Extremity amputation: disseminated intravascular coagulation syndrome

There are occasional reports in medical literature of peripheral gangrene and subsequent extremity amputation following systemic infection. Although the authors of these case reports speculated that the gangrene was due to septic embolization, pathologic study of the amputated tissue failed to reveal evidence of septic emboli. In reviewing reports of amputation following scarlet fever, varicella, pneumococcemia, and appendicitis, we found cases with clinical, hematologic, and pathologic evidence of disseminated intravascular coagulation (DIC). We describe 2 patients who required extremity amputation following an acute, systemic infection: transmetatarsal and Lisfranc amputation following meningococcal meningitis and bilateral below-knee amputation following pneumococcal meningitis. Both of these patients had clinical, hematologic, and pathologic evidence of DIC. Following amputation, both of these patients had significant problems with skin healing and prosthetic fitting. The presence of an acute systemic bacterial or viral infection, coagulation abnormalities and pathologic tissue indicative of DIC, and skin lesions of the extremities progressing to dry gangrene and ultimately requiring bilateral amputation are the key clinical features of this syndrome. We conclude that DIC is a major pathophysiologic mechanism responsible for peripheral gangrene following systemic infection.