case of peripheral gangrene in old age

1. Hunting for a Diagnosis
WD – 14 / 15
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2. Introduction.
 Mr. H, 94 year old farmer from Thalgampala.
 Father of eight children.
 Never had Diabetes, Hypertension and Asthma in the
past.
 No history of prolonged previous hospital admissions.
 Non smoker.
 Has consumed alcohol occasionally in the past.
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3. Reason for admission,
 Painful blackening of bilateral finger tips.
 Onset – insidious
 Progressive over a three weeks.
 Involved bilateral 2nd, 3rd, 5th finger tips on arrival.
 bilateral toes not involved.
 No history suggestive of Raynaud's phenomenon
 No history of rashes elsewhere.
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4. Review of systems
 No history of intermittent claudication
 No history of fever at any point of illness
 No Cough, shortness of breath
 No haematuria
 No history of abdominal pain, especially after meals
 There was no fatigue, recurrent epistaxis, sinus pain,
hearing loss, and arthralgias.
 No history of longstanding joint pain, morning stiffness,
or joint deformities
 No history of snake bite
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5. Contd,
 No history of previous blood transfusions.
 No history suggestive MI, TIA in the past.
 No recent weight loss, good appetite.
 No history of prolonged consumption of
medications
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6. Examination Findings
 Bilateral symmetrical peripheral gangrene involving
finger tips, feet spared.
 Peripheral pulses - palpable
 BP – 130/80 mmHg in both arms.
 No murmurs were audible.
 No rashes
 No pallor, icterus, lymphadenopathy or organomegaly.
 No abdominal masses.
 No joint deformities or nodules.
 No peripheral or CNS involvement.`
 Fundus : no retinal infarction or thrombosis.
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9. • Problem list:

10. Problem list:
 Bilateral symmetrical peripheral gangrene
involving finger tips, sparing feet at extreme of
age in a previously healthy man.
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11. • Differential diagnosis?
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12. Differential diagnosis:
Possibilities include,
1. Vasculitis
2. Recurrent small thromboembolic disease
3. Infective endocarditis
4. Manifestation of a Paraneoplastic syndrome
5. Hyperviscosity syndrome
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13.  Investigations:
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14. Inflammatory markers
 ESR – 110 mm 1st hour.
 CRP – 30 mg/dl
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15.  Urine ward test for albumin – negative
 UFR – No RBC or casts.
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16. FBC
Hb – 11.4 mg/dl
WBC – 8400 Cumm3
RBC – 3.37 x 105
Plt - 157000 Cumm3
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17.  Blood Picture
 Normocytic normochromic anaemia
 WBC – no left shift or toxic granules
 Platelet within normal range.
 No fragmented RBC
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18.  Direct and indirect Coomb’s test
 negative
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19.  Blood cultures were repeatedly normal.
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20.  Rheumatoid factor – positive
 ANA - negative
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21.  VDRL – Negative.
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22.  Mantoux test
 negative
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23.  Cryoglobulin assay
 Not detected after 72 hrs.
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24.  Hep. B surface antigen – negative
 Hep. C antibody - negative
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25.  Coagulation profile
 Normal.
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26.  Urine BJP – negative.
 Skeletal survey – no lytic lesions detected.
 Serum protein electrophoresis – no
monoclonal band observed.
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27.  C-ANCA - negative
 P-ANCA - negative
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28.  Complement assay.
 C3, C4 levels - normal
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29.  2D – Echo – No vegetations, repeatedly.
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30.  USS – Abdomen
 No Para-aortic lymadenopathy
 No hepatosplenomegaly
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31.  Duplex scan of bilateral lower limbs.
 No evidence of DVT
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32.  Contrast CT abdomen, pelvis and Thorax.
 No abnormality detected
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33. How we managed him,
 Multidisciplinary approach
 Rheumatology dept.
 Radiology dept.
 Blood bank
 Vascular surgical team
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34.  Desperate measure,
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35.  Biopsy
 Gangrene following vasculitis is the favored
microscopic diagnosis.
 No granuloma formation observed.
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36.  This scenario fits the ever-widening etiological
spectrum of SPG.
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37.  Symmetrical peripheral gangrene (SPG)
 rare clinical syndrome
 characterized by bilateral distal ischemic damage leading to
gangrene in the absence of major vascular occlusive
disease
 Peripheral pulses are usually palpable as a result of sparing
of larger vessels
 The mechanism of vascular occlusion is poorly understood
 A wide array of infective and non infective etiological factors
 Could be associated with sepsis, low-flow states, vasospastic
conditions, myeloproliferative disorders, and hyperviscosity
syndromes
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39. Thank you!
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