Gangrene is the death of a viable body part due to a lack of blood supply (dry gangrene) or secondary to an infection (wet gangrene).

The cardinal signs of reduced blood supply to the limbs are

  • pain
  • pallor
  • paraesthesias
  • perishingly cold
  • pulselessness and
  • paralysis

A short story of a baby with digital gangrene…

Here is a story of a patient with gangrene of the fingers and toes because of a lack of blood supply. Input is required from the visitors regarding the case.

Gangrene of fingers and toes in a one-year-old baby:

gangrene
gangrene of the toes
gangrene
Gangrene of the fingers of both the hands

Above pictures are of a one-year-old male child, who was brought by the parents with a few days history of fever and bluish discoloration of the fingertips and toes. There was no other significant history of note.

He was started on anticoagulants (enoxaparin) and cloxacillin. His fever settled and the digital gangrene did not progress.

gangrene of fingertips
auto-amputation of the fingertips
gangrene
auto-amputation of the toes

The above pictures were taken after two months of treatment. Initially, he was planned for amputation but the decision was withheld when autoamputation of the digits started.


Causes of clot formation in the blood vessels

Gangrene is the end result of ischemia, thrombosis, and severe infection.

Autoimmune diseases

skin rash gangrene
butterfly rash in SLE

It is commonly seen in disorders of the vessels like vasculitis, autoimmune diseases like systemic lupus erythematosus (SLE), Rheumatoid arthritis and systemic sclerosis.

Embolic phenomena

Digital infarcts may also be seen in embolic phenomena. Emboli most commonly originate from the heart as in infective endocarditis and atrial fibrillation. Emboli can also be seen in severe bacterial infections, disseminated intravascular coagulation, and cancers.

gangrene
emboli in atrial fibrillation lead to digital infarcts

Blood disorders:

Patients with blood disorders like polycythemia, essential thrombocytosis, myeloproliferative disorders, thrombotic thrombocytopenic purpura, and antiphospholipid antibody syndromes can also develop distal ischemia of the toes and fingers.

gangrene in blood disorders
polycythemia vera

Primary Hypercoagulable states:

Other than that, hypercoagulable states like protein C and S deficiency, Factor V Leiden mutations and homocysteinemia can also lead to thrombosis of the vessels resulting in infarction and thrombosis.

Miscellaneous causes:

Thrombosis can also occur in advanced atherosclerotic diseases like the peripheral arterial disease, patients who are using oral contraceptive pills, heparin and warfarin are also at risk of developing thrombosis.

gangrene warfarin induced
warfarin-induced skin necrosis

Heparin may result in autoimmunity, known as HIT or heparin-induced thrombocytopenia, which is a hypercoagulable state leading to thrombosis. Warfarin may also lead to thrombosis especially in the skin, also known as warfarin-induced skin necrosis. This condition can be deadly if not timely treated.

In summary …

Gangrene of the digits makes a person disable, timely investigation and treatment of the underlying disease are very important.


Read More …

 

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Farhan
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Dr. Hajigul I think your patient had an infection that resolved with treatment.
Since the patient improved without steroids or immunomodulators, vasculitis would be down the list of differential diagnosis.
The classic triad of vasculitis is joint/ vascular involvement, skin rash ( purpura) and renal involvement.
I would have requested for an Echocardiography and blood cultures.