INTRODUCTION

H1N1 influenza virus infection is a condition appreciated recently to present with a variety of respiratory symptoms, and most of the complications reported have been pertaining to the respiratory system mainly. However, it has the potential to cause a variety of complications involving different systems of the body.

Symmetrical peripheral gangrene (SPG) is defined as symmetrical distal ischemic damage of two or more sites in the absence of large vessel obstruction. Although it accompanies decreased flow states, such as cardiogenic and hypovolemic shock and various infectious diseases involving bacterial viral pathogens, this is a rare case where the H1N1 infection was associated with SPG.

CASE REPORT

A middle-aged woman presented to casualty with h/o fever since 7 days and bluish discoloration of fingers and palms since 5 days. She had h/o rashes over the hands and legs for 4 days and h/o loose stools four to five episodes for 2 days, 4 days back. On examination, she was febrile with tachycardia (HR – 110/min), and tachypnoea (RR – 28/min) and was in hypotension (BP – 90/60 mmHg). JVP was normal; ecchymotic rashes were present on the forearms up to the elbow and on the legs up to the knee – greenish to purple colored nonblanching. Systemic examination revealed no abnormalities.

Day 2

The patient developed breathlessness that was associated with bilateral basal crepitations and progressive hypoxia. Meanwhile, the bluish discoloration of tips of fingers increased [Figures 1 and 2]. Chest X-ray taken showed a Acute Respiratory Distress Syndrome-like picture.

[Figure ID: F1] Figure 1. Evolving initial ischemic lesions in upper limbs -day 2

[Figure ID: F2] Figure 2. Initial ischemic skin lesions in lower limbs -day 2

The platelet count further dropped to 13,000. Keeping dengue hemorrhagic fever/ARDS due to H1N1 as the tentative diagnosis tab. Oseltamivir 75 mg bid was started and was given for 5 days. A throat swab was sent for H1N1 analysis.

Day 3

Fever reduced and tachycardia decreased. Gangrenous changes progressed with middle and fourth fingers of her right hand frankly turning into dry gangrene. Skin rashes progressed till mid-forearm and in legs up to knee. Over next few days, she was afebrile, but breathlessness persisted and she had extensive crepts over bilateral lung fields. In addition, blackish discoloration increased in intensity and also the rashes which rose up to groin with hands and legs turning edematous. A color Doppler study of peripheral arterial and venous system showed no evidence of large vessel obstruction. Keeping diagnosis of possible vasculitic crisis in mind, the patient was also administered inj. methylprednisolone. Meanwhile, blood culture sent on the first day before initiation of antibiotics showed no growth.

She responded well to steroids and by seventh day, her breathlessness reduced and completely disappeared by eighth day. Skin lesions also improved as evidenced by her decreased edema of hands and legs and progression of the lesions halted. In the meanwhile, the throat swab for H1N1 was positive. At around tenth day, respiratory symptoms completely subsided and the gangrenous changes became restricted to both the hands distal-to-proximal interphalangeal joints [Figures 3 and 4]. A surgical opinion was taken for the same, and she was advised amputation of the upper extremity digits. However, the patient was not willing for surgery and was lost for follow-up next 2 months. By that time, total dry gangrene of the hands distal-to-PIPs had developed [Figures 5 and 6]. This time she was willing for the amputation, and the procedure was performed.

[Figure ID: F3] Figure 3. Gangrenous finger tips –day 10

[Figure ID: F4] Figure 4. Resolving lower limb lesions –day 10

[Figure ID: F5] Figure 5. Dry gangrene of fingers -2 months later

[Figure ID: F6] Figure 6. Dry gangrene of fingers -2 months later

DISCUSSION