CC BY-NC-ND 4.0 · Indian J Plast Surg 2021; 54(02): 237-239
DOI: 10.1055/s-0041-1731853
Letter to the Editor

Acute Extremity Gangrene in COVID-19 Patients

1   Department of Plastic and Reconstructive Surgery, Sakra World Hospital, Bangalore, Karnataka, India
,
Rajendra S. Gujjalanavar
1   Department of Plastic and Reconstructive Surgery, Sakra World Hospital, Bangalore, Karnataka, India
,
Subrata Das
2   Department of Internal Medicine, Sakra World Hospital, Bangalore, Karnataka, India
,
Raghu Janardhan
2   Department of Internal Medicine, Sakra World Hospital, Bangalore, Karnataka, India
,
Pallavi Rao
3   Department of Laboratory Medicine, Sakra World Hospital, Bangalore, Karnataka, India
› Author Affiliations

As elective plastic surgery takes the backseat during the COVID-19 pandemic, we have noticed a pattern in the slew of referrals from the “COVID” ward of the hospital. Among the 2284 COVID-19 positive cases treated, we were asked to manage four cases of acute dry gangrene of extremities. A summary of all the patients is presented in [Table 1].

Table 1

Summary of all patients in the case series

Patient 1

Patient 2

Patient 3

Patient 4

Abbreviations: ARDS, acute respiratory distress syndrome; ATA, anterior tibial artery; CFA/CFV, common femoral artery/vein; DPA, dorsalis pedis artery; DVT, deep vein thrombosis; HIT, heparin-induced thrombocytopenia; IP, interphalangeal; MTP, metatarsophalangeal; PA/PV, popliteal artery/vein; PTA, posterior tibial artery; SFA/SFV, superficial femoral artery/vein.

a Based on Government of India guidelines—https://www.mohfw.gov.in/pdf/ClinicalManagementProtocolforCOVID19.pdf.

Age

56

58

80

60

Sex

Male

Female

Male

Male

Pattern of gangrene

Left thumb up to IP joint

Left 4th toe up to IP joint

Left 1st and 4th toe up to MTP joint. Left 5th toe up to IP joint

Left foot great toe and all toes of right foot—up to IP joint

Onset of gangrene (week of admission)

6th week

3rd week

At presentation

3rd week

Management of gangrene

Revision amputation of left thumb at the head of proximal phalanx under local anesthesia ([Fig. 2])

Conservative

Forefoot amputation under spinal anesthesia ([Fig. 1])

Conservative

Comorbidities

Diabetes

Bronchial asthma

Diabetes, concentric left ventricular hypertrophy

Hypertension, bronchial asthma

Doppler

Not done

Arterial: bilateral CFA, SFA, PA, ATA, PTA, and DPA are patent and show normal flow and spectral waveforms

Venous: bilateral DVT (dilated, noncompressible CFV, SFV with echogenic contents within suggestive of DVT, dilated PV with no flow within.

Not done

Arterial: right—triphasic flow in CFA and SFA. biphasic flow in PA, ATA, PTA. monophasic flow in DPA. Atherosclerotic changes in PA and below

Left—triphasic flow CFA and SFA. Biphasic flow in PA. Monophasic flow in ATA, PTA and DPA

Venous: normal

Angioplasty

Not done

Not done

Left SFA complete occlusion at origin and multilevel stenosis 40–50%

Not done

d-dimer

Not tested in current admission

Elevated

Not tested

Elevated

Vasopressor support

No

Yes

No

Yes

Duration of hospital stay (cumulative)

47 days

39 days

2 days

20 days

Duration of ICU stay

21 days

15 days

16 days

Severity of COVID-19 a

Severe (ARDS)

Severe (septic shock)

Mild

Severe (septic shock)

COVID-19-related complications

Pneumonia, critical care-induced neuromyopathy, grade III sacral pressure sore

Pneumonia, bilateral lower limb DVT, HIT, type 1 respiratory failure, hyperhomocysteinemia

Pneumonia

Outcome

Recovery

Recovery

Recovery

Death

Some authors have provided early evidence of complement-mediated microvascular injury and coagulopathy in severe COVID-19 disease.[1] Wang reported two critically ill patients with COVID-19-related retiform purpura, progressing to digital gangrene, who demonstrated microthrombi in the blood vessels on biopsy, elevated D-dimer levels, antithrombin III deficiency, and positive anticardiolipin IgG/IgM antibodies.[2] A larger study from Italy concluded that the incidence of acute limb ischemia increased during the pandemic, and revascularization was lower than usual due to the procoagulant state.[3]

The common etiological factor proposed is a state of hypercoagulability, which is induced by micro- and macroangiopathy, caused by either a direct complement-mediated effect of the virus or an antibody-mediated immunological response. The delayed immunological response seems to be a logical reason for 3 of 4 patients in our series, since patients 1, 2, and 4 developed gangrene only late in the course of the disease. However, in patient 3, acute gangrene was the presenting symptom in the absence of any other typical symptoms of COVID-19 infection which, might be due to direct effect of the virus on the vasculature.

Differential diagnosis for acute ischaemia in critically ill patients include vasopressor-induced extremity gangrene, myocardial infarction (MI) with thrombi in left ventricle, hypothermia, atherosclerotic thrombi, shock, disseminated intravascular coagulation (DIC), and thrombolytic therapy. In most cases, the causation is multifactorial.

Middeldorp reported COVID-19 patients who received routine prophylactic doses of low-molecular weight heparin (LMWH) had significantly higher venous thromboembolism rate when compared with non-COVID acutely ill patients.[4] This suggests that prophylactic dose of LMWH may not be enough, and initiation of an appropriate dose of anticoagulant might be necessary.[5] Initiation of therapeutic dose of LMWH in admitted COVID-19 patients (with moderate-to-severe pneumonia or d-dimer greater than 500 ng/mL) is our current practice. We have neither seen any adverse effect of this protocol, like bleeding in our patients, nor has this been reported in literature. Those with limb ischemia and no contraindication for heparin use were treated with unfractionated heparin (UFH). We now await what difference this protocol makes in subsequent waves of the pandemic.

Zoom Image
Fig. 1 Preoperative (a) and postoperative (b) pictures of patient 1.
Zoom Image
Fig. 2 Preoperative (a) and postoperative (b) pictures of patient 3.


Publication History

Article published online:
30 June 2021

© 2021. Association of Plastic Surgeons of India. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

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