Indian Journal of Dermatology
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CORRESPONDENCE COLUMN
Year : 2006  |  Volume : 51  |  Issue : 1  |  Page : 69-70
Symmetrical peripheral gangrene with gangrene of tip of nose and Fournier's gangrene


Department of Cardiovascular & Thoracic Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221 005, UP, India

Correspondence Address:
Rahul Prasad
Department of Cardiovascular & Thoracic Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221 005, UP
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.25217

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How to cite this article:
Prasad R, Agrawal D, Lahiri T K. Symmetrical peripheral gangrene with gangrene of tip of nose and Fournier's gangrene. Indian J Dermatol 2006;51:69-70

How to cite this URL:
Prasad R, Agrawal D, Lahiri T K. Symmetrical peripheral gangrene with gangrene of tip of nose and Fournier's gangrene. Indian J Dermatol [serial online] 2006 [cited 2019 Jul 18];51:69-70. Available from: http://www.e-ijd.org/text.asp?2006/51/1/69/25217


Disseminated intravascular coagulation rarely presents with symmetrical peripheral gangrene, which manifests as acral ischemia, without any evidence of obstruction or vasculitis of relevant arteries.[1] We report this case, which presented as gangrene of tip of nose and Fournier's gangrene along with symmetrical peripheral gangrene as a consequence of sepsis and disseminated intravascular coagulation.

A 50 years old male presented to us with gradually increasing blackish discoloration of distal parts of all four limbs, tip of nose and scrotum for 5 days. There was history of fever for last 7 days, which was low grade to start with and on next day high fever followed by blackish discoloration of limbs, tip of nose and scrotum simultaneously. Patient was on broad-spectrum antibiotic since last 5 days. He was addicted to Ganza (Canabis Indica) smoking since last 25 years.

At the time of presentation patient was dehydrated with bilateral pedal edema, his pulse was 100 per minute, blood pressure 100/60 mmHg and respiration was 20 per minute. Distal parts of all four limbs was gangrenous with shrunken hands and edematous feet. The line of demarcation was not clear at the time of presentation. There was 1 x 1 cm necrosed area over tip of nose and 4 x 5 cm necrosed area on under surface of scrotum [Figure - 1]. Radial, dorsalis pedis and porterior tibial pulsations were absent on both sides but brachial and popliteal pulsations were present. Sensation was absent in both hands and feet, restricted movement was present on wrist, ankle joint but there was hardly any movement in joints of fingers and toes. Systemic examination did not reveal any abnormality.

Laboratory investigations: Hb 5.6 gm%, TLC 18,210 per mm3, DLC - N80 L10 E6 M4, ESR - 79 mm, serum sodium 135.5 mEq/L, potassium 3.59 mEq/L, blood urea - 90 mg/dl, creatinine 1.3 mg/dl and fasting blood sugar 76 mg/dl. Liver function test revealed: ALT 55 IU/L, AST 226 IU/L, STB 0.5 mg/dL, SDB 0.3 mg/dL, Alkp 333 IU/L, STP 5.2 gm/dL, SALB 2.1 gm/dL. His coagulation profile revealed prothrombin time test 18 seconds vs a control of 13.3 seconds, Activated partial thromboplastin time test 36 seconds vs a control of 27.7 seconds, platelet count was 67000/mm3. Blood culture was sterile. ELISA for HbsAg and anti HCV was negative. Collagen profile was normal; X-ray chest did not reveal any abnormality. Blood group of the patient was O-positive.

Patient was treated immediately with intravenous fluid, broad spectrum injectable antibiotics, metronidazole, low molecular weight heparin 20 mg SC BD, pentoxyphyline 400 mg BD and dextran-40 500 ml iv daily for first 5 days. Patient improved symptomatically with the treatment and after 5 days we stopped Dextran-40 and continued with rest of the treatment. By tenth day the demarcation line started appearing around gangrene regions, patient was shifted to oral anticoagulants and oral antibiotics. Subsequently the dose of oral anticoagulant was adjusted accordingly to keep INR around 2.5. During first 20 days of hospital stay patient had marked symptomatic improvement, the gangrenous part of scrotal and tip of nose were excised and there was regeneration of skin over the nose and healthy granulation tissue appeared over the scrotal region. The line of demarcation between the gangrenous and non-gangrenous part in extremities was clear. We were planning for amputation of gangrenous segment of the extremities after stopping oral anticoagulations for few days.

But suddenly patient started deteriorating, even after the best possible efforts patient died on day 28. The cause of death was not clear in this patient.

Symmetrical peripheral gangrene (SPG) is a devastating complication with a high mortality up to 40%.[1] Among survivors half require amputation of affected limbs.[1] The condition has been described in association with multitude of medical conditions such as infection, low output state, congestive cardiac failure, use of vasopressors, paraneoplastic syndrome, ergotism or protein C deficiency. Upto 85% of patients with SPG have associated disseminated intravascular coagulation.[1] Aggravating factors include asplenia, immunosuppression, previous cold injury to extremities, diabetes mellitus, or increase sympathetic tone.[2]

The actual reason of vascular occlusion and resulting gangrene is difficult to determine but a low flow state is present in most of the cases. The low flow state results in occlusion of microcirculation of affected part. Pathological examinations of amputated specimens often reveal thrombi concentrated in small vessels and not in the large vessels. Hence attention should be focused on correcting the underlying cause of ischemic phenomenon mainly dehydration and sepsis,[2] drugs and abnormal proteins. The predominant causative bacterii in SPG with DIC as a result of sepsis include group b streptococci, group D enterococcus, group A streptococci, staphylococcus aureus, pneumococcus, Enterobacterie and anaerobic bacteria.[3] Components of the micro organism's cell membrane or bacterial exotoxins may cause a generalized inflammatory response characterized by systemic production of cytokines by activated mononuclear cells and endothelial cells which are responsible for precipitation of DIC. In fact DIC in SPG with sepsis is both a thrombotic and bleeding disorder.[4]

Initial presentation ranges from minimal rash to erythema, oedema, induration or cellulitis. These later develop peau-d-orange appearance, violaceous discoloration, bullae or necrosis.[5] The condition has to be differentiated from purpura fulminans and venous gangrene. Purpura fulminans is an acute progressive microangiopathy occurring in association with DIC resulting in haemorrhagic necrosis of the skin and the subcutaneous tissues of the extremities. In venous gangrene involvement of large veins of the extremities can be demonstrated along with islands of relative sparing of the skin which later coalesce to produce uniform distal gangrene.[6]

Vigorous therapy of sepsis and DIC with intravenous antibiotic therapy and heparinization are essential component of management. Other suggested measures are sympathetic block, intravenous nitroprusside, topical nitroglycerine, intravenous or local alpha blockers and intravenous prostaglandin. Amputation of gangrenous areas may be inevitable but not the urgent requirement.[2] An initial conservative approach stabilizes the patient and demarcates the gangrenous region; release incisions, debridements, excisions, fasciotomy and occasionally skin grafting are the mainstay of surgical management.

There are many reports of SPG with DIC as result of sepsis but our case is a rare presentation of DIC and SPG with involvement of all four limbs along with gangrene of tip of nose and scrotum.

This type of association of SPG, Fournier gangrene and gangrene of tip of nose could not be traced in the literature. Aggressive conservative treatment improved the condition of patient but unfortunately patient died in spite of our best efforts.



 
  References Top

1.Molos MA, Hall JC. Symmetrical peripheral gangrene and disseminated intravascular coagulation. Arch Dermatol 1985; 121:1057-61.  Back to cited text no. 1  [PUBMED]  
2.Parmar MS. Symmetrical peripheral gangrene: a rare but dreadful complication of sepsis. JAMC 2002; 29:167-9.  Back to cited text no. 2    
3.Brook I. Cutaneous and subcutaneous infections in the newborns due to anaerobic bacteria. J Perinat Med 2002; 30:197-208.  Back to cited text no. 3  [PUBMED]  
4.Levi M, DeJonge E: Current management of disseminated intravascular coagulation. Asian J Clin Cardiol 2003;6:15-21.  Back to cited text no. 4    
5.Kothari PR, Kulkarni B Neonatal necrotizing fascitis. Indian Pediatr 2004; 41:1070-71.  Back to cited text no. 5    
6.Lorimer JW, Siemelhago LC, Barber GC. Venous gangrene of the extremities. Can J Surg. 1994; 37:379-84.  Back to cited text no. 6    


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