What are the causes of bilateral dry gangrene in a pediatric patient?

Causes of Bilateral Dry Gangrene in Pediatric Patients

Bilateral dry gangrene in pediatric patients is most commonly caused by severe hypernatremic dehydration leading to hypoperfusion, hyperviscosity, and disseminated intravascular coagulation (DIC), particularly in neonates with inadequate breastfeeding. 1, 2

Primary Etiologies

Hypernatremic Dehydration with DIC

• Severe fluid loss with hypernatremia is the leading cause of bilateral limb gangrene in children, resulting in hypoperfusion, sluggish blood flow from hyperviscosity, and disturbed microcirculation 1, 2, 3
• This mechanism can affect multiple extremities simultaneously, with documented cases showing gangrene of all four limbs, nasal tissue, ear lobes, and digits 1, 2
• The pathophysiology involves peripheral thrombosis secondary to hypotension, hypoperfusion, hypernatremia, and metabolic acidosis 2
• Neonates are particularly vulnerable due to inadequate breastfeeding, with weight loss exceeding 30% of birth weight reported in severe cases 1

Sepsis-Related Causes

Pseudomonas aeruginosa sepsis can cause ecthyma gangrenosum with bilateral necrotic lesions, even in previously healthy children 4

• This presents as cutaneous vasculitis with bacterial invasion of vessel walls, causing dermal necrosis 5
• While classically associated with immunocompromised patients, it can occur in immunocompetent pediatric patients 4

Gram-negative sepsis in neutropenic patients causes bilateral skin manifestations through hematogenous dissemination 5

• Organisms include Pseudomonas, Aeromonas, Serratia, and E. coli 5

Necrotizing Infections

Clostridial sepsis (C. septicum) can cause spontaneous gangrene in patients with neutropenia or gastrointestinal malignancy through hematogenous spread 5

• Develops in normal skin without trauma, progressing rapidly over 24 hours 5

Polymicrobial necrotizing fasciitis may occur in patients with diabetes mellitus, peripheral vascular disease, or following surgery 5

Secondary Contributing Factors

Metabolic and Systemic Conditions

• Diabetes mellitus is a major comorbidity in pediatric patients with extremity ischemia 6
• Renal failure significantly increases risk of peripheral gangrene 6
• Maternal diabetes in neonates predisposes to gangrene 1

Iatrogenic Causes

• Herbal enemas causing severe fluid loss, hypotension, and metabolic derangement have been documented in multiple cases 2
• Inadequate fluid resuscitation in dehydrated states 2

Infectious Endocarditis

• Bacterial endocarditis can cause peripheral embolic phenomena, though this typically presents with other cardiac manifestations 5
• Staphylococcus aureus, coagulase-negative staphylococci, and Candida species are common in neonates with indwelling catheters 5

Critical Diagnostic Considerations

When evaluating bilateral dry gangrene in pediatric patients, immediately assess for:

• Severe dehydration markers: weight loss >20-30%, hypernatremia (>150 mEq/L), elevated creatinine, tachycardia, hypothermia 1
• DIC parameters: pancytopenia, elevated PT/PTT, thrombocytopenia 1
• Sepsis indicators: positive blood cultures, fever or hypothermia, hemodynamic instability 4
• Vascular assessment: absent peripheral pulses, no arterial flow on Doppler studies 1

The association of peripheral gangrene with hypernatremic dehydration may be more frequent than previously recognized, and clinicians should maintain high suspicion in neonates with poor feeding and weight loss 3.