We present the case of a 17-year-old boy who was admitted to the medical ward of MBGH, RNT Medical College, Udaipur with complaints of fever with chills and rigor for 6 days. Patient noticed blackening of his toes and lower limbs on the third day of fever which was associated with pain and numbness. There was no history of trauma, any drug ingestion, alcohol use, and smoking. Examination revealed pulse 110 beats/min, regular, bounding, with all peripheral pulses felt normally, blood pressure - 100/40 mmHg in right brachial artery, temperature of 101.4°F, respiratory rate - 22 breaths/min. On examination, patient was found to have severe pallor, mild icterus, and blackening of third, fourth, and fifth toe of right foot and fifth toe of left foot with circumferentially patchy area of blackening of bilateral lower legs up to mid-shin [Figures and ]. Overlying skin was dry and wrinkled. Per abdominal examination revealed firm splenomegaly 2 cm below costal margin. Neurological examination revealed decreased sensations over hyper-pigmented area. Cardiovascular system examination revealed a soft functional ejection systolic murmur present at pulmonary area heard all over the precordium. Respiratory system examination was unremarkable. Provisional diagnosis of septicemia with SPG was kept and patient was investigated.\nBlood investigation revealed hemoglobin (Hb) 1.1 g%, total leucocytes count (TLC) 1000 cells/mm3, with 55% polymorphs and 40% lymphocytes, platelets 10,000/mm3 with normocytic normochromic picture on peripheral blood film (PBF) with no immature cells and no parasite was seen. Renal and liver functions tests were normal. Malarial parasite quantitative buffy coat was negative but rapid diagnostic kit for P. falciparum was positive. Anti-nuclear antibody, rheumatoid factor, C-reactive protein, human immunodeficiency virus, hepatitis B surface antigen, anti-hepatitis C virus were negative. Prothrombin time-international normalized ratio (PT-INR) was 18 and 1.41 (control 13). Bleeding time, clotting time were normal. Chest X-ray was normal. Ultrasonography of abdomen revealed gall bladder sludge and mild splenomegaly. Blood culture did not show growth of any pathogenic organism. Color Doppler of both lower limbs showed normal caliber, flow and Doppler indices of bilateral femoral, popliteal, anterior and posterior tibial arteries [].\nDiagnosis of complicated P. falciparum malaria with disseminated intravascular coagulation (DIC) with SPG was kept and patient was treated with injection quinine 600 mg intravenous (IV) 12 hourly slow infusion in 10% Glucose Distilled Water, tablet doxycycline 100 mg twice daily, injection ceftriaxone 1 g IV 12 hourly and with supportive three units of packed cell volume and six units of platelets. After a consultation from cardiothoracic vascular surgeon patient was started on low dose heparin infusion for SPG but patient developed epistaxis soon after starting the infusion, so infusion was stopped and managed conservatively. Patient had an uneventful recovery and discharged from hospital after 10 days. On discharge patient's vitals were normal, Hb - 6 g%, PBF showed normocytic normochromic anemia with occasional macrocytes, TLC - 11,000 cells/mm3, platelets - 1.8 lac/mm3, PT-INR - 15 and 1.19.
A 54 years old male Ugandan presented to Kenyatta National Hospital, a major referral tertiary hospital, in Kenya. He had initially reported with headache and joint pain to a local health facility in Uganda and was diagnosed to have severe Plasmodium falciparum malaria infection, and thereafter treatment with intravenous quinine commenced.\nTreatment at the facility had been responsive; however two days after the onset, the patient started experiencing episodes of headache, pain, numbness, coldness, and swelling of the extremities. This was followed by darkening of the digits of his toes and hands, which gradually progressed proximally.\nOn presentation at out institution, he was conscious, alert, oriented, but lethargic and unable to walk. He was a non-smoker and non-alcoholic, and had no history of diabetes, hypertension or any angiopathies. He however had a history of numerous episodes of malaria bouts and a family history of hypertension with his father having succumbed to a stroke.\nOn physical examination, apart from fever, abdominal, cardiovascular, respiratory, and neurological systems were normal. Jaundice, pallor and cyanosis were absent. A right low paramedian scar was noted secondary to appendicectomy conducted in the year 1995. On local examination, the overlying skin cold, dry, wrinkled, and was darkened with a clear line of proximal demarcation (). Pain was present in the regions proximal to the discolouration, and absent in the distal regions.\nInvestigations tested negative for HIV, HBV, HCV, and VDRL on ELISA. Urea, Electrolyte and creatinine tests were normal. Clotting profile showed a prolonged Prothrombin time of 19sec, Prothrombin time index of 74%, and an INR of 1.36. A haemogram showed macrocytic normochromic anaemia (Hb 9.03 g/dL, MCV 89.9fL, MCH 29.5pg, MCHC 27.2g/dL), Hct 33.2%, RBC 3.69x1012/L. WBC 4.39x109, Neutrophils 2.11x109 (48.2%), Lymphocytes 1.73x109 (39.5%), Monocytes 0.314x109 (7.16%), Eosinophils 0.193x109 (4.4%), Basophils 0.035x109 (0.796%).\nAn echocardiogram was normal except for type 1 left ventricular dysfunction and mild tricuspid regurgitation. The Dorsalis pedis pulses showed absence of blood flow, and a diagnosis of Symmetrical peripheral gangrene was made. Management was initiated with clopidogrel, Acetylsalicylic Acid, and Atorvastatin, and quad-amputation recommended. Time was allowed for marginalization of the gangrene, which was noted two months later. Meanwhile fresh frozen plasma was regularly administered to counter suspected thrombophilia.\nFollowing satisfactory marginalization of the gangrene, the patient underwent surgical excision of the necrotic tissue. This involved transmetatarsal amputation of both feet and ray amputation of the hands. The wounds healed well thereafter facilitated by vacuum dressing at -7.5mmHg over one month. He was then referred to plastic surgeons for prosthesis.