Digital Gangrene as a Paraneoplastic Manifestation of Peripheral T-cell Lymphoma Not Otherwise Specified Type.

BACKGROUND: Peripheral T cell lymphoma (PTCL), not otherwise specified (NOS) is a heterogenous group of predominantly nodal T cell lymphomas that generally presents with lymphadenopathy with or without extra nodal involvement. Acral vascular syndrome clinically presents as digital ischemia with Raynaud's phenomenon and acral cyanosis. Although, this condition is commonly associated with connective tissue disorder, smoking and vasculitis, its association with lymphoid malignancy is very rare. Here, we present a case report of a patient with digital gangrene of all toes and fingers as a presenting symptom of PTCL-NOS. CASE DESCRIPTION: A 62 year old male presented with digital ischemia associated with pain, low grade fever, loss of appetite and significant weight loss of 6 kilograms over a period of 3 months. On examination, he was found to have bilateral inguinal and axillary lymph nodes with gangrenous changes over toes and fingers but peripheral pulses were palpable. On evaluation he had anemia, elevated ESR and CRP. CT angiogram revealed thinned out digital arteries with multifocal areas of narrowing. Patient was screened for other causes of digital gangrene and was tested negative for ANCA, ANA, cryoglobulins and viral markers. Lymph node biopsy with IHC was suggestive of peripheral T-cell lymphoma-NOS and was started on CHOP regimen. Lymph nodes size decreased and gangrenous changes resolved. CONCLUSION: Though digital ischemia is a rare paraneoplastic presentation of lymphoma, it should be considered if there is a rapid progression of gangrene. Early initiation of chemotherapy may result in the reduction of further progression of digital gangrene and thus prevent permanent disability. In our patient, progression of gangrene was prevented even though it was an aggressive variant of T cell lymphoma.

Puerperal septic shock complicated with symmetrical peripheral gangrene: A case report.

RATIONALE: Puerperal sepsis is a life-threatening condition caused by infection that can rapidly progress to multisystem infection and toxin-mediated shock. Symmetrical peripheral gangrene is defined as symmetrical distal ischemic damage in two or more sites in the absence of major vascular occlusive disease. The syndrome is devastating and rare. In this study, we introduce a case of puerperal septicemia complicated by symmetrical peripheral gangrene. PATIENT CONCERNS: A 23-year-old woman delivered a live female infant vaginally after cervical balloon dilatation at 39 weeks of gestation. Persistent hyperthermia developed on the first postpartum day. After experiencing ventricular fibrillation, acute liver failure, and acute pulmonary edema, she developed blackened extremities on the 5th postpartum day. DIAGNOSES: Puerperal septicemia complicated by symmetrical peripheral gangrene. INTERVENTIONS: Upon transfer to our hospital, the patient was enrolled in the intensive care unit and underwent anti-infective and amputation surgery. OUTCOMES: After the surgery, the patient recovered well and was successfully discharged from the hospital. LESSONS: Early detection and timely treatment is the best way to reduce the mortality and sequelae of puerperal sepsis. Physicians should be alert to the possibility of comorbid symmetrical peripheral gangrene when sepsis patients present with hepatic impairment.

Compound volvulus: ileosigmoid knot.

Compound volvulus, also known as ileosigmoid knot, is a rare cause of intestinal obstruction due to twisting of the small bowel around the large bowel or vice-versa. It poses a diagnostic dilemma due to the presence of features of closed-loop obstruction of both the small and large bowel. Being a surgical emergency due to the rapid progression to gangrene of involved segments leading to septicaemia, early suspicion of the disease entity, adequate resuscitation and prompt treatment are the need of the hour. Three cases encountered and managed in our setting are described here with a review of the literature.

Symmetrical peripheral gangrene and Roth spots in a patient with infective endocarditis.

We present a case of a young man with symmetrical peripheral gangrene (SPG) resulting from Streptococcus viridans-related infective endocarditis, an association which has not previously been reported. SPG is associated with up to 40% mortality and may necessitate amputation; early identification and treatment of the precipitating factors is very important.

[Venous gangrene of small intestine following coronavirus infection (SARS-COVID-19)]. / Venoznaya gangrena tonkoi kishki na fone koronavirusnoi infektsii (SARS-COVID-19).

The pandemic of a new coronavirus infection has made certain adjustments to modern emergency medicine. Systemic endothelial dysfunction following COVID-19 largely determines hemostatic disorders. Numerous studies revealed that intense platelet adhesion followed by platelet aggregates in COVID-19 patients and functional disorders of fibrinolysis system are combined with activation and severe endothelial dysfunction. The last one inevitably leads to thrombosis and adverse vascular events. There are a lot of studies devoted to deep vein thrombosis and fatal massive pulmonary embolism under COVID-19 infection. However, there are no descriptions of mesenteric thrombosis followed by intestinal wall necrosis. Our experience is based on the treatment and follow-up of 14 patients with venous gangrene of small intestine under COVID-19-induced severe endothelial dysfunction. We present a 40-year-old man with coronavirus infection complicated by ileum gangrene and subsequent favorable outcome.

Polycythemia as an Underlying Cause of Digital Gangrene: A Rare and Unusual Case Presentation.

Digital gangrene is frequently encountered in patients who have diabetes with peripheral vascular compromise, with or without superimposed infection. Preoperative laboratory values and radiographic images are important to determine a proper course of action. Equally important is a thorough history taking to confirm or rule out systemic entities and preexisting conditions that can aggravate or predispose one to the development of digital gangrene. A patient with diabetes presented with a rare and unusual case of digital gangrene, as he clinically had strong pedal pulses. Preoperative workup revealed a suspicion of polycythemia, which was subsequently confirmed. The patient underwent several days of phlebotomy until his hemoglobin and hematocrit levels were brought down to optimized levels before a digital amputation was performed. He went on to heal uneventfully, and he is currently being closely followed by oncology/hematology colleagues with periodic phlebotomy.

Digital Gangrene is a Rare Presentation of Takayasu's Arteritis.

Takayasu's arteritis is a chronic large vessel vasculitis that mainly affects the aorta and its major branches such as brachiocephalic, carotid, subclavian, vertebral, renal, coronary and pulmonary arteries. It most commonly occurs in female at child bearing age and female to male ratio is 8:2. Initial presentations of Takayasu's arteritis may be nonspecific like fever, malaise, weakness, fatigue, arthralgia, myalgia and weight loss but in advanced stage there may be features of vascular inflammation like segmental stenosis, occlusion, dilatation and/or aneurysm. It is a sub acute process over months to years and usually with good collateral formation. So, critical limb ischemia due to acute onset of vascular stenosis is very rare. Here we are reporting a case of a 50-year- old male patient who presented with digital gangrene due to critical limb ischemia. Though the age of onset was at 50 years and the patient lacks clinical features like constitutional symptoms, bruit, claudication, asymmetrical blood pressure, the patient was diagnosed as a case of Takayasus's arteritis. The patient dramatically improved with oral glucocorticoid treatment. Although rare, takayasu's arteritis can presents only with digital gangrene without having other clinical features. The physicians should be aware of this unusual but limb threatening presentation and more studies are needed to find out the exact mechanism of this presentation.

Use of prostaglandin and cyclophosphamide for pediatric lupus with digital gangrene: Back to safety before hitting the axe!

Digital gangrene is a rare presenting feature of childhood lupus and only a reported incidence of 1.3%. We describe two cases of pediatric onset systemic lupus erythematosus (SLE), both 16 years old, presenting with digital gangrene and the successful salvage of the digits after using intravenous cyclophosphamide for immunosuppression and use of intravenous prostaglandin E1 infusions for limb reperfusion. Both of the patients responded exceptionally to the infusions with resolution of gangrene and near-total preservation of the functionality of toes.

First Global Report of Catastrophic Results Due to Internal Herniation of Roux Limb in the Space Between the Gastric Pouch and Band: a Series of 3 Cases of Banded Roux-en-Y Gastric Bypass (BRYGB).

BACKGROUND: Banded Roux-en-Y gastric bypass (BRYGB) is associated with complications known with the bypass along with specific complications related to the band. Roux-limb gangrene, due to herniation between the gastric pouch and band, however, has no mention in literature. METHODS: We report this potentially fatal complication of BRYGB and its management in a series of 3 patients. RESULTS: All 3 patients were women, 35-45 years, with a BRYGB (roux limb-150 cm, biliopancreatic limb-100 cm) using a MiniMizer or a Fobi ring with 2-point fixation to the gastric pouch 2 cm above the gastrojejunostomy. All patients presented 3-4 years post-BRYGB, with an average total body weight loss (TWL%) of 41.28%. To discuss video of a single case, a 35-year-old female presented with abdominal pain, hematemesis and signs of abdominal tenderness and guarding. X-Ray abdomen showed distended small bowel loops and CT-scan revealed ischemic small bowel loops with free fluid. Diagnostic laparoscopy showed alimentary/roux limb (AL) gangrene, from the gastrojejunostomy to the jejunojejunostomy. The entire AL had herniated between the gastric pouch and band which had formed an obstructive ring around the herniated bowel loop and led to compromise of blood supply and gangrene. Resection of gangrenous bowel with reversal of BRYGB was done. CONCLUSION: Early diagnosis and timely management may save a patient from gangrene. It also raises questions: Is a 2-point fixation of the band to the gastric pouch insufficient? Does a longer roux limb make it prone to herniating in the space between the gastric pouch and band?

A Rare Case Of Type II Amyand's Hernia.

Amyand's hernia represents an inguinal hernia containing an appendix within the hernia sac. This extremely rare condition occurs in approximately 1% of all inguinal hernias. This report describes the case of an 84-year-old male who presented with a right inguinal mass that intraoperatively turned out to be Amyand's hernia type-II with a gangrenous and perforated appendix. An appendectomy and peritoneal lavage were performed, followed by a hernioplasty where a modified Bassini repair was used. The patient fully recovered, and was discharged from the hospital on the fourth day. A non-reducible inguinal hernia containing a perforated appendix is a very rare emergency that requires immediate intervention to prevent abdominal sepsis. Therefore, while examining an inguinal hernia, the possibility of Amyand's hernia should always be considered.

[Ischemic gangrene of the upper limb associated with COVID-19 infection: about 2 cases]. / Gangrène ischémique du membre supérieur corrélée à l'infection de la COVID-19: à propos de 2 cas.

Clinical manifestations of COVID-19 have changed a lot, ranging from respiratory and Ear, Nose and Throat (ENT) symptoms to extra pulmonary thrombotic, neurological, cardiac and renal complications. We here report the case of two patients with SARS-CoV-2 pneumonia whose course was marked by prolonged upper limb ischemia. The association between venous, but also arterial, thrombotic complications and viral infection is now well established, and appears to be related to hypercoagulability.

A review of the development of gangrene in patients with systemic lupus erythematosus - A 44-year follow-up study.

OBJECTIVES: This review addresses the question of what happens long-term to those systemic lupus erythematosus (SLE) patients who develop gangrene. It also seeks to find common clinical and serological features, risk factors and triggers and how best to manage this challenging complication. METHODS: We reviewed 850 patients with SLE attending a UK tertiary referral center, followed up over 44 years, assessing their demographics, clinical and serological features, treatment in the acute phase, their long-term outcome and long-term management. RESULTS: Ten out of 850 patients (1.2%) developed gangrene; the mean age of onset was 17 years (range 12-26 years) Eight out of 10 patients had a single episode of gangrene. One of the other two was not willing to have anticoagulation. The first episode of gangrene ranged from presentation to 32 years after SLE onset, mean duration of SLE at the onset of the gangrene was 18.5 years SD 11.5 years. Anti-phospholipid (PL) antibodies were over-represented in the patients with gangrene. All had active SLE at the time the gangrene developed. All patients were treated with intravenous (IV) iloprost infusions, and the antiphospholipid-antibody positive patients were anti-coagulated, most staying on long term anticoagulation. Underlying possible triggers were treated appropriately. Two patients who did not respond to the initial treatment needed further immunosuppression. All patients suffered digit loss. CONCLUSION: Although rare, gangrene is a sinister, potentially late developing complication of SLE, it rarely recurs. It is associated with anti-phospholipid antibodies, active disease, and other possible triggers such as infection and cancer. Anticoagulation therapy, steroids and iloprost, and further immunosuppression may be needed to stop the evolution of gangrene.