Palabras clave
pielonefritis
isquemia
agentes vasoconstrictores
diabetes mellitus
gangrena
Categorías
Cómo citar
Resumen
Resumen
El shock séptico es una emergencia médica caracterizada por disfunción orgánica secundaria a una respuesta inflamatoria sistémica desregulada, que activa la coagulación y favorece trombosis. Una de sus complicaciones infrecuentes es la gangrena periférica simétrica (GPS), con necrosis acral sin oclusión arterial mayor [1,2]. Presentamos el caso de una mujer de 40 años con diabetes mellitus tipo 2 insulino-requiriente, retinopatía diabética, dislipidemia y consumo crónico de cocaína. Ingresó por pielonefritis aguda flegmonosa complicada con shock séptico urinario. Requirió manejo intensivo, ventilación mecánica, vasopresores en altas dosis y antibióticos. Evolucionó con necrosis simétrica distal en dedos de manos y pies, con pulsos conservados y sin estenosis arterial en imágenes. El enfoque fue multidisciplinario, incluyendo terapia antimicrobiana dirigida, soporte intensivo, rehabilitación y amputaciones digitales. Fue dada de alta con seguimiento. Este caso refleja cómo la combinación de sepsis, drogas vasoactivas y factores como diabetes y cocaína puede generar isquemia periférica grave. El reconocimiento precoz permite intervenir a tiempo y preservar la funcionalidad.
Abstract
Septic shock is a medical emergency marked by organ dysfunction due to a dysregulated inflammatory response that activates coagulation and promotes thrombosis. One rare complication is symmetrical peripheral gangrene (SPG), involving acral necrosis without major arterial occlusion[1,2]. We report a 40-year-old woman with insulin-dependent type 2 diabetes, diabetic retinopathy, dyslipidemia, and chronic cocaine use, admitted with phlegmonous pyelonephritis complicated by septic shock. She required ICU care, mechanical ventilation, vasopressors, and antibiotics. She developed symmetrical acral necrosis in hands and feet, with preserved distal pulses and no arterial stenosis. Multidisciplinary management included targeted antibiotics, intensive support, rehabilitation, and digital amputations. She was discharged with follow-up. This case illustrates the interaction between sepsis, vasopressors, and risk factors like diabetes and cocaine, stressing the need for early ischemia detection to prevent permanent damage.
Referencias
1. Guarino M, Perna B, Cesaro AE, Maritati M, Spampinato MD, Contini C, et al. 2023 Update on sepsis and septic shock in adult patients: Management in the emergency department. J Clin Med [Internet]. 2023 Abr 28;12(9):3188. Disponible en: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10179263/
2. Li J, Wang M, Sun T, Dong L, Huang S, Liu J. Symmetrical peripheral gangrene: Potential mechanisms and therapeutic approaches in severe COVID-19. Front Cardiovasc Med [Internet]. 2023;10:1280625. Disponible en: https://doi.org/10.3389/fcvm.2023.1280625
3. La Via L, Sangiorgio G, Stefani S, Marino A, Nunnari G, Cocuzza S, et al. The global burden of sepsis and septic shock. Epidemiologia (Basel) [Internet]. 2024;5(3):456–78. Disponible en: https://doi.org/10.3390/epidemiologia5030032
4. Alhumam T, Alhumam AA, Alhumaidi I, Al Rajeh I, Alduhailan Y. Relationship between symmetrical peripheral gangrene patients and using vasopressors in the intensive care unit. Cureus [Internet]. 2024;16(4):e58117. Disponible en: https://doi.org/10.7759/cureus.58117
5. Dubsky M, Veleba J, Sojakova D, Marhefkova N, Fejfarova V, Jude EB. Endothelial dysfunction in diabetes mellitus: New insights. Int J Mol Sci [Internet]. 2023 Ene 1;24(13):10705. Disponible en: https://doi.org/10.3390/ijms241310705
6. Lu Y, Wang W, Liu J, Xie M, Liu Q, Li S. Vascular complications of diabetes: A narrative review. Medicine (Baltimore) [Internet]. 2023 Oct 6;102(40):e35285. Disponible en: https://doi.org/10.1097/MD.0000000000035285
7. Rümenapf G, Abilmona N, Morbach S, Sigl M. Peripheral arterial disease and the diabetic foot syndrome: Neuropathy makes the difference! A narrative review. J Clin Med [Internet]. 2024 Abr 8;13(7):2141. Disponible en: https://doi.org/10.3390/jcm13072141
8. Sánchez-Puigdollers A, Just-Sarobé M, Pastor-Jané L. Cuadros cutáneo-mucosos asociados al consumo de cocaína. Actas Dermosifiliogr [Internet]. 2023 Feb;114(2):125-31. Disponible en: https://doi.org/10.1016/j.ad.2022.09.005
9. Gómez HL, Corrochano MA, Rodríguez RB. Peripheral symmetric gangrene in patients with SARS-CoV-2 infection. Angiología [Internet]. 2021 Ene;73(5):219-24. Disponible en: https://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S0003-31702021000500006
10. Chen X, Shao G, Zhao S, Li N. Symmetrical peripheral gangrene after cardiac surgery: A case report and review of literature. Medicine (Baltimore) [Internet]. 2025 Feb 14;104(7):e41527. Disponible en: https://doi.org/10.1097/MD.0000000000041527
11. Janotka M, Ostadal P. Biochemical markers for clinical monitoring of tissue perfusion. Mol Cell Biochem [Internet]. 2021;476(3):1313–26. Disponible en: https://doi.org/10.1007/s11010-020-04019-8
12. Chen Y, Liu K, Xu X, Wu G, Zhu L, Zha J, et al. Symmetrical peripheral gangrene caused by urosepsis: Case reports and literature review. Medicine (Baltimore) [Internet]. 2024 Oct 4;103(40):e39508. Disponible en: https://doi.org/10.1097/MD.0000000000039508
13. Warkentin TE, Ning S. Symmetrical peripheral gangrene in critical illness. Transfus Apher Sci [Internet]. 2021;60(2):103094. Disponible en: https://doi.org/10.1016/j.transci.2021.103094
14. Wang M, Sun T, Dong L, Huang S, Liu J. Symmetrical peripheral gangrene: Potential mechanisms and therapeutic approaches in severe COVID-19. Front Cardiovasc Med [Internet]. 2023;10:1280625. Disponible en: https://doi.org/10.3389/fcvm.2023.1280625
15. Deslivia MF, Kim DH, Lee SJ, Kim HJ, Kholinne E, Lee HJ. Identification of risk factors and clinical outcomes for symmetric peripheral gangrene: A new scoring system using a common data model database. J Orthop Surg (Hong Kong) [Internet]. 2024;32(2):10225536241276892. Disponible en: https://doi.org/10.1177/10225536241276892
16. Uncu Ulu B, Yiğenoğlu TN, Hacıbekiroğlu T, Sağlam DA, Kılınç A, İskender G, et al. Recovery of symmetrical peripheral gangrene of limbs in a patient after performing hemoadsorption in septic shock. J Clin Apher [Internet]. 2021;36(4):649–53. Disponible en: https://doi.org/10.1002/jca.21893
Esta obra está bajo una licencia internacional Creative Commons Atribución-CompartirIgual 4.0.
Derechos de autor 2025 Valentina Durán Q, Fabián Toro M, Martín Jerez A, Amanda Bravo M, Dr. Ricardo Pereira H