Dermatology: Practical and Conceptual 220 Letter | Dermatol Pract Concept 2019;9(3):12 Dermatology Practical & Conceptual Introduction Symmetrical peripheral gangrene (SPG) is a rare but severe complication of disseminated intravascular coagulation (DIC) characterized by symmetrical distal ischemic damage that leads to gangrene at 2 or more sites [1]. It occurs in the absence of large blood vessel obstruction, with vasoconstric- tion rather than thrombosis being implicated as the under- lying pathophysiology. DIC arising from sepsis results in uncontrolled activation of the coagulation pathway, and the use of vasopressors simultaneously involves the creation of spasms that affect the vessels; these spasms aggravate micro- circulation problems which result in gangrene [2]. Case Presentation A 64-year-old man with no known comorbidities presented to the emergency department with fever, acute-onset right abdominal pain, and decreased urine output for the preceding 3 days. He had a fever (38°C), tachycardia (102 beats/min- ute), tachypnea (29 breaths/minute), hypotension (88/56 mm Hg), and epigastric tenderness. Ultrasound of the abdomen revealed choledocholithiasis. Cholangitis was diagnosed. The patient was started on parenteral antibiotics and inotropic agents, and percutaneous transhepatic biliary drainage was performed. However, his condition continued to deteriorate and purpuric lesions developed on the skin. On examination he had SPG of the fingers (Figure 1A) along with retiform purpura on the feet (Figure 1B). Hematological examination revealed thrombocytopenia (14,000 cells/mm3), raised prothrombin time (patient: 17 seconds, control: 13 seconds) and elevated d-dimer level (>0.5). Blood cultures were obtained and were positive for Acinetobacter. The diagnosis of sepsis-induced DIC with SPG and purpura fulminans was established. The patient was managed in the intensive care unit with antibiotics, blood components, and inotropes, but he succumbed to his condi- tion in the next 4 days. Symmetrical Peripheral Gangrene Due to Disseminated Intravascular Coagulation Sweta Subhadarshani1, Manik Aggarwal1, Vinod Kumar2 1 Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India 2 Department of Medicine, All India Institute of Medical Sciences, New Delhi, India Key words: symmetrical peripheral gangrene, disseminated intravascular coagulation, sepsis, cholangitis, digital ischemia Citation: Subhadarshani S, Aggarwal M, Kumar V. Symmetrical peripheral gangrene due to disseminated intravascular coagulation. Dermatol Pract Concept. 2019;9(3):220-221. DOI: https://doi.org/10.5826/dpc.0903a12 Accepted: February 17, 2019; Published: July 31, 2019 Copyright: ©2019 Subhadarshani et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: None. Competing interests: The authors have no conflicts of interest to disclose. Authorship statement: All authors have contributed significantly to this publication. Corresponding author: Sweta Subhadarshani, MD, MRCP(SCE), Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India. Email: shweta.aiims07@gmail.com Letter | Dermatol Pract Concept 2019;9(3):12 221 References 1. Davis MDP, Dy KM, Nelson S. Presentation and outcome of pur- pura fulminans associated with peripheral gangrene in 12 patients at Mayo Clinic. J Am Acad Dermatol. 2007;57(6):944-956. 2. Joynt G, Doedens L, Lipman J, Bothma P. High-dose adrenaline with low systemic vascular resistance and symmetrical peripheral gangrene. S Afr J Surg. 1996;34(2):99-101. Conclusions SPG carries very high mortality rates and is almost always associated with DIC. In a brief review of the literature we did not find any cases of SPG occurring in a setting of cholangitis with Acinetobacter. Figure 1. (A) SPG of fingers. (B) Purpura over the patient’s leg in a reticular pattern. [Copyright: ©2019 Subhadarshani et al.] A B