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Symmetric Peripheral Gangrene of digits in a  male child
Paediatric Surgery

Symmetric Peripheral Gangrene of digits in a male child

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Presentation:Darkening of all hands and toes:1month
Patient who is one and a half year old male developed  acute febrile illness of 4 days duration at a district hospital. He was examined and found to be pale.His blood was screened for malaria and found to be positive
Patient was treated for malaria and transfused with packed cells of blood . He developed darkening of both hands and feet after 3 days . this progressed to dry gangrene of all digits will notable sparing of both thumbs .There was no account of seizures nor focal deficits . Childs urine was clear through out period of illness . He was then referred to Komfo Anokye Teaching Hospital
Examination:weight:7.55kg Heart rate 140bpm Temp:36.2deg Celsius
Well nourished child who looked irritable .Both feet were dressed with sterile gauze . Second to fourth fingers on bar hands were dark clawed and gangrenous. Exposure offset revealed wet to dry gangrene with demarcation at the ankle.
Radial and dorsalis pedis pulses were not palpable. Sensation to pain was absent in all the gangrenous areas. Areas just proximal to the gangrene were slightly erythematous and very tender.
Diagnosis: Symmetric peripheral gangrene
Investigations:
Hb:10.7gldl              WBC:9.33                           Neut:2.89                   HCT 32.9%                MCV:78.5 PLT:841             sickling: negative         Hb electrophoresis: A
Na:132             K:4.6
Urea:0.92mmol/ L    Creat
The patient was admitted to the plastic and reconstruction unit where for further evaluation. During an attempt to dress the raw areas around the ankle as seen in the picture the feet auto amputated from the ankle joint to the surprise of the nurse attending to the child. The digits of the upper extremities were carefully debrided and dressed.
The cause and origin of this phenomenon has been the subject of debate among several doctors in the hospital. The pediatrician who referred the child was contacted for further information on the presentation and evolution of the gangrene but she too was baffled at how the digits become gangrenous. There was no clerical error in the work up to blood transfusion. child also did not show any adverse reaction during the period of blood transfusion
A look up in literature came up with reported cases of peripheral gangrene associated with cerebral malaria especially falciparum malaria. Others were associated with disseminated intravascular coagulation after severe sepsis, hypotension, adrenaline,dopamine infusion.
The reported cases of symmetric peripheral gangrene following malaria all occurred in adults. Although all except the thumbs were spared in this 1.5 year old child , the cases that came up in the literature describes  gangrene of variable number of toes.
Attempts have been made to explain the theory behind such phenomenon which cariies a poor outcome. One explanantion could be the conformational changes that occur on the cell membranes of the parasite infected erythrocytes which make them adhere to the vascular  endothelim of their becoming trapped in microvasculature. This leads to further aggregation of cells and impairment of oxygen delivery and cell death.
It remains to be seen whether such cases are frequently recorded in other parts of the country. Answers are yet be provided for the role of early presentation and treatment in averting such unfortunate condition. How can it be prevented or the severity reduced . Why are the digits mostly affected. what accounted for the relative sparing of both thumbs
Presented by :  Dr Richard Ametih, resident general surgery, Komfo Anokye Teaching Hospital , neguseametih@gmail.com
Special thanks to the following:
Dr Joycelyn Asibey , Holy Family Hospital Techiman,
Ward B3 doctors ( Dr(s)  Michael Amoah, Abiboyeh Yifieyeh ,Adu- Gyamfi,  Dickson Bandoh and all the hardworking nurses
Burns and plastic reconstruction team surgery team

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