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Year : 2015  |  Volume : 2  |  Issue : 4  |  Page : 166-167

Symmetrical Peripheral Gangrene Complicating Vivax Malaria

1 Department of Medicine, ESI Medical College, Joka, Kolkata, West Bengal, India
2 Department of Medicine, Kolkata Medical College, Kolkata, West Bengal, India

Date of Web Publication13-Apr-2016

Correspondence Address:
Krishnarpan Chatterjee
Department of Medicine, ESI Medical College, Joka, Kolkata, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-0820.180128

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We present a case of Plasmodium vivax malaria who presented with distal lower limb gangrene. Large vessels of the lower limb were normal. After ruling out other causes, a diagnosis of symmetrical peripheral gangrene was made. The dry gangrene was treated conservatively, and amputation planned after the line of demarcation was seen.

Keywords: Plasmodium vivax, malaria, symmetrical peripheral gangrene

How to cite this article:
Chatterjee K, Sen C. Symmetrical Peripheral Gangrene Complicating Vivax Malaria. Indian J Vasc Endovasc Surg 2015;2:166-7

How to cite this URL:
Chatterjee K, Sen C. Symmetrical Peripheral Gangrene Complicating Vivax Malaria. Indian J Vasc Endovasc Surg [serial online] 2015 [cited 2022 Nov 26];2:166-7. Available from:

A 20-year-old man presented with 10 days history of high-grade intermittent fever with chills and rigors followed. The patient had noticed blackish discoloration of the toes 1 week after the onset of fever. There was no history of headache or seizures. There was no history of jaundice, bleeding manifestations, or decreased urine output. There was no history of similar history in past. He had no history of transfusions. On examination, he was febrile; there was no pallor, jaundice, or purpure. Mild dehydration was present. He had hepatosplenomegaly. There was bilateral dry gangrene involving the distal feet and toes with clear line of demarcation. All lower limb peripheral pulses were equal and symmetrical. Upper limbs examination was normal. Cardiovascular system examination revealed no abnormalities. There were no signs of meningeal irritation. Fundus was within normal limits. A peripheral smear showed ring forms of Plasmodium vivax and thrombocytopenia (platelet count 95,000/mL). Malarial antigen test was also positive. To evaluate for disseminated intravascular coagulation (DIC), prothrombin time, activated partial thromboplastin time, D-dimer, and fibrin degradation product were done which were all within normal limits. Antinuclear antibody was negative. Liver enzymes were raised (serum glutamic oxaloacetic transaminase - 256, serum glutamic pyruvic transaminase - 262). Renal functions were normal. Arterial Doppler of lower limbs was normal. With a provisional diagnosis of complicated vivax, malaria patient was treated with artemisinin-based combination therapy (artemether and lumefantrine) and other supportive measures. He became afebrile after 2 days. A peripheral angiogram showed normal large vessels of the lower limbs. Vascular surgery opinion was taken, and amputation was planned. Mummification of the feet and toes occurred after 2-3 weeks [Figure 1] and [Figure 2]. A diagnosis of symmetrical peripheral gangrene (SPG) complication P. vivax was made.
Figure 1: Mummification of the bilateral toes

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Figure 2: Autoamputation of the left foot

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SPG was first described by Hutchison in 1891. [1] It is defined as distal symmetric ischemic damage in two or more areas without large vessel obstruction or vasculitis. [2] In spite of first being reported in the 19 th century, most documented cases in literature have been in the form of case reports. A few case series have been published in the last decade. [3],[4],[5] It has commonly been reported in association with DIC and septicemia. [6],[7]

Malaria-induced gangrene has been reported with falciparum, vivax, and mixed malaria in India. [8],[9] Gangrene associated with severe malaria has also been reported from Thailand and African countries such as Zimbabwe and Kenya. [10],[11],[12] Some cases have also been reported in travelers returning from endemic countries. [13] Clemens et al. showed that severe malaria activates the intrinsic clotting pathway and complement system. [14] In their study, thrombin-AT III complexes were elevated, and protein C activity decreased in severe malaria. Malaria-induced gangrene commonly affects the distal limbs, ear and nose tip, and scalp. The management of malaria-induced gangrene remains in early identification of the identifying cause and its prompt treatment along with correction of DIC if present. The gangrenous extremity should be treated conservatively. The prognosis remains poor. Amputation has been reported in 8 out of 9 and 6 out of 9 survivors in different case series. [3],[4] Mortality has been reported in 10-33% of patients. [3],[4],[5] Leukopenia has been associated with a worse outcome. [4]

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  References Top

Hutchison J. Severe symmetrical gangrene of the extremities. Br Med J 1891;2:8-9.  Back to cited text no. 1
McGouran RC, Emmerson GA. Symmetrical peripheral gangrene. Br Heart J 1977;39:569-72.  Back to cited text no. 2
Davis MD, Dy KM, Nelson S. Presentation and outcome of purpura fulminans associated with peripheral gangrene in 12 patients at Mayo Clinic. J Am Acad Dermatol 2007;57:944-56.  Back to cited text no. 3
Ghosh SK, Bandyopadhyay D, Ghosh A. Symmetrical peripheral gangrene: A prospective study of 14 consecutive cases in a tertiary-care hospital in Eastern India. J Eur Acad Dermatol Venereol 2010;24:214-8.  Back to cited text no. 4
Tiwary SK, Shankar R, Khanna R, Khanna AK. Symmetrical peripheral gangrene. Int J Surg 2006;7:2.  Back to cited text no. 5
Molos MA, Hall JC. Symmetrical peripheral gangrene and disseminated intravascular coagulation. Arch Dermatol 1985;121:1057-61.  Back to cited text no. 6
Ghosh SK, Bandyopadhyay D. Symmetrical peripheral gangrene. Indian J Dermatol Venereol Leprol 2011;77:244-8.  Back to cited text no. 7
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Kakati S, Doley B, Barman B, Devi A. Symmetric peripheral gangrene and falciparum malaria. J Assoc Physicians India 2004;52:498-9.  Back to cited text no. 8
Agrawal A, Rastogi A, Tiwari D. Symmetric peripheral gangrene with mixed malaria. Indian J Pediatr 2007;74:587-8.  Back to cited text no. 9
Thanachartwet V, Krudsood S, Wilairatana P, Phumratanaprapin W, Silachamroon U, Looareesuwan S. Peripheral gangrene in patients with severe falciparum malaria: Report of 3 cases. Korean J Parasitol 2006;44:139-43.  Back to cited text no. 10
Chittichai P, Chierakul N, Davis TM. Peripheral gangrene in nonfatal pediatric cerebral malaria: A report of two cases. Southeast Asian J Trop Med Public Health 1991;22:190-4.  Back to cited text no. 11
Alkizim FO, Matheka D, Mwanda OW. Malaria complicated by gangrene: A case presentation and review. Pan Afr Med J 2011;10:46.  Back to cited text no. 12
Liechti ME, Zumsteg V, Hatz CF, Herren T. Plasmodium falciparum cerebral malaria complicated by disseminated intravascular coagulation and symmetrical peripheral gangrene: Case report and review. Eur J Clin Microbiol Infect Dis 2003;22:551-4.  Back to cited text no. 13
Clemens R, Pramoolsinsap C, Lorenz R, Pukrittayakamee S, Bock HL, White NJ. Activation of the coagulation cascade in severe falciparum malaria through the intrinsic pathway. Br J Haematol 1994;87:100-5.  Back to cited text no. 14


  [Figure 1], [Figure 2]


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