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LETTER TO THE EDITOR
Year : 2018  |  Volume : 22  |  Issue : 3  |  Page : 200-201

Symmetrical gangrene in both lower limbs in pneumococcal pneumonia


1 Department of Medicine, PGIMER, Dr. RML Hospital, New Delhi, India
2 Department of Medicine, Sucheta Kriplani Hospital, LHMC, New Delhi, India

Date of Web Publication16-Mar-2018

Correspondence Address:
Dr. Subodh Kumar Mahto
Department of Medicine, PGIMER, Dr. RML Hospital, OPD Block, New Delhi - 110 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijccm.IJCCM_530_17

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How to cite this article:
Mahto SK, Balakrishna AM, Aggarwal N, Goel A. Symmetrical gangrene in both lower limbs in pneumococcal pneumonia. Indian J Crit Care Med 2018;22:200-1

How to cite this URL:
Mahto SK, Balakrishna AM, Aggarwal N, Goel A. Symmetrical gangrene in both lower limbs in pneumococcal pneumonia. Indian J Crit Care Med [serial online] 2018 [cited 2018 Oct 16];22:200-1. Available from: http://www.ijccm.org/text.asp?2018/22/3/200/227757




Sir,

Symmetrical peripheral gangrene (SPG) is a well-documented but rare clinical syndrome characterized by symmetrical distal ischemic damage leading to gangrene of two or more sites in the absence of large vessel obstruction or vasculitis.[1] Herein, we present a case of SPG due to Streptococcus or pneumococcal pneumonia.

A 35-year-old male presented to our hospital with complaints of high-grade fever of 10 days along with cough and expectoration. He also noticed bluish discoloration of his toes which progressively increased up till his bilateral knees within the next 5 days. He was diagnosed as a case of upper respiratory infection and was given symptomatic treatment for 6 days at a private clinic with no relief. Hence, he has referred to our hospital. On examination, bilateral lower limbs with bluish discoloration of toes and ankles were noted along with tender pitting edema [Figure 1]. Anterior tibial artery, posterior tibial, and dorsalis pedis artery were not palpable in both lower limbs [Table 1]. Respiratory examination revealed bronchial breath sounds with crackles on inspiration in the right infrascapular area.
Figure 1: Bilateral symmetrical gangrene in both lower limbs on the day of admission

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Table 1: Examination of peripheral artery in both lower limbs

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Laboratory tests revealed hemoglobin 12.5 g/dL of hemoglobin with a total leukocyte count of 29,000 cells/mm 3 with normal platelet and differential counts. Kidney and liver function tests were within normal limit. Chest X-ray revealed a homogeneous opacity in the right lower zone with syn-pneumonic pleural effusion. Lower limb arterial and venous Doppler scan revealed reduced velocity of jet in bilateral lower limbs. Blood culture was positive for Streptococcus pneumoniae after 48 h of incubation which was sensitive to ceftriaxone, azithromycin, linezolid, vancomycin, and levofloxacin. He was started injection ceftriaxone 1 g intravenous (IV) twice a day, and injection azithromycin 500 mg IV once a day with supportive treatment. Within 24 h his condition improved and later on, he was discharged on the 10th day on oral antibiotics. However, during subsequent outpatient visits, the patient presented with well-demarcated gangrene of all the toes for which he underwent below ankle amputation [Figure 2].
Figure 2: Bilateral well demarcated Gangrene during subsequent outpatient visit

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The pathogenesis of SPG is not well understood. A low-flow state is commonly present in association with a hypercoagulable vasospastic situation leading to microcirculatory occlusion. The ischemic changes begin distally and may advance proximally to involve a whole extremity. The pathogenesis of SPG may involve the Schwartzman reaction, bacterial endotoxin release, and platelet plugging in peripheral arterioles due to vascular collapse and disseminated intravascular coagulation.[2] Empirical treatment includes IV antibiotics (a) a respiratory fluoroquinolone or (b) b-lactam plus a macrolide. Increasing resistance rates have suggested that empirical therapy with a macrolide alone can be used only for the treatment.[3],[4] Amputation of gangrenous areas is deferred till the general condition of the patient improves, and the gangrenous area is well-demarcated.[5]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kalajian AH, Turpen KB, Donovan KO, Malone JC, Callen JP. Phenylephrine-induced microvascular occlusion syndrome in a patient with a heterozygous factor V Leiden mutation. Arch Dermatol 2007;143:1314-7.  Back to cited text no. 1
[PUBMED]    
2.
Tripathy S, Rath B. Symmetric peripheral gangrene: Catch it early! J Emerg Trauma Shock 2010;3:189-90.  Back to cited text no. 2
    
3.
Gleason PP, Meehan TP, Fine JM, Galusha DH, Fine MJ. Associations between initial antimicrobial therapy and medical outcomes for hospitalized elderly patients with pneumonia. Arch Intern Med 1999;159:2562-72.  Back to cited text no. 3
[PUBMED]    
4.
Brown RB, Iannini P, Gross P, Kunkel M. Impact of initial antibiotic choice on clinical outcomes in community-acquired pneumonia: Analysis of a hospital claims-made database. Chest 2003;123:1503-11.  Back to cited text no. 4
[PUBMED]    
5.
Parmar MS. Symmetrical peripheral gangrene: A rare but dreadful complication of sepsis. CMAJ 2002;167:1037-8.  Back to cited text no. 5
[PUBMED]    


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