|Year : 2012 | Volume
| Issue : 11 | Page : 292-295
Symmetrical peripheral gangrene: A rare complication of dengue fever
Dolanchampa Modak1, Subhasish K Guha2
1 School of Tropical Medicine, Kolkata, India
2 Department of Tropical Medicine, School of Tropical Medicine, Kolkata, India
|Date of Web Publication||29-Jul-2013|
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Symmetric peripheral gangrene is associated with a variety of infective and non-infective etiologies. SPG is always presented with disseminated intravascular coagulation (DIC) and carries a higher mortality. Herein, we describe a 42-year-old female with dengue fever and rash developed bilateral symmetric dry gangrene of 2 nd and 3 rd toes. There was no history of taking B-blockers, ergot etc. All the peripheral pulses of the affected limbs were palpable. Color Doppler of lower limb vessels was done, which indicated normal flow. Blood was positive for Fibrin degradation products and D dimers. Patient was managed with IV fluids, LMWH, FFP etc. Her general condition improved within 72 hours with no further progression of gangrene.
Keywords: Dengue, disseminated intravascular coagulation, symmetrical peripheral gangrene
|How to cite this article:|
Modak D, Guha SK. Symmetrical peripheral gangrene: A rare complication of dengue fever. Indian J Med Sci 2012;66:292-5
| ¤ Introduction|| |
Symmetrical peripheral gangrene (SPG), a rare but well-documented clinical syndrome, is characterized by symmetrical distal acrocyanosis, leading to gangrene of two or more sites in the absence of large vessel obstruction or vasculitis.  Here, we are reporting a case of symmetrical peripheral gangrene developed in feet of a lady in an uncomplicated dengue infection where diabetes mellitus acted as an aggravating factor.
| ¤ Case Report|| |
A 42-years-old diabetic female was presented at emergency with fever, severe myalgia, and pain in small and large joints for seven days with generalized maculopapular, erythematous itchy rash, which appeared on fourth day of fever and gradually decreased over next 3 days. She was complaining of excruciating pain along with symmetric blackish discoloration of second and third toes of both legs. Local examination revealed cold, dry, wrinkled skin of 2 nd and 3 rd toes of both foot with a clear line of proximal demarcation and incipient gangrenous changes [Figure 1],[Figure 2] and [Figure 3]. All the peripheral pulses of the affected limbs were palpable. There was no history of taking B-blockers, ergot etc., She became afebrile on eighth day. Her hemoglobin was 10 gm%, WBC 3400/cmm, platelet 80,000/cmm, SGPT-32 IU/ml, SGOT-16/ml, alkaline phosphatase-168 IU/ml, and serum electrolytes were normal. Serum IgM dengue antibody was positive in high titer. Blood was positive for Fibrin degradation products and D dimers. Prothrombin time was 26 Sec, with INR of 2.8. Anti-nuclear factor, anti-CCP antibody, anti-phospholipid antibody, antibodies to protein C and S were negative. C3, C4, cryogloglobulins, pANCA, and cANCA values were normal. Color Doppler of lower limb vessels was done, which indicated normal flow. Echocardiography did not reveal any evidence of vegetation or thrombus. Histopathology of affected area demonstrated marked hyperkeratosis, hypergranulosis, and acanthosis in epidermis, along with downward elongation of rete ridge. Papillary dermis was unremarkable, and no vasculitis and inflammatory infiltrates was observed on vascular walls.
With an early suspicion of disseminated intravascular coagulation (DIC), intravenous fluid, low molecular weight heparin, broad-spectrum intravenous antibiotic, fresh frozen plasma transfusion, warming of extremities and insulin therapy for strict glycemic control were initiated. Her general condition improved within 72 hours with no further progression of gangrene. Clear line of demarcation appeared on 5 th day of admission, and surgical consultation was done. Surgical amputation was advised, but patient refused amputation of toes.
| ¤ Discussions|| |
Symmetric peripheral gangrene, first described by Hutchison in 1891,  is characterized by symmetrical distal ischemic damage, leading to gangrene of two or more sites in the absence of major vaso-occlusive disease. A low-flow state along with disseminated intravascular coagulation (DIC) is usually present.  Fever followed by marked coldness, pallor, cyanosis, pain, and restricted mobility of extremity should always raise suspicion of SPG. A large variety of infective and non-infective causes is responsible for development of SPG. Common pathogens are Pneumococcus, Staphylococcus, Streptococcus, Klebsiella, Neisseria, Enterococcus Plasmodium falciparum, Rubella, Varicella zoster etc., Myocardial infarction, pulmonary embolism, cardiac failure, hypovolemic shock, systemic lupus erythematous is few non-infective etiologies. Asplenia, immunosuppression, diabetes mellitus, and renal failure, corticosteroid, and vasopressors are aggravating factors for development of SPG. The pathogenesis of SPG may include the Schwartzman reaction, bacterial endotoxin release, and platelet plugging in peripheral arterioles due to vascular collapse and DIC. 
By exclusion of other possible causes, it is tempting to consider dengue infection as the cause of SPG in this case. Dengue fever is the most important arthropod-borne arboviral infection. WHO currently estimates that there may be 50-100 million dengue infections worldwide every year.  Severe complications of dengue infections such as liver failure, disseminated intravascular coagulation, encephalopathy, myocarditis, acute renal failure, and hemolytic uremic syndrome are rare but have been frequently noted in recent epidemics.  Though idiopathic purpura fulminans as a rare complication of dengue hemorrhagic fever was reported earlier,  to our knowledge, SPG associated with dengue infection has not yet been reported anywhere.
Recent literature suggests DIC (100%), up to 35% mortality rate, 70% to 90% amputation rate, and a possible correlation with the winter season  are associated with SPG. The upper and lower extremities, tip of the nose, borders of the ears, genitalia, and scalp are the areas of predilection.  Leukopenia, in particular, is a poor prognostic factor of SPG, reported to be associated with a high mortality rate.  Identification and treatment of underlying etiological factors and treatment of DIC have remained the mainstays of management. Other measures that might be helpful are sympathetic blockade (Ganglion block or intravenous trimethaphan therapy), intravenous nitroprusside therapy, topical nitroglycerine ointment, local or intravenous infusion of a α-blocker (phentolamine, chlorpromazine) and intravenous infusion of prostaglandin (epoprostenol), Papaverine, reserpine, streptokinase, dextran, and hyperbaric oxygen therapy have not been shown to be of value. 
| ¤ Conclusion|| |
SPG carries a high morbidity and mortality. A high index of suspicion and prompt management with usual measures may limit the progression and damage of gangrene.
| ¤ References|| |
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[Figure 1], [Figure 2], [Figure 3]