Symmetrical peripheral gangrene and disseminated intravascular coagulation associated with pelvi-ureteric junction obstruction.

To cite: Reid VL, McLay J. BMJ Case Reports Published online: [please include Day Month Year] doi:10.1136/ bcr-2012-006519 DESCRIPTION An 87-year-old woman presented to the emergency department with confusion, sinus tachycardia, hypotension and fever. Laboratory investigations confirmed metabolic acidosis, acute kidney injury (urea 18.5 mmol/l, serum creatinine 197 mmol/l and Egfr 21 ml/min/1.73 m), depressed bone marrow function (platelets 136×10/l and white cell count (WCC) 3.0×10/l) and elevated prothrombin and activated partial thromboplastin time (PT 15.8 s and APTT 61 s). Urinalysis was positive for blood, protein and leucocytes. Severe sepsis was diagnosed and treatment with intravenous fluids, co-amoxiclav and vitamin K was initiated. Proteus mirabilus was later identified from blood cultures. Despite treatment the patient deteriorated with abdominal tenderness, refractory hypoglycaemia, mucocutaneous bleeding, symmetric areas of petechiae, ecchymotic plaques and dry gangrene of the upper and lower extremities (figures 1 and 2). Laboratory investigations suggested disseminated intravascular coagulation (DIC) (platelets 13×10/l, PT 23.3 s, APTT 68.5 s and normal fibrinogen). Avasculitis screen was negative. She was treated with intravenous tazocin, hydrocortisone and platelets. On day 7, CT imaging demonstrated left pelvi-ureteric junction (PUJ) obstruction, rupture of the left renal tract (figure 3) and multiple abdominal and pelvic fluid collections. A left-sided ureteric stent was inserted by the urologists, and the digits affected by dry gangrene were autoamputated under the plastic surgeons. Symmetrical peripheral gangrene (SPG) is a rare, but devastating complication of DIC, characterised by SPG with no evidence of large-vessel occlusion or vasculitis. Microorganisms commonly implicated include meningococci, pneumococci, streptococci and staphylococci. To our knowledge, this is the first reported case of SPB caused by proteus spp. Learning points