Peripheral symmetrical gangrene (PSG) is a condition defined by sudden onset of acral, frequently symmetrical purpura and gangrene involving all four limbs, both hands or both feet.1 PSG is a rare but welldocumented condition, which can occur at any age and has no gender predilection. Extreme cold, pallor and pain in the affected areas herald the onset of PSG. These symptoms and findings progress to acrocyanosis and, if not reversed, to frank gangrene. We report the case of a patient with acute lymphatic leukaemia who developed the typical lesions of PSG due to disseminated intravascular coagulation (DIC) secondary to septicaemia induced by Escherichia coli and Enterococcus faecalis.A 47-year-old man with acute lymphatic leukaemia started a chemotherapy regimen with cyclophosphamide, vincristine, adryamicin, prednisone and imatinib. After a few days, he developed fever and watery diarrhoea, and his fingers and toes became cold, pale and cyanotic. The acral cyanosis was symmetrical and the tips of the digits were bluish-black, suggesting impending gangrene ( Fig. 1a and b). Within 24 hours, the condition progressed rapidly to gangrene, with formation of haemorrhagic bullae involving the hands, feet, forearms and the distal third of the legs (Fig. 1c). Peripheral pulses were intact.Skin biopsy showed microthrombi in the lumen of the capillaries of the superficial and deep vascular plexus with intraluminal deposition of fibrin and subtle extravasation of red blood cells. Neither vasculitis nor inflammatory infiltrates were observed on the vascular walls ( Fig. 2a and b).Laboratory investigations found pancytopenia with severe thrombocytopenia (platelet counts < 20 · 10 9 ⁄ L; normal 150-400 · 10 9 ⁄ L), increased levels of D-dimers, low levels of prothrombin, protein C and antithrombin III, and a prolonged prothrombin time. Escherichia coli and E. faecalis were isolated on blood cultures.The clinical, histological and laboratory findings were thought to be consistent with PSG secondary to DIC caused by Gram-negative sepsis. An echocardiographical study revealed dilation of the right cavities with systolic dysfunction of both ventricles and signs of pressure overload. Intraperitoneal free liquid and bilateral pleural effusion plus cardiomegaly was found in a thoracoabdominal scan.The patientÕs general condition deteriorated over the next few days and, in spite of treatment with broadspectrum antibiotics and inotropic support (dobutamine, nitroglycerin and fluids), he went on to develop multiorgan failure and died within 1 week. During this time, the gangrene had also progressed, with new haemorrhagic bullae formation and involvement of more proximal areas.The aetiopathogenesis of PSG, first described by Hutchinson in 1981, 2 is unknown, but it seems that any condition that critically diminishes blood flow and therefore compromises the supply of nutrients or oxygen to acral areas for a prolonged period can lead to PSG. PSG is most frequently seen in the context of DIC (85% of cases), 3 often secondary to infection. P...