Retiform purpura and ischemic limb gangrene with pulses

Abstract is not required for Clinical Imagesis not required for Clinical Images (This page in not part of the published article.) International Journal of Case Reports and Images, Vol. 7 No. 11, November 2016. ISSN – [0976-3198] Int J Case Rep Images 2016;7(11):773–775. www.ijcasereportsandimages.com Nai et al. 773 CASE REPORT OPEN ACCESS Retiform purpura and ischemic limb gangrene with pulses Qiang Nai, Rafay Khan, Sabrina Arshed, Shuvendu Sen, John Middleton


CLINICAL IMAGES PEER REVIEWED | OPEN ACCESS
disseminated intravascular coagulopathy (DIC) that was likely triggered by bacterial endotoxin related to facial infection. However, the microbiology studies were negative. Patient was given broad spectrum antibiotics including vancomycin, piperacillin (that was subsequently switched to imipenem), fluconazole, acyclovir, as well as permethrin cream pediculosis capitis. Aggressive intravenous fluid and multiple vasopressors were administered to maintain the blood pressure. Fever and acute respiratory distress syndrome occurred shortly after admission, and she was subsequently intubated. The upper eyelid and radix evolving necrosis ( Figure 1A) necessitated multiple debridements. Retiform purpura developed in hands ( Figure 1B) blisters on dorsum and feet ( Figure 1C) despite detectable pulses (cross marks). Thrombosed plantar cutaneous veins became apparent six days after admission. Skin punch biopsy and subsequent histology study revealed mild fibrinoid necrosis of the upper dermis and bulla formation with complete separation at the epidermal junction. Ischemic limb gangrene with pulses occurred in the lower extremities ( Figure 1D-E), which led to bilateral below knee amputation.

DISCUSSION
We report a case of ischemic limb gangrene with pulses in a female patient who was initially admitted for septic shock. Although she was treated aggressively with broad spectrum antibiotics, unfortunately the gangrene eventually led to bilateral lower extremity amputation. Therefore, it is critical to recognize this disorder early and provide immediate management. Ischemic limb gangrene with pulses can result from DIC, calciphylaxis, and atheroembolism [1,2]. In our case, the focal facial skin infection was very likely the cause of the toxic shock syndrome (TSS) and the resultant DIC, which subsequently led to shock, microvascular thrombi in various organs, retiform purpura, and dry gangrene in the limbs [3,4]. Furthermore, the vasoconstriction due to multiple vasopressors may have aggravated the development of ischemic necrosis and limb gangrene [5].
In cases of ischemic limb gangrene, the existence of pulse should be determined first, and subsequent evaluation should assess the occurrence of DIC [2]. Furthermore, the early recognition of microthrombosisassociated ischemic injury can be facilitated by two clinical signs. One is the presence of retiform purpura, which is purpuric instead of erythematous. The second sign is the absence of induced bleeding upon puncturing a purpuric skin area to 3-4 mm in depth [6].

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