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VOLUME 22 , ISSUE 12 ( 2018 ) > List of Articles


Management of symmetrical peripheral gangrene

Agus Foead, Amuthaganesh Mathialagan, Raghu Varadarajan, Michael Larvin

Keywords : Disseminated intravascular coagulation, microthrombosis, procoagulant–anticoagulant balance, purpura fulminans, symmetrical peripheral gangrene

Citation Information : Foead A, Mathialagan A, Varadarajan R, Larvin M. Management of symmetrical peripheral gangrene. Indian J Crit Care Med 2018; 22 (12):870-874.

DOI: 10.4103/ijccm.IJCCM_379_18

License: CC BY-ND 3.0

Published Online: 01-06-2018

Copyright Statement:  Copyright © 2018; The Author(s).


Symmetrical peripheral gangrene (SPG) is a rare, debilitating disease that deserves more widespread concern among the medical fraternities. The objective of this review is to outline the etiology, pathology findings, and management practices of SPG. About 18%–40% mortality rate was reported, and survivors have high frequency of multiple limb amputations. SPG is the hallmark of disseminated intravascular coagulation (DIC). The main pathogenesis theory, to date, is microthrombosis associated with disturbed procoagulant–anticoagulant balance. The treatment of SPG is largely anecdotal and theoretically involves heparin-based anticoagulation and substitution of natural anticoagulants. Early recognition, prompt management of DIC, and underlying conditions may halt the progression of the disease. The multicenter randomized controlled trial should be set up to formulate the proper treatment guidelines.

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  1. Sharma BD, Kabra SR, Gupta B. Symmetrical peripheral gangrene. Trop Doct 2004;34:2-4.
  2. Chalmers E, Cooper P, Forman K, Grimley C, Khair K, Minford A, et al. Purpura fulminans: Recognition, diagnosis and management. Arch Dis Child 2011;96:1066-71.
  3. Ghosh SK, Bandyopadhyay D, Dutta A. Purpura fulminans: A cutaneous marker of disseminated intravascular coagulation. West J Emerg Med 2009;10:41.
  4. Warkentin TE. Ischemic limb gangrene with pulses. N Engl J Med 2015;373:642-55.
  5. Tuddenham EG, Takase T, Thomas AE, Awidi AS, Madanat FF, Abu Hajir MM, et al. Homozygous protein C deficiency with delayed onset of symptoms at 7 to 10 months. Thromb Res 1989;53:475-84.
  6. Lerolle N, Carlotti A, Melican K, Aubey F, Pierrot M, Diehl JL, et al. Assessment of the interplay between blood and skin vascular abnormalities in adult purpura fulminans. Am J Respir Crit Care Med 2013;188:684-92.
  7. Wong VK, Hitchcock W, Mason WH. Meningococcal infections in children: A review of 100 cases. Pediatr Infect Dis J 1989;8:224-7.
  8. Manco-Johnson MJ, Abshire TC, Jacobson LJ, Marlar RA. Severe neonatal protein C deficiency: Prevalence and thrombotic risk. J Pediatr 1991;119:793-8.
  9. Ghosh SK, Bandyopadhyay D. Symmetrical peripheral gangrene. Indian J Dermatol Venereol Leprol 2011;77:244-8.
  10. Ghosh SK, Bandyopadhyay D, Ghosh A. Symmetrical peripheral gangrene: A prospective study of 14 consecutive cases in a tertiary-care hospital in Eastern India. J Eur Acad Dermatol Venereol 2010;24:214-8.
  11. Johansen K, Hansen ST Jr. Symmetrical peripheral gangrene (purpura fulminans) complicating pneumococcal sepsis. Am J Surg 1993;165:642-5.
  12. Davis MD, Dy KM, Nelson S. Presentation and outcome of purpura fulminans associated with peripheral gangrene in 12 patients at mayo clinic. J Am Acad Dermatol 2007;57:944-56.
  13. Kashyap R, Behl RK, Mahajan S, Jaret P, Patial RK, Kaushal SS, et al. Symmetrical peripheral gangrene due to viral gastroenteritis. J Assoc Physicians India 2004;52:500-1.
  14. Rice L. A clinician's perspective on heparin-induced thrombocytopenia: Paradoxes, myths and continuing challenges. In: Warkentin E, Greinacher A, editors. Heparin-Induced Thrombocytopenia. 5th ed. Boca Raton, FL: CRC Press; 2013. p. 608-17.
  15. Kullberg BJ, Westendorp RG, van 't Wout JW, Meinders AE. Purpura fulminans and symmetrical peripheral gangrene caused by Capnocytophaga canimorsus (formerly DF-2) septicemia – A complication of dog bite. Medicine (Baltimore) 1991;70:287-92.
  16. Abdali N, Malik AM, Kamal A, Ahmad M. Symmetrical peripheral gangrene due to Plasmodium falciparum malaria. BMJ Case Rep 2014;2014. pii: bcr2014204268.
  17. Patial T, Sharma K, Jaswal AS, Thakur V, Negi S. Symmetrical peripheral gangrene and tuberculosis: A rare kinship. Int J Mycobacteriol 2017;6:407-9.
  18. McGouran RC, Emmerson GA. Symmetrical peripheral gangrene. Br Heart J 1977;39:569-72.
  19. Neki NS, Jain A, Bajaj R, Jindal MM, Chavan V, Kumar H. Symmetrical peripheral gangrene: An unusual presentation of dengue fever. JK Sci 2015;17:104-5.
  20. Roh SS, Gertner E. Digital necrosis in acquired immune deficiency syndrome vasculopathy treated with recombinant tissue plasminogen activator. J Rheumatol 1997;24:2258-61.
  21. Vaiphei K, Vaidya PC, Vignesh P, Barwad P, Gupta A. Recurrent ventricular tachycardia and peripheral gangrene in a young child. Indian Pediatr 2016;53:815-21.
  22. Molos MA, Hall JC. Symmetrical peripheral gangrene and disseminated intravascular coagulation. Arch Dermatol 1985;121:1057-61.
  23. Klein L, Galvez A, Klein O, Chediak J. Warfarin-induced limb gangrene in the setting of lung adenocarcinoma. Am J Hematol 2004;76:176-9.
  24. Warkentin TE, Whitlock RP, Teoh KH. Warfarin-associated multiple digital necrosis complicating heparin-induced thrombocytopenia and Raynaud's phenomenon after aortic valve replacement for adenocarcinoma-associated thrombotic endocarditis. Am J Hematol 2004;75:56-62.
  25. Diwan AG, Mittal J, Jadhay A, Pradhan AB. Symmetrical peripheral gangrene with multifactorial origin. J Indian Acad Geriatr 2005;3:103-9.
  26. Yoo JH, Min JK, Kwon SS, Jeong CH, Shin WS. Symmetrical peripheral gangrene complicating Klebsiella pneumoniae sepsis associated with antiphospholipid antibodies. Ann Rheum Dis 2004;63:459-60.
  27. Fagan S, Spies M, Hollyoak M, Muller MJ, Goodwin CW, Herndon DN. Exfoliative and necrotizing diseases of the skin. In: Herndon DN, editor. Total Burn Care. 3rd ed. Edinburgh, London: Elsevier; 2007. p. 554-65.
  28. Dalai SP, Meher LK, Behera SK, Nayak S, Tripathy SK. An unusual case of HCV negative cryoglobulinemia presenting as symmetrical peripheral gangrene. J Clin Diagn Res 2016;10:OD18-9.
  29. Colak T, Erdogan O, Yerebakan O, Arici C, Gurkan A. Symmetrical peripheral gangrene and dopamine. Ulus Travma Acil Cerrahi Derg 2003;9:222-4.
  30. Hayes MA, Yau EH, Hinds CJ, Watson JD. Symmetrical peripheral gangrene: Association with noradrenaline administration. Intensive Care Med 1992;18:433-6.
  31. Joynt G, Doedens L, Lipman J, Bothma P. High-dose adrenaline with low systemic vascular resistance and symmetrical peripheral gangrene. S Afr J Surg 1996;34:99-101.
  32. Farah RE, Shay MD. Symmetrical peripheral gangrene and neutropenia following propylthiouracil. Ann Pharmacother 2006;40:1211.
  33. Crisci A, Giannarini G, Selli C. Symmetrical peripheral gangrene after suprapubic prostatectomy. Scand J Urol Nephrol 2002;36:478-80.
  34. Phan PN, Acharya V, Parikh D, Shad A. A rare case of symmetrical four limb gangrene following emergency neurosurgery. Int J Surg Case Rep 2015;16:15-8.
  35. Ikezoe T. Thrombomodulin/activated protein C system in septic disseminated intravascular coagulation. J Intensive Care 2015;3:1.
  36. Moake JL. Disseminated Intravascular coagulation (DIC) (Consumption Coagulopathy; Defibrination Syndrome). MSD Manual Professional Version. Available from: https// [Last revision on 2018 Jul 20].
  37. Meyers BR, Hirschman SZ, Sloan W. Generalized Shwartzman reaction in man after a dog bite. Consumption coagulopathy, symmetrical peripheral gangrene, and renal cortical necrosis. Ann Intern Med 1970;73:433-8.
  38. Fox B. Disseminated intravascular coagulation and the Waterhouse-Friderichsen syndrome. Arch Dis Child 1971;46:680-5.
  39. Perkins JM, Magee TR, Galland RB. Phlegmasia caerulea dolens and venous gangrene. Br J Surg 1996;83:19-23.
  40. Hamdy RC, Babyn PS, Krajbich JI. Use of bone scan in management of patients with peripheral gangrene due to fulminant meningococcemia. J Pediatr Orthop 1993;13:447-51.
  41. Wada H, Matsumoto T, Yamashita Y. Diagnosis and treatment of disseminated intravascular coagulation (DIC) according to four DIC guidelines. J Intensive Care 2014;2:15.
  42. Warren BL, Eid A, Singer P, Pillay SS, Carl P, Novak I, et al. Caring for the critically ill patient. High-dose antithrombin III in severe sepsis: A randomized controlled trial. JAMA 2001;286:1869-78.
  43. Bernard GR, Vincent JL, Laterre PF, LaRosa SP, Dhainaut JF, Lopez-Rodriguez A, et al. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med 2001;344:699-709.
  44. Ranieri VM, Thompson BT, Barie PS, Dhainaut JF, Douglas IS, Finfer S, et al. Drotrecogin alfa (activated) in adults with septic shock. N Engl J Med 2012;366:2055-64.
  45. Denning DW, Gilliland L, Hewlett A, Hughes LO, Reid CD. Peripheral symmetrical gangrene successfully treated with epoprostenol and tissue plasminogen activator. Lancet 1986;2:1401-2.
  46. Stewart S. Symmetrical peripheral gangrene and the use of systemic hyperbaric oxygen therapy. J Wound Care 2012;21:615-6, 618-9.
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