Reactions 1680, p261 - 2 Dec 2017 Symmetrical peripheral gangrene: case report A 63-year-old woman developed symmetrical peripheral gangrene (SPG) during treatment with norepinephrine. The woman, who developed Plasmodium falciparum malaria was admitted to the ICU with hypotension and stuporous condition. She was initiated on treatment with IV quinine and doxycycline. She was also initiated on norepinephrine. Her tests revealed an INR of 1.2, with elevated levels of D-dimers and von Willebrand factor (VWF), along with undetectable ADAMTS13 activity. She also showed hypoxaemia, refractory hypotension and neurological worsening. She showed symptoms of respiratory distress syndrome. She was mechanically ventilated. Her norepinephrine was increased to an infusion rate of 46 µg/minute [initial dosage and route not stated]. Echocardiography showed acute ventricular dysfunction. She also developed acute renal failure requiring continuous venous haemofiltration. She showed signs of multiple organ failure and initiated on exchange transfusion therapy. She also developed epistaxis and rectal bleeding. Tests showed a slight increase in ADAMTS13 activity. From day 2, she showed blackish discolouration of both hands and feet followed by definite line of demarcation between gangrenous and normal skin. Her gangrene progressed during one month in the ICU, and SPG was suspected. Her clinical course was complicated by the development of Pseudomonas aeruginosa, repeated candidaemia and Enterococcus faecalis. The woman’s norepinephrine treatment was suspended by day 14. Based on an endoscopy on day 11 and a colonoscopy on day 28, she was diagnosed with ischaemic injury that had disseminated in the sigmoid colon. She regained consciousness on day 22, and was extubated by day 32. A quadriamputation was planned after her consent. The surgery was performed two months after the diagnosis of SPG. Her renal function recovered and she was transferred to rehabilitation. Author comment: "Patients treated with high doses of norepinephrine are also particularly at risk of developing SPG." Masse E, et al. Plasmodium falciparum malaria complicated by symmetrical peripheral gangrene, bowel ischemia, repeated candidemia, and bacteraemia. Case Reports in Medicine 2014: Apr 2014. Available from: URL: http:// doi.org/10.1155/2014/696725 - Belgium 803285357 0114-9954/17/1680-0001/$14.95 Adis © 2017 Springer International Publishing AG. All rights reserved Reactions 2 Dec 2017 No. 1680
Reactions Weekly – Springer Journals
Published: Dec 2, 2017
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