Surgical Science, 2013, 4, 411-414
http://dx.doi.org/10.4236/ss.2013.410080 Published Online October 2013 (http://www.scirp.org/journal/ss)
HIV Quadruple Limb Gangrene: An Unusual Presentation
and Review of Literature
Edwin Omon Edomwonyi*, John Enekele Onuminya, Alfred Oghogho Ogbemudia,
Osita Chizoba Nwokike, Emeka Blessius Kesieme
Department of Orthopaedics and Traumatology, Irrua Specialist Teaching Hospital, Irrua, Nigeria
Received August 7, 2013; revised August 28, 2013; accepted September 3, 2013
Copyright © 2013 Edwin Omon Edomwonyi et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Vasculitis is one of the less common but important cons equence in patients with Hu man Immunodeficiency Virus (HIV)
infections and presentation with multiple limb gangrene is rare. We therefore report a novel case of quadruple limb
gangrene in a patient with HIV infection.
Keywords: HIV; Quadruple Limb Gangrene; Presentation; Amputation; Irrua
1. Introduction
Quadruple limb gangrene associated with HIV infection
is rare. The common aetiologies of gangrene of th e limbs
are trauma, diabetes mellitus and artherosclerosis [1].
However, systemic lupus erythematosus, progressive
sclerosis, henoch scholein syndrome, takayasu arteritis,
antineutrophil cystoplasmic antibody (ANCA) associated
vasculitis, gangrene associated with procoagulant states
due to malignancy, and anticardiolipin antibody syn-
drome are some important causes of gangrene of the ex-
tremities. Rare causes of gangrene include heparin in-
duced thrombocytopenia (HIT), hemolytic uremic syn-
drome (HUS) and Human immunodeficiency virus (HIV)
infection [2].
HIV infection is multisystemic, and cardiovascular
involvement is not an exception. It may present with ar-
terial occlusive disease, aneurismal disease, aortic dis-
section or AV fistula [2,3]. Vasculitis is one of the less
common but important consequences of HIV. Peripheral
arterial disease (PAD) is more prevalent in the HIV-
infected population than in the general population. Wide-
spread digital ischaemic changes and gangrene of the
hands and feet are uncommon in patients with HIV in-
fection [2-7]. A few cases of one or two limb gangrene
associated with HIV infection have been reported from
other centres [2-10]. The only reported case of quadruple
limb amputation reported in our environment was due to
trauma [1].
Quadruple gangrene of the extremities associated with
HIV infection is therefore reported to highlight the rare
complication and challenges. Relevant literature is also
reviewed.
2. Case Report
A 28-year-old southern lady presented wounds in both
upper and lower limb of two months duration via the
Accident and Emergency department of Irrua Specialist
Teaching Hospital, Irrua. She was in her usual state of
health until 6 months prior to presentation when she de-
veloped pepperish/tingling sensations on both upper and
lower limbs. She wasn’t a known hypertensive or dia-
betic. Subsequently, she noticed that the feet became
swollen and later ulcerated. She sought help in a native
herbal home where topical herbal preparation was ap-
plied on scarification marks. Three months later, darken-
ing of the toes was noticed which gradually spread to
both feet with loss of sensation. A month later, a similar
process repeated itself in both upper limbs following the
same chronology.
The husband was a long distant driver who abandoned
her in the course of the ailment claiming he does not un-
derstand the nature of the ailment. She never smoked
cigarette, ingest tobacco. No past history of suggestive of
coronary disease or stroke. On examination, we saw an
emanciated young lady in mild painful distress. She was
pale with bilateral inguinal lymphadenopathy. Nil axil-
lary lymph node enlargement. Vitals were within normal
range. She was hemodynamically stable. Abdomen and
*Corresponding a uthor.
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E. O. EDOMWONYI ET AL. 412
Respiratory systems were essentially normal.
Extremities were darkish in colour and withering of
both hands and feet. The clinical appearances of the
quadruple gangrene of the feet and hands are shown in
Figures 1((a)-(c)). Feet were almost severed at the ankle
joints exposing the ligament, tendons and bones with
offensive discharge. Sensory loss in both feet was up to
the distal third. Dorsalis pedis and posterior tibial arterial
pulsations were absent. Popliteal arterial pulsation felt
but faint.
(a)
(b)
(c)
Figure 1. Clinical appearances of the quadruple gangrene of
feet and hands: (a) Gangrene of the feet with autodisarticu-
lation at the ankle joints from a traditional surgeon’s home;
(b) Gangrene of the left hand; (c) Gangrene of the right
hand.
There was hyperpigmentation of both hands up to the
metacarpophalangeal joints , and the metacarpophanlangeal
joints were in fixed flexion deformity with sensory loss.
Radial arterial pulsation was present in both upper limbs.
RBS was 86 mg/dl, Pcv was 27%, total Wbc, 4600
c/mm3; Platelet, 397,000 c/mm3; Na 140 mmole/l, K 2.9
mmole/l, Cr 0.8, CD4 count was 324 cl/ul. While she
was being worked up for emergency surgery it was dis-
covered she was HIV positive.
Emergency bilateral BKA were done under GA. Two
weeks later bilateral BEA was done on both upper limbs.
Lower limbs wounds were discovered to be infected and
this was managed by regular povidone iodine wound
dressing and antibiotics. The medical team also assessed
her and commenced HAART, lamivudine, nevirapine,
zidovudine as well as hematinics.
Wound cleaned out and refashioning of stumps were
done at intervals and wounds healed satisfactorily. Post
operative period was largely uneventful. Majority of
other requested investigations (Doppler USS, lipids etc.)
were not done due to financial constraints. The Manage-
ment of the hospital wrote off the bill and was finally
discharged after 114 days on admission without prosthe-
ses owing to lack of fund.
3. Discussion
Peripheral vascular disease is a common indication for
amputation of patients in the developed world and the
rever se is the cas e in Nigeri a where tr aumas an d diabe tes
lead [1].
Peripheral artery disease is more prevalent in the HIV
infected population than in the general population and
there is a six fold increased risk for Peripheral artery
disease in the HIV infected individuals as well as an ear-
lier onset of the disease compared with HIV negative
patients [9].
Almost every pattern and type of vasculitis of small,
medium and large vessels has been encountered in HIV
setting [3]. Widespread digital ischemic changes and
gangrene of the hands and feet is one uncommon presen-
tation in patients with HIV infection [8], which makes
this case stand out.
HIV positive patients with vasculopathy are younger
with an average age of 40 yrs in comparison to 55 yrs in
patients with artherosclerotic disease [3]. This is in sup-
port of our case who was 28 yrs of age. HIV associated
vascular disease is a specific disease entity which differs
from artherosclerotic disease in many aspects. Risk fac-
tors for artherosclerosis like smoking, hypertension and
diabetes mellitus are lower in incidence among patients
with HIV than peripheral vascular disease. This patient
never sm oked. She was ne i ther hyp ertensive nor dia be t ic.
CD4 T cell count 200 cells/ul was found as a signifi-
cant predictor of peripheral artery disease in HIV [9]. As

E. O. EDOMWONYI ET AL. 413
shown in this case CD4 count of patients with HIV vas-
culopathy are less than normal in 90% and the CD4/CD8
ratio is usually reversed, indicated of advanced Immu-
nosuppression [3]. Infection, occlusive disease due to
hypercoagulable states, vasculitis is some of the mecha-
nisms suggested for gangrene of the extremities in HIV.
Psychiatric symptoms complicating amputation is not
out of place as noticed in our patient, the physical reality
of mutilation, bod y image changes and diagnos is of HIV
in a patient is strong enough stress.
Risk of HIV was obvious in this patient; the husband
being a long distance driver who even neglected the pa-
tient when she became ill. She was seriously handi-
capped financially. Hence, she was unable to do most
investigation and her bills had to be written off after sev-
eral weeks of neglect following discharge from hospital.
3.1. Etiology of Gangrene in HIV
Vasculitis, occlusive disease and infections, hypercoagu-
lable states. Deficiency of protein C and free protein S,
antiThrombin III. Anti phospholip id syndrome have been
implicated as mechanism. Antiretroviral medications
could lead to endothelial damage too.
3.2. Clinical Feature
1) Male preponderance for obscure reasons; 2) Rest pain
of the limbs from ischemia; 3) Intermittent claudication
Gangrene.
3.3. Diagnosis
HIV associated gangrene may be associated with a
known pathogen or trigger or may occur in the absence
of one. To determine this, either a serological test, stain-
ing of smears, light microscopy, culture, immunohisto-
chemistry testing and viral markers may be done de-
pending on the clin ical presentation.
Work up for protein C, S, antithro mbin III, antinuclear
antibodies, antiphospholipid antibodies. Ankle index
(AB1) testing would help to identify those with Periph-
eral vascular disease.
Doppler study of the vascular system is essential.
Spotting within the arterial wall test described as string
of pearl sign [3].
Diagnostic angiography would identify the location of
occlusive or aneurysm. Care should be taken to heparinize
these patients before the procedure because of the high
risk of thrombosis.
3.4. Management
HIV vasculopathy and gangrene represent an advanced
stage of the disease process. It is advisable to commence
HAART irrespective of the CD4 count.
Patients with unsalvageable limb should have primary
amputation. When limb is salvageable, treatment options
include endovascular procedure like thrombectomy,
thrombolysis or by-pass procedures. Limb salvage rate
has been in the region of 27% [3]. Widespread ischemic
necrosis and gangrene may require treatment with corti-
costeroids (in the event of vasculitis), thrombolytic
agents (for thrombotic component), or both. Vascular
surgical principles should be adhered to and management
should be individu alized. When patien ts present late with
gangrene as in the index case amputation is the option of
surgical treatment and in this case the morbidity was high.
The challenges were multiple in ev ery respect.
4. Conclusions
Quadruple limb gangrene associated with HIV infection
is a rare and novel report from Irrua. In the light of the
foregoing, this is a wakeup call for clinicians. Clinicians
should consider HIV as an important cause of limb gan-
grene and screen for presence of HIV antibodies while
evaluating a patient with non-traumatic limb gangrene.
Early detection and timely commencement of appro-
priate treatment may prevent vascular complication and
subsequent gangrene in asymptomatic patients.
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