Bilateral ascending dry gangrene following documented smear-positive malaria in a patient with multivalvular rheumatic heart disease and normal CT angiography findings: a case report
Tilahun Deresse, Herbert Butana, Theobald Hatangimana, David Cyubahiro, J.M.V. UkizentaburuweIntroduction:
Symmetrical peripheral gangrene (SPG) is a rare syndrome characterized by distal ischemic necrosis affecting two or more extremities in the absence of major arterial occlusion or vasculitis. Malaria is an uncommon but recognized trigger, most often described in association with severe
Case presentation:
A 57-year-old woman presented with rapidly progressive bilateral lower-limb pain, swelling, blistering, discoloration, and tissue necrosis shortly after treatment for smear-positive malaria at a rural health center. The health center record noted malaria parasites with trophozoites graded 3 +, after which she was treated with dihydroartemisinin-piperaquine. Three days later, she developed sudden, severe bilateral leg pain and swelling, followed by blistering and progressive distal discoloration. Laboratory evaluation showed leukocytosis (11.2 × 10 3 /µL; neutrophils 82.5%), anemia (hemoglobin 8.9 g/dL), a normal platelet count (156 × 10 3 /µL), preserved renal function (creatinine 48 µmol/L), mild hyperkalemia (5.47 mmol/L), and negative blood cultures. PT/PTT/INR and D-dimer were unavailable locally. Transthoracic echocardiography demonstrated multivalvular rheumatic heart disease with preserved left ventricular systolic function. CT angiography showed no major arterial occlusion. She was treated with intravenous furosemide, ceftriaxone, metronidazole, oral azithromycin, and subcutaneous enoxaparin, but because the gangrene was already advanced, she ultimately underwent bilateral below-knee amputations.
Discussion:
The chronology, the bilateral distal ischemic pattern, and normal CT angiography support malaria-associated SPG or microvascular ischemia as the most plausible unifying diagnosis. However, malaria is cautiously presented as the likely trigger because alternative contributors, including DIC, low-flow ischemia related to rheumatic heart disease, cardioembolic disease, vasculitis, hypercoagulable states, and delayed presentation, could not be completely excluded.
Conclusion:
This case highlights malaria-associated SPG as a rare but devastating cause of bilateral lower-limb gangrene. In malaria-endemic settings, new distal pain, discoloration, or gangrenous change after malaria should prompt urgent evaluation because delayed recognition may result in irreversible necrosis and major amputation.