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Welcome to the April, 2013 edition of SciEP newsletter, providing monthly summaries of articles on science & education related topics of interest to scientist and professionals. The mission of our journals is to provide an open access forum for publishing new findings on issues pertinent to scientific and academic field. We also invite you to submit original research papers, review articles, short reports, or case studies are considered for publication in our Multidisciplinary Journals.

American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
DOI: 10.12691/ajmbr-1-1-2

The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

American Journal of Medical Sciences and Medicine
DOI: 10.12691/ajmsm-1-1-1

Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
DOI: 10.12691/ajidm-1-1-2

The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

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American Journal of Cancer Prevention
American Journal of Medicine Studies
American Journal of Infectious Diseases and Microbiology
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American Journal of Biomedical Research
American Journal of Mechanical Engineering
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Journal of Preventive Medicine
American Journal of Food and Nutrition
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Symmetrical Peripheral Gangrene, a Serious Complication of Sepsis

Lakshmi Kant Pathak*, Vimala Vijayaraghavan, Nataliya Ana Wilson

Assistant Professor of Medicine, University Of North Dakota, Fargo, ND, USA

Abstract: Symmetrical peripheral gangrene (SPG) is a rare but devastating complication of septicemia, with a high mortality rate. About half of the patients who survive require amputation of the affected limb. The common etiologies include both infective and non-infective etiologies. Aggravating factors include asplenia, immunosuppression, and previous cold injury to extremities, diabetes mellitus, renal failure, increased sympathetic tone and use of vasopressors. [1] SPG is defined as symmetrical distal ischemic damage at two or more sites in the absence of large vessel obstruction or vasculitis, sometimes used synonymously as purpura fulminans. Disseminated intravascular coagulation (DIC) and hemorrhagic infarction of skin with uninvolved proximal arteries are hallmark of this condition [2].

Keywords: symmetrical peripheral gangrene , septicemia

Received May 30, 2015; Revised July 31, 2015; Accepted August 19, 2015

Citation: Lakshmi Kant Pathak, Vimala Vijayaraghavan, Nataliya Ana Wilson, Symmetrical Peripheral Gangrene, a Serious Complication of Sepsis. American Journal of Medical Case Reports, 3 (9). 286-287. January 2015. doi:10.12691/ajmcr-3-9-6

1. Case Report

1.1. Learning Objectives

1) To recognize symmetrical peripheral gangrene as a rare cutaneous manifestation of sepsis

2) To recognize the high mortality associated with this condition and need for early intervention.

1.2. History of Present Illness

The patient is an 80 year old female who presented to the Emergency Department with complaints of generalized weakness, dysuria, abdominal pain and lethargy of four days duration. Her vitals on arrival were T 99F, BP 71/48 mmHg, HR 91 bpm, RR 20 bpm with SpO2 94% on room air.

1.3. Past Medical History

HTN and colon cancer s/p surgery.

1.4. Physical Examination

Her physical examination was unremarkable except for the presence of diffuse abdominal tenderness without guarding.

1.5. Laboratory values

Laboratory values were significant for Hb 12 g/dl, WBC 16.8, platelets 76, INR 1.3, PTT 39, d dimer 248, fibrin split products 160 and peripheral smear showed schistocytes. Blood cultures grew E.coli.

1.6. Hospital Course

She was diagnosed with septic shock from urinary tract infection. Her initial management comprised of Vancomycin and Zosyn in addition to fluids and nor epinephrine. On the second hospital day, her hands and feet were cold to touch with peripheral cyanosis at the tips of all the fingers except the thumb and all the toes and associated with pain. The cyanosis progressed to gangrene at the finger tips by day 5. Her peripheral pulses were well palpable throughout. The nor-epinephrine was weaned but could be discontinued only on day 5. Despite the aggressive management, the patient succumbed on hospital day 11.

1.7. Images

Picture 1.

Picture 2.

Picture 3.

Picture 1, 2 and 3 showing symmetrical peripheral gangrene involving hands and feet.

2. Discussion

The exact pathogenesis is unknown but low flow states coupled with endothelial damage in association with hypercoagulable state leads to micro- circulation occlusion.

The etiologies could be myriad with bacterial, viral or parasitic infection versus non infective causes like cardiogenic shock, massive pulmonary embolism, and use of vasopressors, paraneoplastic syndrome, auto immune disorders and various malignancies.

By far bacterial septicemia is the most frequent cause and lead to considerable morbidity and mortality.

DIC is associated in majority of cases and is the final common pathway of micro- circulation occlusion.

SPG should be suspected at the first sign of marked coldness, pallor, cyanosis or pain in the extremity, as the condition can progress rapidly to acrocyanosis and, if not corrected to gangrene. The ischemic changes begin distally but soon may progress proximally to involve the whole limb.

These changes are associated with intact distal pulses as confirmed by Doppler study because the large vessels are often spared. The peripheral extremities, tip of the nose, scalp and genitalia are areas most commonly affected. Patients usually have features of hypotension and shock. The laboratory investigation is directed towards determining the underlying cause. It may include septic screen, DIC and auto antibody panel and evaluation of arterial circulation with Doppler’s.

Pathologic examination of amputated specimens often reveals thrombi concentrated in the small vessels with sparing of large vessels.

The treatment is supportive and is focused to the underlying etiology.

No treatment is universally effective. Early recognition and immediate discontinuation or reduction, if possible, of vasopressor therapy (as it aggravates the low-flow state by enhancing vasoconstriction) and vigorous therapy of sepsis and DIC with intravenous antibiotic therapy and heparinization are essential components of SPG management [3].

In extreme cases amputation of gangrenous area may become necessary to save life.

References

[1]   | CMAJ • OCT. 29, 2002; 167 (9) Symmetrical peripheral gangrene: a rare but dreadful complication of sepsis.
[2]   | JAPI • VOL. 56 • JUNE 2008 R Avasthi, SC Chaudhary, KP Singh, JS Makker.
[3]   | Ghosh SK, Bandyopadhyay D. Symmetrical peripheral gangrene. Indian J Dermatol Venereol Leprol 2011; 77: 244-8.