the three females included were pregnant. Twenty patients (95.2%) described an acute onset abdominal pain, with 83.3% experiencing the pain nocturnally, while asleep. The median duration of symptoms at presentation was 12.5 hours (range 2-39 hours). At admission, leucocytosis (WCC > 11x10³/dl) was noted in eleven patients (52.4%). Seventy-three per cent of patients were noted to have electrolyte derangements at presentation. Seven patients (33.3%) had recorded episodes of severe hypotension (SBP < 90) prior to surgery. The most common preoperative diagnosis, based on both clinical assessment and plain x-ray evaluation, was sigmoid volvulus (52.4%), with no preoperative diagnosis of ileo-sigmoid knotting being made. All patients had gangrenous small bowel, with 81% having a gangrenous sigmoid colon. All cases underwent small bowel resection and primary anastomosis plus Hartmann's procedure. Postoperatively, eleven patients (52.4%) developed septic shock, while 62% required blood transfusion. There was one (4.8%) early postoperative mortality.

CONCLUSION

To avoid mortality, the diagnosis of ileo-sigmoid knotting should be entertained and the imperative of emergency surgery recognised in the young male or pregnant female patient with acute nocturnal onset abdominal pain, a rapidly deteriorating small bowel obstruction clinical picture and with radiological features suggestive of both small and large bowel obstruction.

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.

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.

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.

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.

Digital gangrene induced by inadvertent intra-arterial cocktail injection of anesthetic agents such as pentazocine, promethazine, and atropine: A serious adverse drug experience

Gangrenous changes in skin due to accidental intra-arterial injection of promethazine and pentazocine have been reported. Accidental intra-arterial injection is most commonly encountered in the antecubital fossa. However, recent reports in the radial and ulnar arteries have also been encountered. We hereby report a serious, preventable adverse drug experience in the form of digital gangrene induced by inadvertent intra-arterial cocktail injection of anesthetic agents such as pentazocine, promethazine, and atropine, which seems to be in the radial artery as the lateral three digits and dorsum of the hand are affected.

[Secondary amputation of the limb after primary surgery of open fractures of the lower limb]

This study reports the complications occurred during the management of open fractures of the lower limbs, resulting in secondary amputations, observed in clinicians' practice in recent years as well as different risk factors and possible deficiencies in management at the origin of these complications. We conducted a retrospective study over a period of 06 years (January 2006 - January 2012). It included patients with open fracture of the lower limb initially treated in our institution and whose complications resulted in amputation. All patient undergoing emergency amputation after examination at the Emergency Department were excluded. All patient treated in another hospital before being referred to us were excluded by the study, even if secondary amputation had been performed in our institution. We collected data by analyzing the records of patients (clinical and complementary examinations, surgical reports). We evaluated our management of open fractures of the lower limb according to the guidelines and recommendations found in the literature. These complications were observed in 9 out of 306 open fractures of the lower limb treated in the same period (January 2006 - January 2012), reflecting a rate of 2.9%. The average age was 42.6(26-57) years, all patients were male. We recorded 1 case of fracture of the femur, 7 cases of fracture of 2 leg bones and 1 case of foot crushing. These were open fractures including 1 case of type 1 fracture, 3 cases of type II fracture and 5 cases of type III fracture, according to Gustilo and Anderson classification. We performed 5 amputations of the thigh and 4 amputation of the upper third of the leg. Various complications motivated these amputations, including bone infections or soft-tissue gangrenes of ischemic or infectious origin. The patients had no morbidities such as diabete and were not chronic smokers. No patient died. Open fractures deserve special attention of the surgeon on immediade complications both from a diagnostic and therapeutic point of view in order to reduce the amputation rates after primary surgery giving patients the impression that they had an incorrect procedure performed on them. Particular attention should be paid to the degree of initial contamination and to the presence of a virulent germ at the site of trauma which may motivate particular attitudes during primary management.

[Balloon angioplasty of the radial artery in critical hand ischaemia]

Presented herein are the results of treatment of five 63-to-72-year-old patients (four men and one woman) with critical upper limb ischaemia, which is one of rarely encountered pathologies. All patients suffered from type 2 diabetes mellitus. Two of them had end-stage renal disease (ESRD) and for 2 years were on haemodialysis. Four patients had gangrene of 1 finger and one patient had gangrene of 2 fingers. The main diagnostic methods included duplex scanning with measuring the gradient of pressure between the humeral and radial arteries, and MSCT angiography. The patients with ESRD received conservative therapy with the use of prostaglandin E1 and after limitation of necrosis sustained amputation of the fingers. Three patients were successfully managed by recanalization and balloon angioplasty of the radial artery's occluded segment. The patients underwent follow-up examinations at 1, 6, 12, 18 and 24 months. During this period two patients with ESRD died. They had no relapses of critical ischaemia of the hand but developed gangrene of toes and were both subjected to successful balloon angioplasty of the crural arteries. One patient at 18 postoperative months was found to have reocclusion of the radial artery with hand pain at rest. He was subjected to successful repeat balloon angioplasty of the radial artery. CONCLUSION: Timely restoration of blood flow in this situation reduces the frequency of amputation. Percutaneous balloon angioplasty may become a method of choice in treatment of patients with critical hand ischaemia caused by occlusive lesions of arteries of the forearm.

Ecthyma gangrenosum in a 3-month-old, previously healthy infant: A Case Report

RATIONALE

Ecthyma gangrenosum (EG) is an aggressive cutaneous disease caused by local or systemic infection with Pseudomonas aeruginosa. EG is characterized by cutaneous manifestations ranging from nodule and papule, to necrotic ulceration with surrounding erythema, especially with black eschar or central crust. EG presents with characteristic skin lesions which is important to establish diagnosis of sepsis caused by P aeruginosa, a serious condition that can be treated efficiently if diagnosed early.

PATIENT CONCERNS

A 3-month-old female infant was presented with characteristic skin lesions of EG and developed sepsis 3 days later.

DIAGNOSES

Ecthyma gangrenosum and sepsis caused by Pseudomonas aeruginosa.

INTERVENTIONS

Meropenem was used in combination with ceftazidime at first and excision of necrotic skin lesions was performed later.

OUTCOMES

Cure.

LESSONS

Early recognition of EG plays an important role in providing appropriate empiric antibiotic treatment at early stage of sepsis, and improves the prognosis. Surgical excision may be helpful if no improvement was achieved via antibiotic treatment.

An unexpected gangrenous duplication of ileum

Alimentary tract duplication is a rare congenital anomaly which may involve any part of the alimentary tract extending from stomach to rectum. Clinical presentation may mimic an inflamed appendix as described in this case. A 9-year-old boy with a clinical diagnosis of perforated appendix was noted to have a normal appendix intra-operatively. On further search for an underlying pathology, a gangrenous ileal duplication was discovered. En-bloc resection with primary bowel anastomosis was done. Histopathology report revealed a gangrenous small bowel duplication. We discuss the preoperative diagnostic dilemma and management options in approaching this rare entity.

Gallstone ileus presenting as obstructive gangrenous appendicitis

We present the very unusual case of a 38-year-old woman with acute appendicitis and intestinal obstruction. During surgery, a 2.5 cm gallstone impacted at the base of the cecal appendix was found as the cause of a gangrenous appendicitis and obstruction; a choledochal-duodenal fistula was found during the same surgery with no gallstones remaining in the gallbladder or elsewhere. The case was managed by appendectomy with retrieval of the gallstones and no other procedure was performed for the gallbladder or the fistula, since no other gallstone was found on examination. Previously, she was found to have a round, radio-opaque image on the right iliac fossa on imaging, initially identified as an appendicolith, but after pathological examination it turned out to contain cholesterol and calcium bilirubinate. Gallstone ileus as the cause of an obstructive gangrenous appendicitis is a very unusual disease presentation that should be kept in mind when finding an unusual appendicolith presentation in or out the appendix.

Hemodialysis patient with finger ulcerations

The patient reported pain and paresthesias of his left ring finger, and his left hand was cooler than his right. An angiogram helped us recognize the cause of his symptoms.

['Life-saving' interventions in subacute thrombosis of crural and plantar arteries]

The authors report a clinical case concerning successful endovascular treatment for subacute thrombosis of crural and plantar arteries in a patient with the only leg, substantiating therapeutic decision making with due regard for the duration of thrombosis and localization of the lesion of the arterial bed. Taking into consideration the statistical data on survival in case of performing major amputation in this cohort of patients, an 'aggressive' endovascular approach including three vascularizations made it possible not only to preserve the leg but also to save the patient's life.

[COMPLEX TREATMENT OF PURULENT-NECROTIC COMPLICATIONS IN THE PATIENTS, SUFFERING DIABETIC FOOT SYNDROME, USING NEGATIVE TRESSURE AND CAPICOR PREPARATION]

The comparative analysis data were presented, concerning the results of complex treatment of 28 patients, suffering ischemic-gangrenous form of the diabetic foot syndrome, developing on background of chronic ischemia of the lower extremities stage IV. In 14 patients (main group) a routine complex of the treatment measures was added by application of an active pressure (negative pressure wound therapy - NPWT) and a capicor preparation; 14 patients (the comparison group) were treated in accordance to routine scheme. In accordance to the comparative analysis data, in patients of the main group the wound surface sarea have kept reducing in twice more rapid, than in a comparison group, the wounds healing was achieved in 94% patients, duration of the patients’ stationary stay have reduced by (5.2 ± 1.4) days.

[АNALYSIS OF LETHALITY IN COMPLICATED DIABETIC FOOT SYNDROME AND SEPSIS]

There were examined in dynamics 724 patients, in whom complicated diabetic foot syndrome (DFS) was diagnosed, and in 71 (9.8%) of them the disease was complicated by sepsis. The state severity in a DFS patients have depended upon duration of purulent-necrotic process on the foot, in septic patients such dependence was not revealed. All the DFS patients without sepsis were operated on. In total 36 died (lethality 5.5%), in presence of sepsis - 42 (lethality 59.1%). The cause of sepsis in the patients, suffering complicated DFS, was predominantly a wet gangrene of the lower extremities. Among those, who were not operated on, 13 (30.9%) septic patients died, of them 5 – who refused operative intervention performance - died in first hours after admittance to hospital due to irreversible injury of organs and systems.

[Salvation of the diabetic foot through a comprehensive individualized treatment of the patient with type 2 diabetes: case study]

This is a case of men with type 2 diabetes mellitus and diabetic foot. The patient was in danger of limb amputation. After improvement of diabetes, hypertension and dyslipidemia therapies a comprehensive treatment of diabetic foot including angioplasty, antibiotics and local maggot therapy was used for diabetic foot management. Therapy result was very satisfying for the patient. Despite of amputation of the 2nd digit due to advanced gangrene, the whole foot function was saved.Key words: diabetes foot - maggot therapies - type 2 diabetes mellitus.

Foot Gangrene in Patients with End-Stage Renal Disease: A Case Control Study

The prevalence of peripheral arterial disease (PAD) in patients with end-stage renal disease (ESRD) is high, with an annual risk of amputation estimated at 13%, and indications for limb revascularization in patients combining ESRD with stage IV PAD (foot gangrene) are still controversial. This case-controlled study compared survival, limb salvage, and quality of life in a group of patients hospitalized for foot gangrene according to their renal status (ESRD versus no renal insufficiency). All patients with ESRD hospitalized for foot gangrene (n=16) from 1996 to 2002 were compared with a control group with normal creatininemia (n=24) hospitalized for foot gangrene due to peripheral atherosclerotic arterial disease. The 2 groups were matched for age, sex ratio, and number with diabetes mellitus. After a mean follow-up of 467 ±410 days, patients with ESRD had a more severe prognosis as regards mortality (68.7% vs 12.5%, p=0.0005) and major amputation (31% versus 8%, p=0.09). The ESRD group was characterized by more frequent extensive arterial calcifications (16/16 vs 13/24, p=0.002), owing to a higher level of the calcium phosphorus product (3.54 ±1.2 vs 2.4 ±0.6, p=0.0023), and by impaired microcirculatory perfusion, as indicated by a lower oxygen pressure (TcPO2) (15.6 ±12 mm Hg vs 26 ±16, p=0.07). ESRD implies a poor prognosis in patients with stage IV peripheral arterial disease.