Ewha Med J.  2025 Jan;48(1):e77. 10.12771/emj.2024.e77.

Determining the timing and extent of amputation in symmetrical peripheral gangrene: a report of three cases from Korea

• Deslivia MF
• Lee HJ
• Jeon IH
• Kochhar H
• Kim HJ
• Kim PT

• KMID: 2567566
• DOI: http://doi.org/10.12771/emj.2024.e77

Abstract

Symmetrical peripheral gangrene is a severe condition marked by symmetric acral necrosis without obstruction of the major blood vessels. This case report examines the critical decisions involved in choosing between early and delayed amputation, as well as determining the extent of the necessary amputation. We present three cases: one involving antiphospholipid syndrome, another with disseminated intravascular coagulation, and a third associated with diabetes mellitus. All three cases ultimately required amputation due to symmetrical peripheral gangrene. In the first two cases, amputation was delayed, which is typically advantageous as it allows for the clear demarcation of necrotic tissue. However, in the third case, where infection was evident, immediate amputation was necessary despite the patient's overall poor health.

Keyword

Amputation; Antiphospholipid syndrome; Disseminated intravascular coagulation; Diabetes mellitus; Gangrene

Figure

• 

  Fig. 1. A 76-year-old woman with sharp aggravating pain and cyanotic changes on the tips of fingers and toes. She was diagnosed with antiphospholipid syndrome and later experienced dark discoloration with symmetric progression up to middle phalanges. The patient then underwent a series of amputations involving the fingers and toes on both sides.

• 

  Fig. 2. A 49-year-old man who later showed a septic manifestation and consumptive coagulopathy. On the second day of inotropic use, dry gangrene of the digits developed and progressed symmetrically up to (A) the bilateral wrists and (B) distal calf, including the ankles and feet.

• 

  Fig. 3. A 53-year-old woman with end-stage kidney disease on dialysis and a long history of diabetes mellitus had gangrene with infection at the fourth fingertip of her right hand and both feet. Due to the presence of an infection, the patient underwent prompt amputation.

Reference

References

1. Goodwin JN. Symmetrical peripheral gangrene. Arch Surg. 1974; 108(6):780–784. DOI: 10.1001/archsurg.1974.01350300022006. PMID: 4597966.

2. Parmar MS. Symmetrical peripheral gangrene: a rare but dreadful complication of sepsis. CMAJ. 2002; 167(9):1037–1038.

3. Gonzalez ME, Kahn P, Price HN, Kamino H, Schaffer JV. Retiform purpura and digital gangrene secondary to antiphospholipid syndrome successfully treated with sildenafil. Arch Dermatol. 2011; 147(2):164–167. DOI: 10.1001/archdermatol.2011.4. PMID: 21339444.

4. Sheng GH, Aronowitz P. The lesser known side-effect of warfarin: warfarin-induced venous limb gangrene. Mayo Clin Proc. 2014; 89(5):E47. DOI: 10.1016/j.mayocp.2013.05.037. PMID: 24797650.

5. McGouran RC, Emmerson GA. Symmetrical peripheral gangrene. Br Heart J. 1977; 39(5):569–572. DOI: 10.1136/hrt.39.5.569. PMID: 861101. PMCID: PMC483277.

6. Singh S, Chand G, Charan S, Arora S, Singh P. Peripheral arterial disease and digital gangrene: a rare presentation of diabetic hand syndrome. J Clin Diagn Res. 2013; 7(1):2286–2287. DOI: 10.7860/JCDR/2013/5584.3498. PMID: 24298503. PMCID: PMC3843397.

7. Schlienger JL. Complications du diabète de type 2. Presse Med. 2013; 42(5):839–848. DOI: 10.1016/j.lpm.2013.02.313. PMID: 23528336.

8. Frykberg RG, Wittmayer B, Zgonis T. Surgical management of diabetic foot infections and osteomyelitis. Clin Podiatr Med Surg. 2007; 24(3):469–482. DOI: 10.1016/j.cpm.2007.04.001. PMID: 17613386.

9. Aragón-Sánchez J, Quintana-Marrero Y, Lázaro-Martínez JL, Hernández-Herrero MJ, García-Morales E, Beneit-Montesinos JV, et al. Necrotizing soft-tissue infections in the feet of patients with diabetes: outcome of surgical treatment and factors associated with limb loss and mortality. Int J Low Extrem Wounds. 2009; 8(8):141–146. DOI: 10.1177/1534734609344106. PMID: 19703949.