Limb gangrene: What is the best initial approach? A problem with serious controversy among rheumatologists

Mohammad Bagher Owlia, Mohammadreza Ahmadpour- Baghdadabad,, Ali Dehghan, Hossein Soleymani


Critical ischemia of any organ is potentially the most devastating condition threatening all living organs. Gangrene or necrosis of organs is a common problem in routine clinical practice that mostly directed initially to surgical departments due to emergent nature of condition in nearly all cases with one exception of myocardial ischemia or infarction. Basic mechanism for non-traumatic vascular compromise is rather similar in nearly all organs however interestingly clinical approach is highly different in diverse clinical settings. Rather a thorough medical approach is as critical as debridement and revascularization techniques in order to diagnose and treat ongoing underlying pathologies. In this report we analyzed all different approaches of several rheumatologists in a real case scenario of unilateral foot gangrene. In this study, using e-mail questionnaire contacts, we sent the medical history of our patient with unilateral foot gangrene together with predesigned short questions and asked the opinions of 50 experienced rheumatologists from several parts of the world regarding initial management plan to handle the case. The responses were collected and analyzed. Twenty-six physicians (52%) responded of whom 22 (84%) suggested administration of heparin. Thrombolytic therapy was recommended by 3 (11.5%). There were many diverse ideas about starting intravenous (IV) steroid pulse: 15 (57.6%) recommended steroid pulse and 7 (27%) discouraged it. Two rheumatologists believed that this case is actually a surgical case and should not be handled in rheumatology service. We concluded that there is a serious controversy among rheumatologists regarding the management of patients with acute limb ischemia. Also, we suggest that in all uncertain vascular compromise, considering early institution of anti-inflammatory, anti-thrombotic therapies along with vasodilators could be a rational initial approach until further information is obtained from tissue biopsy and full panel laboratory investigation.



vascular rheumatology; ischemia; gangrene; vasculitis

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Owlia MB, Salimzadeh A, Alishiri G, Kargar S: Ischemic toes after venous thromboembolism: a difficult differential diagnosis with good response to combination therapy-a case report. Case Rep Med 2012:403685, 2012.

Alishiri GH, Salimzadeh A, Owlia MB, Forghanizadeh J, Setarehshenas R, Shayanfar N: Prevalence of amyloid deposition in long standing rheumatoid arthritis in Iranian patients by abdominal subcutaneous fat biopsy and assessment of clinical and laboratory characteristics. BMC Musculoskelet Disord 7:43, 2006.

Shafi N, Kasner SE: Treatment of acute ischemic stroke: beyond thrombolysis and supportive care. Neuro- therapeutics : J Am Soc Exp NeuroTherap 8:425-433, 2011.

Piriou V, Feugier P, Granger S, Gueugniaud PY: [Ischaemia of the lower limbs: anaesthesia and intensive care]. Ann Franc D'anesth Reanim 23:1160-1174, 2004.

Dickinson BP, Jimenez JC, Lawrence PF, Derubertis BG. Functional limb salvage following muscle rigor in a pediatric patient. Vascul Endovascul Surg 44:315-318, 2010.

Petri M, Fye KH: Digital necrosis: a paraneoplastic syndrome. J Rheumatol 12:800-802, 1985.

Current care guidelines: peripheral arterial disease]. Duodecim; Laaketieteellinen Aikakauskirja 126:1433-1434, 2010.

Alonso-Coello P, Bellmunt S, McGorrian C, Anand SS, Guzman R, Criqui MH, Akl EA, Olav Vandvik P, Lansberg MG, Guyatt GH et al. Antithrombotic therapy in peripheral artery disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2 Suppl):e669S-690S, 2012.

Becker MO, Riemekasten G. Critical limb ischemia in systemic sclerosis. Zeitschrift fur Rheumatologie 71:261-269, 2012.

Pasquet F, Karkowski L, Hajek V, Pavic M, Guilloton L: [Ischemic stroke as the first manifestation of Wegener's granulomatosis]. La Revue de medecine interne / fondee par la Societe nationale francaise de medecine interne 33:e6-9, 2012.

Gallagher CG, Gallagher EA, Crowe JP: Asymptomatic giant cell arteritis. Archives of internal medicine 145:2122, 1985.

Owlia MB, Sami R, Akhondi M, Salimzadeh A: Cryoglobulinaemia in hepatitis C-positive patients in Iran. Singapore Med J 48:1136-1139, 2007.

Gross RL, Brucker J, Bahce-Altuntas A, Abadi MA, Lipoff J, Kotlyar D, Barland P, Putterman C: A novel cutaneous vasculitis syndrome induced by levamisole- contaminated cocaine. Clin Rheumatol 30:1385-1392, 2011.

Cottencin O, Karila L, Lambert M, Arveiller C, Benyamina A, Boissonas A, Goudemand M, Reynaud M: Cannabis arteritis: review of the literature. J Addict Med 4:191-196, 2010.

Nahas GG: Cannabis arteritis. New Engl J Med 284:113, 1971.

Saha K, Chabra N, Gulati SM: Treatment of patients with thromboangiitis obliterans with cyclophosphamide. Angiology 52:399-407, 2001.

Zheng P, Fu PB, Wang WC, Xu WY, Tang XM, Ye M, Chen ZR: Immunological studies on thromboangiitis obliterans. Chinese Med J 102:129-136, 1989.


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