Symmetrical peripheral gangrene associated with peripartum cardiomyopathy
Thirty-year-old, para 4, seven days post-partum with unbooked pregnancy, home conducted delivery with alive infant was admitted with chief complaints of progressive dyspnoea for 4 days, orthopnea for 1 day, cough with pink frothy sputum, decreased urine output, and swelling feet for 1 day. There was no history of chest pain, palpitation, and fever. There were no neurological complaints. Lochia, urinary, and bowel habits were normal. At admission, patient was afebrile, had blood pressure of 96/60 mm of Hg, pulse rate of 102/min, and respiratory rate was 28/min. Jugular venous pressure was raised up to 6 cm above angle of Louis. Pedal edema was present. There was bluish discoloration of fingers of both hands. Beside this dorsal aspect of bilateral feet showed edema, lividity, and cyanotic hue on plantar aspect. Bilateral toes showed symmetrical gangrenous changes with eschar formation [Figures -]. All peripheral pulses were palpable, regular, and of normal volume. On systemic examination, there were bilateral basal crepitations in chest, tender hepatomegaly, and S3 gallop. Investigations revealed hemoglobin 9.8 g% and total leukocyte count 15,600/cumm. Peripheral blood smear revealed normocytic hypochromic picture with neutrophilia and shift to left. Biochemistry revealed following parameters: Random blood glucose-110 mg%, total bilirubin-1 mg%, SGOT-110 IU/L, SGPT-102 IU/L, alkaline phosphatase-90 IU/L, albumin-3.0 g%, urea-120 mg%, creatinine-1.5mg%, uric acid-3.6 mg%, calcium-9 mg%, and phosphorous-4.6 mg%. Electrolytes, lipid profile, and coagulogram were normal. Urine showed albumin 1+ on dipstick and was negative for pus cells, red blood cells cast, active sediment. Urine and blood cultures were sterile. HBsAg, anti-HCVIgG, VDRL, ELISA for HIV, and antinuclear antibody were negative. Chest X-ray revealed bat wing appearance with cardiomegaly. Electrocardiogram showed sinus tachycardia. 2D echocardiogram revealed global hypokinesia with left ventricular ejection fraction (LVEF) of 40%. Doppler study for upper and lower limb arteries was normal. After examination and investigation, clinical possibility of PPCM with SPG was kept. Patient was treated with back rest, oxygen inhalation, enoxaparin (low molecular weight heparin), aspirin, diuretics, and low dose angiotensin-converting enzyme (ACE) inhibitors. After 5 days of in hospital treatment, patient's blood pressure normalized to 110/80 mm of Hg. Pedal edema and raised jugular venous pressure resolved. Over next few days, patient's renal function test and liver function test were normalized, gangrenous changes in fingers improved, and dry gangrene became confined to bilateral toes. Patient was ambulatory at discharge, normotensive, and advised follow up in general surgery for management of dry gangrene of toes. On follow up at 4 weeks, 2D echo showed LVEF of 52% and bilateral toes were dry, shriveled with features of auto amputation.