Symmetrical Peripheral Gangrene associated to norepinephrine in a patient with urosepsis due to Escherichia coli

Abstract

Background: symmetrical peripheral gangrene is a devastating complication associated with norepinephrine use in critically ill patients, characterized for ischemia of acral distribution in absence of large vessel obstruction.
Objective: to underscore the relevance of a rare complication to a medication of common use and a frequent disease.
Clinical case: a thirty-six-year-old woman with history of urolithiasis was admitted to the emergency room for septic shock secondary to acute pyelonephritis. She was transferred to the intensive care unit where antimicrobial therapy, mechanical ventilation and vasopressor support with norepinephrine was given. Four days later, progressive cyanosis of the four limbs became apparent, evolving to symmetrical peripheral gangrene. Cultures revealed the presence of a usual resistance pattern Escherichia coli. Given the presence of severe anemia and thrombocytopenia, disseminated intravascular coagulation was suspected. A poor response was observed in the patient as she underwent plasmapheresis and glucocorticoid pulse therapy, limiting necrosis to acral regions of the limbs. In the end required amputation of the digits. The laboratory studies rule out other possible etiologies leading to a final diagnosis of SPG associated to vasopressor support.
Conclusions: a case of digital necrosis in the context of urosepsis is presented. Multiple risk factors where present (severe sepsis, norepinephrine use, Escherichia coli infection). Escherichia coli endotoxemia may have a physiopatological role in these cases.

DeCS: GANGRENE; NOREPINEPHRINE; ESCHERICHIA COLI; ADULT; CASE REPORTS.