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Recent studies have shown an association between infections, such as influenza, pneumonia, or bacteremia, and acute cardiac events. We studied the association between foot infection and myocardial infarction, arrhythmia, and/or congestive heart failure. We analyzed the records of 318 consecutive episodes of deep soft tissue infection, gangrene, and/or osteomyelitis in 274 patients referred to a vascular surgery service at a tertiary center. We identified 24 acute cardiac events in 21 of 318 (6.6%) episodes of foot infection or foot gangrene. These 24 events included 11 new myocardial infarctions (3.5%), 8 episodes of new onset or worsening congestive heart failure (2.5%), and 5 new arrhythmias (1.6%). Tachycardia and systemic inflammatory response syndrome were associated with acute cardiac events ( P < .05 for each). The 1-year survival of patients with acute cardiac events was 50.4%, significantly lower than the 91.7% 1-year survival of patients without acute cardiac events ( P < .0015). Acute cardiac complications are not uncommon among patients presenting with severe foot infection and are associated with a high 1-year mortality. Primary care physicians, cardiologists, and vascular and orthopedic surgeons must keep a high index of suspicion for the occurrence of an acute cardiac event.

To establish human biliary protein expression profiles of gangrenous cholecystitis, chronic cholecystitis, and to discover differently expressed proteins for gangrenous cholecystitis by comparative proteomics, we gathered human gallbladder bile samples from gangrenous cholecystitis and chronic cholecystitis patients, respectively After removing the bile salts and lipid peptide fragments were identified by the iTRAQ-coupled LC-MS/MS technology,then identified in SwissProt with Mascot software. A total of 2251 proteins from chronic cholecystitis patients and 2180 proteins from gangrenous cholecystitis patients were identified. A total of 575 differential proteins were found between gangrenous cholecystitis and chronic cholecystitis, 159 proteins were over-expressed and 416 proteins were under-expressed in gangrenous cholecystitis. By bio-informatics analysis, in gangrenous cholecystitis, cell death, necrosis,immune response of neutrophils, apoptosis and degranulation of cells were activated; while cell survival, fatty acid metabolism, transport of molecular and proliferation of cells were inhibited, which might reflect the de-compensatory phase. Pathway analysis showed acute phase proteins were changed, indicating the role of the inflammatory response in the pathogenesis of gangrenous cholecystitis. Six acute phase proteins were found up-regulated,implying a close linkage to gangrenous gallbladder. Our study could be applicable in the biomarker discovery of gangrenous cholecystitis., (Copyright © 2018. Published by Elsevier Ltd.)

We describe a case of progressive cutaneous mucormycosis, which caused gangrenous necrotizing fasciitis, in an immunocompetent neonate from Oman. Extensive wound contamination and a favorable environment for the growth of Mucorales were the predisposing factors. Early aggressive management including frequent wound debridement, targeted pharmacotherapy with liposomal amphotericin B and supportive care is pivotal for improved outcomes.

Heparin-induced thrombocytopenia (HIT) is an acquired immune-mediated hypercoagulability state that is strongly associated with thrombosis. During the 1970s and 1980s, the prevailing concept was that HIT was associated only with arterial thrombosis, through its unique pathogenesis via heparin-dependent, platelet-activating IgG antibodies. However, in 1990, when I began to encounter HIT in my clinical practice, I found that most such patients developed symptomatic venous thrombosis. This historical sketch summarizes some of the research that challenged the dogma of HIT being a mainly arterial prothrombotic disorder. Two studies - one a substudy of a randomized trial of post-orthopedic surgery thromboprophylaxis, and the second a retrospective five-hospital analysis of consecutive patients with positive test results for HIT antibodies - showed a marked predominance of venous over arterial thrombosis complicating HIT (~ 4 : 1). By the end of the 1990s, an even more dramatic manifestation of HIT-associated venous thrombosis was recognized: venous limb gangrene. Here, ischemic limb necrosis occurs despite palpable arterial pulses, as a result of both macrovascular and microvascular venous thrombosis. The surprising explanation was natural anticoagulant impairment (severe depletion of protein C, a vitamin K-dependent anticoagulant) resulting from treatment of HIT-associated deep vein thrombosis with warfarin (vitamin K antagonist). These insights from HIT research helped to elucidate the pathogenesis of ischemic limb losses in other intense non-HIT hypercoagulability states, including warfarin-associated venous limb gangrene complicating cancer-associated hypercoagulability, and symmetrical peripheral gangrene complicating disseminated intravascular coagulation of critical illness, in which proximate 'shock liver' helps to explain the profound failure of natural anticoagulant systems (protein C; antithrombin) in predisposing to peripheral limb microthrombosis in circulatory shock., (© 2018 International Society on Thrombosis and Haemostasis.)

Introduction: Critical limb ischemia (CLI) is a leading cause of lower extremity amputation. When CLI is identified, revascularization should be performed if possible. When options for revascularization do not exist, use of a noninvasive intermittent pneumatic compression device (NPCD) can be considered., Objective: Presented here are 2 cases of patients with nonreconstructable CLI at risk for limb loss who were serially assessed with indocyanine green fluorescence angiography (ICGFA) to determine the effects of NPCD use on local tissue perfusion., Materials and Methods: Both patients were treated with the NPCD for 1 hour, 3 times per day, for 4 weeks. Serial ICGFA utilizing a ICGFA device was performed at various time points to monitor the effects of NPCD use on tissue perfusion., Results: The treatment of both patients with serial ICGFA provided limited objective evidence of increased local tissue perfusion which expedited wound resolution., Conclusions: Larger randomized control trials of this modality of perfusion assessment and NPCD use are recommended.

Intravenous substance abuse is often associated with physical and psychological harm, and often requires urgent medical attention. We report a case of a young male who presented with life-threatening complications of intravenous drug abuse, but refused to give details or agree to the proposed treatment, raising concerns for the team of doctors. A compos mentis patient has a right to decide what should be done to his body. Medical management or surgical interventions cannot be initiated without the patient's consent even if these are lifesaving procedures, or a procedure meant to benefit the patient. Medical practitioner can be liable for assault (criminal law), medical negligence (law of tort), damages (civil action) and even human rights issues may be raised if a patient's autonomy is not respected.

Arteriovenous access ischaemic steal is a serious complication following arteriovenous fistula (AVF) construction. The aim of treatment is to improve distal circulation without impairing the function of the fistula. Therefore, any repair should be performed with intraoperative monitoring. We report 2 cases of this disorder treated using perioperative measurement of skin perfusion pressure (SPP) for preoperative surgical planning and intraoperative guidance. A 73-year-old woman with a left cubital AVF developed gangrene of the tip of the left little finger. Arteriovenous access ischaemic steal was suspected. The SPP of the little finger was 18 mm Hg, which increased to 65 mm Hg after manual occlusion of the fistula. A 58-year-old woman with a left antebrachial AVF had gangrene of the tip of the left middle finger. The SPP was 19 mm Hg, and steal syndrome was suspected based on angiography and the SPP with manual occlusion of the fistula. In both cases, serial plication of the fistula was performed based on intraoperative perfusion pressure monitoring, leading to the successful resolution of the ischaemic steal syndrome. In both cases, haemodialysis could be continued through the repaired fistula., (© 2018 Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Distal hallux gangrene and neuropathic ulceration associated with digit deformity frequently result in osteomyelitis of the distal phalanx. Ideal treatment would involve limited resection to preserve function. We describe our surgical technique and retrospective results for distal Syme hallux amputation with plantar flap closure. An institutional review board-approved review was conducted on cases performed over 8 years. A total of 15 consecutive patients (16 digits) with hallux soft tissue loss who had undergone distal Syme hallux amputation were included. In each case, initial resection removed the distal hallux wound, nail bed, and distal phalanx. The proximal phalanx tip was remodeled, allowing margin biopsy and reduction of prominence. Of the 16 digits, 5 (31.3%) had hammertoe deformity and 1 (6.3%) was excessively long. Positive probe-to-bone status was identified in 8 of the 16 digits (50.0%). All 8 ulcers (100.0%) that probed to bone had histologic or culture results consistent with distal phalanx osteomyelitis. A proximal margin biopsy was taken in 12 of 16 digits (75.0%), and proximal phalanx osteomyelitis was observed in 4 of 12 proximal margin biopsies (33.3%). Two digits (12.5%) failed to heal. Three digits (18.8%) required a more proximal amputation, and the remaining 13 (81.3%) were found to be well-healed and functional at the final follow-up examination. The mean follow-up period was 27.6 (range 8 to 97) months. We have found distal Syme hallux amputation to be an effective treatment when used judiciously for distal hallux gangrene and osteomyelitis associated with neuropathic ulceration. This procedure permits bone biopsy for early diagnosis, confirmation of clean margins, removal of nonviable tissue and the abnormal toenail, and some deformity correction., (Copyright © 2017 The American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Acute compartment syndrome of the foot and ankle is a relatively rare clinical finding. Lower extremity compartment syndrome is customarily due to vascular or orthopedic traumatic limb-threatening pathologic issues. Clinical correlation and measurement of intracompartmental pressure are paramount to efficient diagnosis and treatment. Delayed treatment can lead to local and systemically adverse consequences. Frostbite, a comparatively more common pathologic entity of the distal extremities, occurs when tissues are exposed to freezing temperatures. Previously found in military populations, frostbite has become increasingly prevalent in the general population, leading to more clinical presentations to foot and ankle specialists. We present a review of the published data of acute foot compartment syndrome and pedal frostbite, with pathogenesis, treatment, and subsequent sequelae. A case report illustrating 1 example of bilateral foot, atraumatic compartment syndrome, is highlighted in the present report. The patient presented with changes consistent with distal bilateral forefoot frostbite, along with gangrenous changes to the distal tuft of each hallux. At admission and evaluation, the patient had increasing rhabdomyolysis with no other clear etiology. Compartment pressures were measured in the emergency room and were >100 mm Hg in the medial compartment and 50 mm Hg dorsally. The patient was taken to the operating room urgently for bilateral pedal compartment release. Both pathologic entities have detrimental outcomes if not treated in a timely and appropriate manner, with amputation rates increasing with increasing delay., (Copyright © 2018 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

We report a young female who presented with saddle-nose and bilateral cauliflower ear deformities along with pyoderma gangrenosum-like ulcers, digital gangrene and pulselessness. Subsequently, she was found to have bilateral conductive hearing loss, a corneal opacity, mild aortic regurgitation and radiological evidence of cavitary changes in lungs and aortoarteritis. Our patient had a constellation of symptoms which posed a diagnostic challenge. Finally, a diagnosis of relapsing polychondritis with several unusual features was made. Overlap with Takayasu's arteritis and granulomatosis with polyangitis, which has been reported rarely in the literature, cannot be excluded., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Infections are an important differential diagnosis in patients presenting with features of systemic vasculitis. We report a young lady with constitutional features, leg ulcers, digital gangrene and absent peripheral pulses with cervical adenopathy. Chest imaging revealed multiple necrotic lung lesions and involvement of left subclavian artery at its origin from the aorta, Histopathology from cervical lymph nodes showed multiple caseated lymph nodes, which in the context of a positive Mantoux test led us to diagnose tuberculosis and institute appropriate therapy. This is only the second report of tuberculosis presenting as peripheral gangrene, cutaneous ulcers and absent pulses, and serves to educate rheumatologists regarding the need to consider infections as mimics of vasculitis, especially in the developing countries.

Aim: Diabetic foot ulcers are associated with an increased risk of death. We evaluated whether ulcer severity at presentation predicts mortality., Methods: Patients from a national, retrospective, cohort of veterans with type 2 diabetes who developed incident diabetic foot ulcers between January 1, 2006 and September 1, 2010, were followed until death or the end of the study period, January 1, 2012. Ulcers were characterized as early stage, osteomyelitis, or gangrene at presentation. Cox proportional hazard regression identified independent predictors of death, controlling for comorbidities, laboratory parameters, and healthcare utilization., Results: 66,323 veterans were included in the cohort and followed for a mean of 27.7months: 1-, 2-, and 5-year survival rates were 80.80%, 69.01% and 28.64%, respectively. Compared to early stage ulcers, gangrene was associated with an increased risk of mortality (HR 1.70, 95% CI 1.57-1.83, p<0.001). The magnitude of this effect was greater than diagnosed vascular disease, i.e., coronary artery disease, peripheral arterial disease, or stroke., Conclusion: Initial diabetic foot ulcer severity is a more significant predictor of subsequent mortality than coronary artery disease, peripheral arterial disease, or stroke. Unrecognized or under-estimated vascular disease and/or sepsis secondary to gangrene should be explored as possible causal explanations., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Alimentary tract duplication is a rare congenital anomaly which may involve any part of the alimentary tract extending from stomach to rectum. Clinical presentation may mimic an inflamed appendix as described in this case. A 9-year-old boy with a clinical diagnosis of perforated appendix was noted to have a normal appendix intra-operatively. On further search for an underlying pathology, a gangrenous ileal duplication was discovered. En-bloc resection with primary bowel anastomosis was done. Histopathology report revealed a gangrenous small bowel duplication. We discuss the preoperative diagnostic dilemma and management options in approaching this rare entity.

Background: Thrombotic cutaneous gangrene is a rare extra-intestinal manifestation of ulcerative colitis with a severe prognosis., Case Report: A 35-year-old woman with a 7-year history of ulcerative colitis presented with extensive ecchymotic lesions that began a few hours earlier. On examination, she was febrile with multiple necrotic lesions. Skin biopsy showed multiple microthrombi in the dermal vessels. A diagnosis of thrombotic cutaneous gangrene was established. The patient was treated with heparin and systemic corticosteroids. The majority of cutaneous lesions showed improvement after 1 month. Thrombophlebitis of the left lower limb occurred subsequently., Conclusion: Thrombotic cutaneous gangrene is attributed to microvascular thrombosis, which arises from the hypercoagulability observed in ulcerative colitis. Complete blood and coagulation tests must be performed and early anticoagulation with heparin must be considered in order to prevent the progression of cutaneous infarction., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

A 15-month-old boy presented with atypical haemolytic uraemic syndrome (HUS) (without antecedent diarrhoea or dysentery) following a gluteal abscess and subsequently developed digital gangrene. During plasma infusion therapy for HUS, the clinical features of Kawasaki disease (KD) evolved. Intravenous immunoglobulin and aspirin therapy led to resolution of the KD. The case is notable for development of digital gangrene, a rare phenomenon described with HUS, as well as the development of features of KD. This is the first report of atypical HUS in association with peripheral gangrene and KD. The possible pathophysiological mechanisms are discussed.

Strangulated intestinal obstruction is one of the most common types of acute abdomen and requires urgent surgical treatment. Herein, we report a very rare case of strangulated intestinal obstruction caused by an ileo-ileal knot. An 80-year-old woman was admitted to our hospital with suspicion of strangulation ileus and underwent emergency laparotomy after investigation by exploratory single-port laparoscopy. During surgery, a small bowel gangrene caused by an ileo-ileal knot was found. The gangrenous segment was resected, and primary anastomosis was performed. Post-operative recovery was uneventful except for a minor wound infection. Our extensive search of the literature found only 7 case reports of ileo-ileal knot including ours. An ileo-ileal knot should be considered in the differential diagnosis of acute intestinal obstruction, because this rare phenomenon requires urgent surgical treatment; and some complications should be considered during or after surgery.

Retroperitoneal Gangrene is a serious condition whose causes are many. We report three originally cases of anorectal suppuration complicated by retroperitoneal gangrene without Fournier's gangrene until there ever described in the literature. The diagnosis was made in all cases on CT because of atypical clinical presentation. The surgical approach was carried out in different ways to treat perineal and retroperitoneal lesions.

We report a case of a 75-year-old female with acute torsion of the gallbladder with gangrene and cholelithiasis. On admission, the patient underwent physical examination, laboratory blood analysis, abdominal ultrasound and plain abdominal x-ray. Due to the signs of acute abdomen and poor general condition of the patient, urgent surgical procedure was indicated. Intraoperatively, the gallbladder was found to be greatly enlarged, gangrenous and greatly distended with 360° clockwise torsion around its mesentery. Cholecystectomy was performed. Gallbladder torsion is a rare surgical emergency which physicians should bear in mind when encountering patients with symptoms of acute cholecystitis. The only treatment for this condition is urgent cholecystectomy with prior detorsion. The mortality rate in patients not undergoing surgery is 100%.

Background: Our previous retrospective study revealed the three preoperative predictors of complicated appendicitis (perforated or gangrenous appendicitis), which are body temperature ≥37.4 °C, C-reactive protein ≥4.7 mg/dl, and fluid collection surrounding the appendix on computed tomography. We reported here an additional prospective study to verify our ability to predict complicated appendicitis using the three preoperative predictors and thus facilitate better informed decisions regarding emergency surgery during night or holiday shifts., Methods: We prospectively evaluated 116 adult patients who underwent surgery for acute appendicitis from January 2013 to October 2014. Ninety patients with one or more predictive factors of complicated appendicitis underwent immediate surgery regardless of the time of patient's presentation. Twenty-six patients had no predictive factors and thus were suspected to have uncomplicated appendicitis. Of the 26 patients, 14 who presented to our hospital during office hours underwent immediate surgery. The other 12 patients who presented to our hospital at night or on a holiday underwent short, in-hospital delayed surgery during office hours., Results: All patients with no predictive factors had uncomplicated appendicitis, whereas 37 %, 81 %, and 100 % of patients with one, two, or all three factors, respectively, were diagnosed with complicated appendicitis. The emergency operation rate decreased from 83 % before to 58 % after adopting this scoring system, but no significant differences in postoperative complication rates and hospitalization periods were observed., Conclusions: The above-mentioned preoperative factors predictive of complicated appendicitis preoperatively are useful for emergency surgical decisions and reduce the burdens on surgeons and medical staff.

Purpose: Our aim was to establish the role of hyperbilirubinemia as a predictive parameter for the prediction of either acute, or gangrenous/perforated appendicitis as well as to compare other parameters in a similar role., Methods: Medical files of the patients who underwent appendectomies between September 2013 and September 2014 were evaluated. Age, gender, preoperative white blood cell count (WBC), neutrophil count (NEU), neutrophil percentage (NEU%), C-reactive protein (CRP), total/direct/indirect bilirubin levels, and the postoperative histopathological findings were recorded. The Fisher's exact, Pearson's χ (2), ANOVA, and Kruskal-Wallis tests while logistic regression for multivariate analysis was performed. p < 0.05 was accepted as statistically significant., Results: The study group of 162 patients consisted of 97 (60 %) men and 65 (40 %) women with a median age of 36 (18-90). Histopathological examinations revealed normal appendix in 21 (13 %) patients, non-complicated acute appendicitis in 100 (62 %), and appendiceal gangrene/perforation in 41 (25 %) patients. WBC, NEU, NEU%, and CRP levels were significantly higher in cases of acute and gangrenous/perforated appendicitis (p < 0.01). Total and direct bilirubin levels were also significantly elevated in patients with acute and gangrenous/perforated appendicitis (p < 0.01). According to multivariate analysis, elevated CRP levels were associated with 14 times, elevated total bilirubin levels were associated with five times, and elevated direct bilirubin levels were associated with 36 times greater risk for appendiceal gangrene/perforation (p < 0.01, p < 0.05, p < 0.01, respectively)., Conclusions: Hyperbilirubinemia, especially with elevated direct bilirubin levels, may be considered as an important marker for the prediction of appendiceal gangrene/perforation.

Background: Following digital surgical procedures, the ensuing post-operative course may be complicated by the presence of underlying ischaemic or vasospastic process. In the presence of such conditions, post-operative ischaemic changes may be further exacerbated with the use of local anaesthetics in combination with epinephrine., Case Details: We report a 21 year-old female who presented with an amputated fifth digit due to a rapidly spreading gangrene which started immediately after the surgical repair of a traumatic laceration which was infiltrated with a pre-mixed solution of lignocaine and epinephrine 3 hours earlier. The patient's final diagnosis was epinephrine-associated digital gangrene in the background of primary Raynaud's Phenomenon (RP)., Conclusion: The author reports this case in order to reiterate the importance of thorough clinical evaluation prior to the use of epinephrine in digital anaesthesia as well as to increase awareness on how primary RP can be complicated by gangrene.

Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract. Most often is asymptomatic but it may give a number of complications including gastrointestinal bleeding, obstruction and inflammation. Axial torsion and gangrene of MD are exceptional. The correct diagnosis of MD could only be made during surgery. Early surgery is important to reduce morbidity, especially perforation. Laparoscopy aided in the diagnosis and adequate treatment. We herein describe the case of a 4-year-old boy with axial torsion of MD. Clinical and radiographic finding suggest a segmental volvulus. Laparoscopy contributes to diagnosis and treatment of torted MD.

Background: Venous gangrene complicating deep vein thrombosis in the context of anticoagulation use in patients with gynecologic malignancy is rarely reported. We report an unusual presentation of venous gangrene of the lower limbs associated with warfarin therapy in a 53-year-old woman from the Cook Islands with an occult ovarian cancer., Case Presentation: A 53-year-old woman of Cook Islands origin presented with exertional dyspnea, rapid atrial fibrillation, bilateral lower limb edema, and painful digital ischemia of her hallux. She was on warfarin therapy for atrial fibrillation and had a stable therapeutic international normalized ratio. Bilateral proximal lower limb deep vein thrombosis and digital gangrene subsequently developed in the setting of a supratherapeutic international normalized ratio and platelet count depletion. Her warfarin was reversed and heparin therapy was commenced with resulting correction of her thrombocytopenia., Conclusions: We would like to attract the attention of the reader to the potential hazard of the use of warfarin in patients with malignancy. In our case, we also demonstrated a predictive value of supratherapeutic international normalized ratio and platelet count depletion that could herald massive thrombosis and gangrene in a patient who was previously stable on warfarin therapy. Early recognition and prompt reversal of warfarin in these circumstances is essential to correct the unbalanced prothrombotic process that leads to extensive thrombosis and gangrene. The outlook of such cases remains dismal and results in extensive morbidity and mortality.

We aimed to prepare guidelines for the management of diabetic ulcer/gangrene with emphasis on the diagnosis and treatment of skin symptoms. They serve as a tool to improve the quality of the diagnosis and treatment in each patient and, further, to improve the level of the care for diabetic ulcer in Japan by systematically presenting evidence-based recommendations for clinical judgments by incorporating various viewpoints., (© 2016 Japanese Dermatological Association.)

A 43-year-old man with pancytopenia from chemotherapy for acute myeloid leukemia developed left scrotal pain, fever, and rigors. Physical exam revealed an ulcerating lesion with central necrosis and eschar surrounded by a halo of erythema on the inferior aspect of the left scrotum. The condition indicated an early necrotizing soft tissue infection. The patient was started on broad-spectrum antibiotics and taken to the operating room for a wound debridement. Blood and tissue cultures grew Pseudomonas aeruginosa, which confirmed the diagnosis of ecthyma gangrenosum of the scrotum. The fever resolved, and the wound healed without further progression after wet to dry dressing changes.

We report the case of a 10-year-old male who developed gangrene of his fingers and toes following severe dengue fever complicated by disseminated intravascular coagulation (DIC). Child developed bilateral dry gangrene of fingers and toes. All the peripheral pulses of the affected limbs were palpable. The child had no history of taking B-blockers, ergot alkaloids or other related medications. Color Doppler of peripheral arterial and venous systems of all limbs indicated normal flow. Blood was positive for D-dimers and fibrin degradation products. The patient was managed with broad spectrum antibiotics, fluid resuscitation, low molecular weight heparin, blood transfusions, fresh frozen plasma and other supportive measures. Peripheral gangrene seen in DIC associated with dengue is very rare and carries a higher mortality.

The male patient reported here presented as gangrene and central diabetes insipidus (CDI), who had characteristics of vasculitis. The patient complained about polydipsia and polyuria half a year ago, and then developed tingling, pain and blackish discoloration of some fingers and toes 3 month ago. He also had Raynaud's phenomenon. After admission, his laboratory examination showed the rise of erythrocyte sedimentation rate, C-reactive protein, immunoglobulin, β2-glycoprotein I and the activity of rheumatoid factors, lupus anticoagulant test. his pituitary gland showed loss of posterior signal on magnetic resonance imaging. In addition, his vasopressin test was active. However, there was no sufficient evidence to diagnose any specific disease; as a consequence the patient was diagnosed as idiopathic systemic necrotizing vasculitis (SNV). For SNV, the patient was treated with glucocorticoid 40 mg/d and impact therapy of cyclophosphamide 0.4 g every 2 weeks. He also received symptomatic treatment for gangrene and CDI. Cutaneous involvement leading to gangrene was widely reported in SNV, however pituitary involvement in SNV leading to CDI was rare. The prognosis of this patient was poor.

Pulmonary gangrene is a life-threatening condition, which represents the fulminant end of the infectious lung diseases usually caused by polymicrobial infection. Aerobic and anaerobic bacteria act synergistically to produce massive tissue necrosis which might be augmented by the angioinvasive nature of fungi like Mucor. We report a successfully treated case of pulmonary gangrene in a poorly controlled diabetic patient, which was associated with polymicrobial infection. It was caused by Rhizopus spp., Staphylococcus aureus, Klebsiella pneumoniae and unusual anaerobic organism Sarcina. This is the first report describing the presence of Sarcina organisms in a case of pulmonary gangrene. Adequate glycemic control, treatment of coexisting polymicrobial infection and prompt antifungal therapy along with surgical intervention were useful in the index patient. This case also highlights the effectiveness of combined medical and surgical intervention in a case of pulmonary gangrene.

The authors present a case report of a 39-year-old woman with acute abdomen - a comorbid patient with systemic lupus erythematosus, chronic renal insufficiency as a complication of lupus nephritis, included in a haemodialysis programme. The patient had also undergone transplantation of the left kidney in the past. She was initially admitted to the Department of Traumatology for a total endoprosthesis procedure due to bionecrosis of the head of the thigh bone. Postoperatively, the patients condition was complicated by gangrene of the colon confirmed by CT scan and during the operation. The patient was operated on - subtotal colectomy, terminal ileostomy and left-sided ovariectomy was performed. The postoperative course was complicated by perforation of the jejunum which was sutured. The patient was admitted to ICU and, after recovery, to our surgical department. Because of the metabolic disturbance she was treated in the internal medicine department. After 60 days she was discharged in a good condition, walking and with full per os realimentation.Key words: lupus erythematosus gangrene of the colon acute abdomen.

A 83-year-old male was admitted to the Emergency Department with acute haematochezia and abdominal pain. At digital rectal examination multiple soft distensions were palpable. Sigmoidoscopy revealed ischaemia of the rectum with severe gangrene. The patient was discharged after fluid resuscitation. Follow-up sigmoidoscopy 4 weeks later showed a fully recovered rectum.

This pictorial review aims to illustrate the various manifestations of the diabetic foot on magnetic resonance (MR) imaging. The utility of MR imaging and its imaging features in the diagnosis of pedal osteomyelitis are illustrated. There is often difficulty encountered in distinguishing osteomyelitis from neuroarthropathy, both clinically and on imaging. By providing an accurate diagnosis based on imaging, the radiologist plays a significant role in the management of patients with complications of diabetic foot.

We report a case of digital ischaemia in a 31-year-old man who presented with sudden hand numbness, swelling, and cyanosis 4 days after a jellyfish sting. This is a rare complication of jellyfish sting, characterised by a delayed but rapid downhill course. Despite serial monitoring with prompt fasciotomy and repeated debridement, he developed progressive ischaemia in multiple digits with gangrenous change. He subsequently underwent major reconstructive surgery and aggressive rehabilitation. Although jellyfish stings are not uncommon, no severe jellyfish envenomation has been reported in the past in Hong Kong and there has not been any consensus on the management of such injuries. This is the first local case report of jellyfish sting leading to serious hand complications. This case revealed that patients who sustain a jellyfish sting deserve particular attention to facilitate early detection of complications and implementation of therapy.

Phlegmasia cerulea dolens (PCD) is an aggressive and life-threatening form of venous thrombosis complicated by ischemic necrosis. Massive thrombosis extends to collateral veins resulting in venous congestion with fluid sequestration in the interstitium causing collapse of arterioles, which progresses to ischemia and, if severe, circulatory collapse and shock. The mortality rate for PCD is as high as 40%, especially when gangrene develops. PCD has been associated with acquired thrombophilias, including malignancy and antiphospholipid syndrome (APS). We present a unique case of a patient with PCD refractory to anticoagulant and thrombolytic therapy, whose fulminant course was attributed to concurrent cholangiocarcinoma and antiphospholipid antibodies identified by a positive lupus anticoagulant assay. This case highlights the importance of uncovering precipitating causes of thromboembolism, which may offer prognostic information and may necessitate therapy beyond anticoagulation and thrombolysis to reduce the morbidity of PCD. The current literature on PCD and APS, along with their associations with malignancy, is reviewed.

Purpose: Elevation of the serum total bilirubin (STB) level not stemming from hepatic dysfunction or biliary obstruction may be seen in cases of acute appendicitis. This paper deals with the clinical significance of such elevations., Methods: Data from 410 appendectomized patients classified into two groups (a high preoperative STB group and a normal preoperative STB group) were analyzed to reveal the significance of preoperative hyperbilirubinemia. We also examined whether the preoperative STB level might serve as a risk factor for gangrenous appendicitis by a multivariate analysis., Results: Gangrenous appendicitis was more common in the high preoperative STB group (p < 0.001). The multivariate analysis revealed that an elevated preoperative STB level (odds ratio 1.7919) was a risk factor for gangrenous appendicitis., Conclusion: In patients with an elevated preoperative STB level, it is very likely that the inflammation is severe and that the disease has progressed to a severe condition histopathologically; therefore, meticulous attention should be paid to the selection of the surgical procedure, as well as to the postoperative clinical course.

Introduction: Leptospirosis is a zoonosis caused by the spirochete, Leptospira interrogans. While most cases of leptospirosis are mild to moderate, the course may be complicated by multiorgan dysfunction. We present a rare case of leptospirosis with acute myocarditis, pancreatitis, polyarthritis, mononeuritis multiplex and severe vasculitis with necrosis of the extremities., Case Presentation: A 32-year-old man from Congo presented with high-grade fever, confusion and headache. He developed tachycardia and hypotension followed by electrocardiogram changes and elevation of troponin I levels suggesting myocarditis. A physical examination revealed conjunctival suffusion, polyarthritis of his lower extremities and cutaneous necrosis of his feet due to vasculitis. Laboratory findings included amylase levels 10-fold the upper normal serum levels and thrombocytopenia. The diagnosis was confirmed by a positive leptospira immunoglobulin M, negative immunoglobulin G and a positive rapid agglutination test. Our patient recovered progressively with antimicrobials and supportive care., Conclusions: Because the clinical features and diagnostic findings of leptospirosis are not specific, a high index of suspicion must be maintained for the diagnosis. Serology is the most important tool for accurate and quick diagnosis in order to administer the appropriate therapy.

Limb gangrene in a neonate is an extremely rare clinical problem and bilateral symmetrical lower limbs type is even rarer. Only few clinical cases have been reported thus far with idiopathic etiology or associated with rare conditions. Known causes in literature are sepsis, extravasation of intravenous fluid, following a complicated delivery and secondary to invasive monitoring. This report describes neonate was first developed sepsis and later was exposed to cold leading to bilateral gangrene of lower limbs.

Trench foot is a relatively rare condition in tropical countries. We present here a case report of trench foot in a child who was put on hip spica for her hip ailment. Although rare, awareness on the part of the clinician can prevent this potentially serious condition and early diagnosis and treatment can prevent further consequences.