Symmetrical peripheral gangrene: A rare clinical entity
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A 75?year?old female patient presented with a 2-week history of pain and darkening of all her fingers and toes. A month prior to visiting the hospital she developed a constant rest pain in her hands and feet. The pain was exacerbated by manual work and was not relieved by analgesia. She highlighted intermittent episodes of severe pain in her hands and feet occurring over the last 1 year. Her fingers and toes became dusky in appearance, and this was associated with blistering of the fingers and toes. The patient highlighted sensory loss in her fingers and toes. There was no history of intermittent claudication.

Examination of the patient at the referral center revealed she was fully conscious, and not in any apparent distress. She had a normal pulse rate of 90 beats per minute, with normal blood pressure (systolic reading of 128 mm Hg and diastolic of 59 mm Hg). She had pyrexia of 37.8°C with no lymphadenopathy. There were no Janeway lesions or Xanthoma on examination. The cardiac, respiratory, and abdominal examinations were normal. On examination of the hands, the patient had dry gangrene of all the fingers of the hands which had demarcated. She had very good peripheral pulses in the upper limbs. In the lower limbs, she had dusky hyperpigmented toes. All the peripheral pulses in the lower limb were present and full volume.

The complete blood count on admission showed a raised white cell count of 16.1 × 109/L, with a low hemoglobin of 11.6 g/dL. Her renal function and lipid profile were normal. A random blood sugar done on admission was within normal limits. A chest x?ray and electrocardiogram (ECG) were done and were normal. An echocardiogram (Echo) was done as part of her workup, and she had a structurally normal heart with no thrombi and a good ejection fraction of 67%.

Fluid resuscitation was commenced with an intravenous crystalloid solution and empiric antibiotics therapy with her pyrexia settling on the third day after admission. Her toes demarcated as dry gangrene by day 3 postadmission. The patient consented for amputation of the gangrenous parts of her hands and feet. Amputation of the digits of her fingers was done with transmetartasal amputation of her feet done bilaterally. The surgery was uneventful. Two weeks after the initial surgery, the patient had split skin grafting to cover the bare amputation sites with excellent uptake of the grafts. See Figure 2. The pathological evaluation of amputated tissue did not report any vasculitis. There were microthrombi in the small vessels with sparing of the large-caliber vessels.