Symmetrical Peripheral Gangrene Due to Disseminated Intravascular Coagulation

Abstract

A 50-year-old white man developed fevers, chills, shortness of breath, and a cough that produced green sputum. Five days later, he was prostrate and was admitted to his local hospital with fulminant septic shock and associated disseminated intravascular coagulation, renal failure, and adult respiratory distress syndrome. Staphylococcus aureus was cultured from samples of his sputum and blood. He required ventilator support, fluids, and inotropic support to maintain arterial blood pressure, and he underwent hemodialysis for renal failure. He received intravenous antimicrobial therapy, initially with erythromycin, ceftriaxone, and gentamicin, later with piperacillin sodium–tazobactam sodium, and then with vancomycin hydrochloride. Twenty-four hours after admission, his fingers and toes became cyanotic. This condition progressed rapidly to gangrene involving the hands, feet, tip of the nose, ears, and posterior scalp area. Hydrocortisone (100 mg every 6 hours) was administered intravenously for 6 days and then slowly tapered. The patient’s general condition stabilized, but the gangrene persisted. After 3 months, he was transferred to Mayo Clinic, Rochester, Minn, for consideration of amputation of the gangrenous areas. On physical examination, symmetrical well-demarcated dry gangrene involving the hands (to the wrists), feet, legs (to the level of the knees), tip of the nose, ears, and posterior scalp area was noted (Figure).