Rare case of symmetrical peripheral gangrene due to septic shock, disseminated intravascular coagulation and inotropic use

Albano, Miguel Nico; Brazao, Sofia Gomes; Caroço, Teresa Vieira; Louro, João; Coelho, Maria Inês; Almeida, Carlos Costa; Reis, Luís; Almeida, Carlos M. Costa

doi:10.1016/j.amsu.2018.09.025

Cited by 7 publications

(14 citation statements)

References 13 publications

(16 reference statements)

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“…2 summarizes the typical clinical, laboratory, and temporal clinical picture of patients who develop SPG in the setting of critical illness. Since the recognition of a role of proximate shock liver in helping to explain subsequent SPG [1,2,8,40], recent SPG papers by others [90,91] have commented on the occurrence of prodromal shock liver.…”

Section: Prodromal Shock Livermentioning

confidence: 99%

Symmetrical peripheral gangrene in critical illness

Warkentin

Ning

2021

Transfusion and Apheresis Science

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Symmetrical peripheral gangrene (SPG) is a disabling complication that affects a small proportion of patients who survive critical illness. Its pathogenesis reflects profoundly disturbed procoagulant-anticoagulant balance in susceptible tissue beds secondary to circulatory shock (cardiogenic, septic). There is a characteristic SPG triad: (a) shock (hypotension, lactic acidemia, normoblastemia, multiple organ dysfunction), (b) disseminated intravascular coagulation (DIC), and (c) natural anticoagulant depletion (protein C, antithrombin). In recent years, risk factors for natural anticoagulant depletion have been identified, most notably acute ischemic hepatitis ("shock liver"), which is seen in at least 90% of patients who develop SPG. Moreover, there is a characteristic time interval (2-5 days, median 3 days) between the onset of shock/shock liver and the beginning of ischemic injury secondary to peripheral microthrombosis ("limb ischemia with pulses"), reflecting the time required to develop severe depletion in hepatically-synthesized natural anticoagulants. Other risk factors for natural anticoagulant depletion include chronic liver disease (e.g., cirrhosis) and, possibly, transfusion of colloids (albumin, high-dose immunoglobulin) lacking coagulation factors. A causal role for vasopressor therapy is unproven and is unlikely; this is because critically ill patients who develop SPG do so usually after at least 36-48 hours of vasopressor therapy, implicating a time-dependent pathophysiological mechanism. The most plausible explanation is a progressive time-dependent decline in key natural anticoagulant factors, reflecting ongoing DIC ("consumption"), proximate liver disease whether acute or chronic ("impaired production"), and colloid administration ("hemodilution"). Given these evolving concepts of pathogenesis, a rationale approach to prevention/treatment of SPG can be developed.

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Section: Prodromal Shock Livermentioning

confidence: 99%

Symmetrical peripheral gangrene in critical illness

Warkentin

Ning

2021

Transfusion and Apheresis Science

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“…Albano et al 12 describe another case report of a 45-year-old patient with septic shock, in this case, due to a urinary tract infection.…”

Section: Discussionmentioning

confidence: 82%

Distal Ischemia of the Four Limbs: A Case Report and Literature Review

Masaragian¹,

Perin²,

Coria³

et al. 2019

Journal of Foot and Ankle Surgery (Asia Pacific)

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The symmetrical peripheral gangrene syndrome is characterized by ischemic distal lesions in two or more extremities, without the obstruction of large vessels. The ischemia affecting extremities takes place when the arterial blood flow is insufficient to satisfy the metabolic demands of muscles in rest. We present a 22-year-old patient treated with norepinephrine after a septic shock suspicion who presented distal ischemia of fingers, toes, and scalp. There is no consensus about the initial treatment. Improved data gathering is necessary for a better understanding of the mechanisms involved, which could improve treatment and prevent amputation as the final therapeutic option.

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“…5 Another report by Miguel N. Albano et al presents a case of SPG secondary to septic shock due to a urinary tract infection. 7 The patient was managed similarly, followed by amputation of distal phalanges of fingers and toes. Hector Masaragian et al, present a case of four-limb gangrene resulting from septic shock after surgical rhinoplasty.…”

Section: Discussionmentioning

confidence: 99%

“…Regrettably, established gangrene cannot be reversed despite good maintenance of blood flow which ultimately results in amputation. 7,8 However, aggressive and prompt management limits progression to gangrene and reverses ischemia.…”

Section: Discussionmentioning

confidence: 99%

Postpartum septic shock presenting as symmetrical peripheral gangrene: A rare entity

et al. 2023

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Symmetric peripheral gangrene (SPG) is a rare clinical entity defined as ischemia of peripheral parts of the body without underlying vaso-occlusive disease. Its pathogenesis is unknown, but it is seen from previous reports that SPG is a sequel of underlying Disseminated Intravascular Coagulation (DIC). We report a case of a middle-aged woman who developed high-grade fever followed by painful black discoloration of the digits of four limbs, few days after spontaneous vaginal delivery at home. The patient developed septic shock. However, peripheral pulses were palpable and radiologic and laboratory investigations did not show any evidence of vessel occlusion. The patient had neutrophilic leukocytosis and a deranged clotting profile. Blood culture revealed growth of Staphylococcus Aureus and Pseudomonas Aeruginosa. The patient was diagnosed with SPG due to postpartum sepsis and DIC. She was managed with fluids, antibiotics, aspirin, and heparin but unfortunately, the patient underwent amputation of limbs due to irreversible ischemia. Therefore, prompt diagnosis and management of SPG are crucial to prevent mortality and morbidity. doi: https://doi.org/10.12669/pjms.39.3.7277 How to cite this: Batool W, Naveed S, Khan S, Ahmed SM. Postpartum septic shock presenting as symmetrical peripheral gangrene: A rare entity. Pak J Med Sci. 2023;39(3):916-918. doi: https://doi.org/10.12669/pjms.39.3.7277 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Rare case of symmetrical peripheral gangrene due to septic shock, disseminated intravascular coagulation and inotropic use

Cited by 7 publications

References 13 publications

Symmetrical peripheral gangrene in critical illness

Symmetrical peripheral gangrene in critical illness

Distal Ischemia of the Four Limbs: A Case Report and Literature Review

Postpartum septic shock presenting as symmetrical peripheral gangrene: A rare entity

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