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Case Reports

Indian Pediatrics 2005; 42:1156-1158 

Neonatal Lower Extremity Gangrene


Paras R. Kothari
Arun Gupta
Bharati Kulkarni

From the Department of Pediatric Surgery, LTMMG and General Hospital, Sion, Mumbai 400 002, India.

Correspondence to: Dr Paras R Kothari, Lecturer, Department of Pediatric Surgery, L.T.M. Medical College and General Hospital, Sion, Mumbai 400 022, India.
E-Mail : [email protected]

Manuscript received: September 23, 2004; Initial review completed: October 18, 2006;
Revision accepted: June 6, 2005.

Abstract:

Four neonates suffering from bilateral lower limb gangrene were referred to us for further management. Two neonates had no contributory etiology. All four received appropriate treatment thus avoiding mortality but morbidity could not be avoided. All four neonates recovered uneventfully.

Key words: Gangrene, Lower Extremity, Neonate.

Bilateral lower limb gangrene in neonates is a rare event of obscure etiology. It generally has a poor outcome. Early diagnosis and properly timed intervention may help in some cases where the etiology is known. Idiopathic gangrene with delayed treatment poses a challenge to Paediatric surgeons, as it is associated with increased morbidity and mortality.

Case Report

Table I details the clinical presentation, investigations, treatment, and outcome in four neonates with gangrene of both lower limbs.
 

Table I

 Clinical Profile of Neonatal Gangrenes.

Patient 1 Patient 2 Patient 3 Patient 4
Antenatal history
Uneventful
Uneventful
Uneventful
Uneventful
Mode of delivery
FTND
FTND
Low birth wt.
FTND
Day of presentation/ Sex
Day 1/M
Day 3/M
Day 5/F
Day 26/M
Predisposing factors
Exchange 
transfusion
None
Exchange  
transfusion
None
Gangrene onset
Day 3
Day 3
Day 4
Day 20 
Hyperthermia 
Present 
Present
Present
Present
Anemia
Present
Present
Present
Present
Loss of soft tissue
Absent 
Absent
Absent
Present (Fig. 1)
Line of demarcation
Absent
Absent
Absent
Present
Hemoglobin (g/dL)
10
11.4
10.8
8.1
Total WBC counts 
20700
18700
15800
26700
C-reactive protein 
Raised
Raised
Raised
Raised
Blood culture
Staph. aureus
No growth
Staph. aureus
No growth
X rays of lower limbs
No bony 
abnormality
No bony 
abnormality
No bony 
abnormality
No bony 
abnormality
Doppler studies

Absent blood 
flow beyond 
popliteal artery
Absent blood
flow beyond
popliteal artery
Absent blood
flow beyond
popliteal artery
Initial Management 



Blood 
transfusion
Flow enhancers
Antibiotics
Dressings 
Blood 
transfusion
Flow enhancers
Antibiotics
Dressings
Blood 
transfusion
Flow enhancers
Antibiotics
Dressings
Blood 
transfusion
Flow enhancers
Antibiotics
Dressings
Progression to gangrene 
Present
Present
Present
 
 
Definitive management 
Amputation
Amputation
Amputation
Amputation
Postoperative recovery
Smooth 
Smooth
Smooth
Smooth

 

Fig. 1. Photograph showing neonate with loss of soft tissue of both lower limbs with exposed bones.

Mothers of all these babies had received immunization at proper time. Antenatal sonography although done in later stages of pregnancies in all the mothers had revealed no abnormalities. None of the mothers were diabetic nor anyone had prolonged labour.

Three neonates were initially managed by giving intravenous antibiotics, flow enhancers, (heparin, vasodilators, lomodex, hyper baric oxygen, etc.) blood transfusions and regular dressings. Wounds were regularly cleansed by hydrogen peroxide. Eusol and salutyl ointment were used as slough removers. Local ointments like betadine and soframycin were used for regular dressings. Dry dressing was applied over gangrenous area. Inspite of conservative management for two weeks, ischemia progressed to form gangrene; line of demarcation appeared so formal amputations were done. Neonate with exposed bones was operated upon immediately; as to cover them with flaps was impossible. All four neonates had a smooth post-operative recovery.

Discussion

Bilateral idiopathic lower limb gangrene in neonates is extremely rare and very few cases have been recorded. Predisposing factors include prematurity hyper-coagulable state, umbilical artery cannulation, arterial thrombosis, intravenous hyperosmolar infusions, sepsis, thermal abnormality, in utero arterial thrombosis and maternal diabetes(1-3).

Abnormal fetal presentation can cause ischemia due to direct compression of an extremity in utero(1). Arterial occlusion due to normal obliteration of ductus arteriosus or umbilical arteries can lead to high incidence of gangrene in lower extremities(4). However, review of the available literature reveals that upper limb gangrene is more frequent as compared to lower limbs(1-5).

Management includes giving medications (systemic and local) and supportive care like heparin, vasodilators, lomodex, hyperbaric oxygen, sympathectomy, preventing trauma and sepsis(1, 2). Early surgical intervention is indicated in presence of severe or progressive ischemic changes. More often there has been progression to spontaneous slough or autoamputation(3). Amputation was done following appearance of demarcation line. Care was taken to preserve the growing epiphyseal end so as to achieve a good stump length for prosthetic fitting in the later age. A high index of suspicion and timely treatment is highly decisive in treating septicemia in neonates(5).
 

 References


1. Giannakopoulou C, Korakaki E, Hatzidaki E, Manoura A, Aligizakis A, Velivasakis E. Peroneal nerve palsy: a complication of umbilical artery catheterization in the full-term newborn of a mother with diabetes. Pediatrics. 2002; 109: e66.

2. Long DK, Lorant DE. Multiple arterial thrombi and in utero leg gangrene in an infant of a diabetic mother. J Perinatol 2002; 22: 424-427.

3. Ibrahim H, Krouskop R, Jeroudi M, McCulloch C, Parupia H, Dhanireddy R. Venous gangrene of lower extremities and Staphylococcus aureus sepsis. J Perinatol 2001 21: 136-140.

4. Henry W, Johnson BB, Petersen AL. Left common iliac arterial embolectomy in the newborn. Western J Surg 1960; 68: 352.

5. Okoko BJ, Ota MO, Arowolo JO, Whittle HC. Peripheral gangrene complicating Salmonella typhi septicemia in a Gambian infant. J Trop Pediatr 2001; 47(4): 250-251.

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