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SYMMETRICAL
PERIPHERAL GANGRENE
DR IHEJI CHUKWUNONSO

OUTLINE
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Case Summary
Introduction
Epidemiology
Etiology/Risk Factors
Pathogenesis
Clinical Features
Investigations
Differentials
Treatment
Literature Review
References

CASE SUMMARY
 A 5week old female who presented with Poor
weight gain from birth, Passage of mucoid
watery stool and post-prandial Vomitting

 At presentation was in respiratory distress,
Febrile (38
...

aureus

• Treatment was IV Fluids and Antibiotics

• About 20hrs into admission, bluish discoloration of
right hand which started from the tip of the fingers to
lower 3rd of the hand was noticed
• Later progressed within 48 hrs to involve both feet, and
the left hand
...


OUR PATIENT

INTRODUCTION
• DEFINITION OF TERMS
• GANGRENE; tissue death caused by inadequate
blood supply which may be due to injury,
infection, trauma or an underlying illness
• DRY GANGRENE; form of coagulative necrosis
that develop in ischemic tissue where blood
supply is inadequate to keep tissue viable
...

• First described by Hutchison in 1891 in a
patient who developed gangrene of extremities
following shock
• Peripheral pulses are usually palpable as a
result of sparing of larger vessels

• Is proposed to be a cutaneous marker of
disseminated intravascular coagulopathy

Epidemiology
• Commonly affected sites are fingers, toes, ear lobules
and penis
...

• Most common implicated organisms are gram positive
and negative cocci
...


Infective causes

Non infective causes

Miscellanous

BACTERIAL

CARDIOVASCULAR SYSTEM

Deficiency of Protein C and S

Streptococcus pneumonia

Myocardial infarction

Dog bite

Staphylococcus aureus

Cardiac failure

Appendicitis

Neisseria Meningitides

Hypovolemic shock

Sickle cell disease

Streptococcus Pyogenes

Hypertension

Hypernatremic dehydration

Klebsiella Pneumonia

Pulmonary embolism

SLE

Proteus Vulgaris

DRUGS

Antiphospholipid syndrome

Enterococcus Fecalis

Adrenaline

Mycobacterial tuberculosis

Noradrenaline

PARASITIC

Dopamine

Plasmodium Falciparum

MALIGNANCIES

VIRAL

Hodgkins lymphoma

Viral gastroenteritis

Acute lymphatic leukemia

Varicella zoster

PATHOGENESIS

THROMBOTIC OCCLUSIONS
• Pathogenesis is not well understood
• Low blood flow states coupled with endothelial
damage and platelet plugging due to hypercoagulable
state
...


• Hallmark is the occurrence of microcirculatory failure

NON THROMBOTIC OCCLUSION
• Intense reflex vasoconstriction in the digital
vessels of the extremities seen Eg; winter
season, use of vasopressors
• Adherence of infected erythrocytes to
microvascular endothelium and
sequestration of parasitized erythrocytes
cause microcirculatory occlusion in Malaria
...

• The gangrenous lesions initially appear in form
of acrocyanosis and dusky discoloration of the
skin
...


Investigations
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Diagnostic
FBC:
Platelet count ↓
Assays of the natural anticoagulants; protein C
and protein S ( low levels of protein C and S)

• PT/PTT

• Elevated levels of cytokines
• Peripheral doppler ultrasound
• Post amputation autopsy finding of occluded
microvasculature is the hallmark of SPG

• Supportive
• FBC—PCV,Leukopenia/leucocytosis
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Blood culture
Urinalysis,
FBG/RBG
Serum electrolytes
Serum lactate(Increased)
Increased D-dimer

DIFFERENTIAL DIAGNOSIS
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1)Thromboangitis obliterans
2)Atherosclerosis
3)Diabetic neuropathy
4)Vasculitic gangrene

Treatment
• No specific treatment has been shown to
consistently prevent the progression of SPG or
reverse it
...

• Treat underlying course
...


Medical treatment
• Anti coagulants maybe considered if microthrombi
is the major feature
• Other treatment modalities
• Sympathetic blockade – ganglion blocker,
Trimethaphan
• Intravenous sodium nitroprusside ,topical
nitroglycerine, intravenous prostaglandins(
epoprostenol)
• Alpha blocker – Phentolamine , chlopromazine
• Parenteral antibiotics
• Interdigital padding and protection from trauma
may also decrease tissue injury
...


• 2)Conservative local debridement
• 3)Skin grafting
...

-Mortality is estimated to be up to 40%
...
5 months to
12 years (median age, 2 years)
...


METHOD: Retrospective Study of
children diagnosed with PF Between
January 1996 and 2004
...
5 months females; mean age: 43
...
The remaining 3 patients
a shock syndrome
...

Among the 13 infants and small
 In 12 patients, the cause of SPG was
children, 7 (43%) had infection, 2 had
infective, Pneumococcus (commone
CHD, and 1 infant and 3 children had
st)
different miscellaneous disorders
 2 patients developed DIC and SPG
postoperatively

 FV mutation was present in 6 of the
13 under 4’s (46%)

 9 patients survived and the
remaining 5 (35
...
6 (37
...
These deficiencies,
except one for protein S, were
acquired

 3 patients had leukopenia and all
died

 10 patients except two who were
diagnosed at this center were treated
with fresh frozen plasma
...

 9 (69%) of the 13 children ≤ 4 years
and one of the older children (33%)
required amputation
...
5% total
amputation)

 Amongst the survivors, 4 had
auto‐amputation of some parts
of distal limbs; surgical
amputation was done in 2
...
8% total amputation)

 THE STUDY SUGGESTS that an age of ≤  CONCLUSION: SPG carries a high
4 years is a risk factor for the
mortality rate frequently requiring
development of PF during severe
multiple limb amputations in
infections, especially in the presence
survivors
...

occur universally

 Because infectious disease aggravates
PF by the presence of the FV
mutation, all patients with PF should
be screened for the FV G1691A
mutation
 Early recognition of this mutation may
initiate prompt and appropriate
therapy, including prophylactic anticoagulation that may prevent necrosis

 The survival rate among the subjects
 CF(35
...


• The gangrene was confined to the feet, was not
associated with definite clinical evidence of
coagulopathy, sepsis or vasculitis, and resolution of
the lesions was complete
• The cause of peripheral gangrene in the 2 girls
remains uncertain
...


• CONCLUSION: The physician managing children
with cerebral malaria should be aware of this
complication
• Exclusion and treatment of other causes of focal
ischemia (such as frank DIC) and institution of
measures which ensure adequate peripheral
perfusion (such as prompt rehydration) should be
carried out without delay
...


REFERENCES
• McGouran RC, Emmerson GA
...
Br
Heart J 1977;39:569-72
• Kalajian AH, Turpen KB, Donovan KO, Malone JC, Callen JP
...
Arch
Dermatol 2007;143:1314-7
• Davis MD, Dy KM, Nelson S
...
J Am Acad Dermatol 2007;57:944-56
• Jaryal A, Raina S, Thakur S, Sontakke T
...
Indian
Dermatol Online J 2013;4:228-30
• Hutchison J
...
Br
Med J 1891;2:8

THANK YOU SO
MUCH



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