Symmetric gangrene of the legs revealing granulomatosis with polyangiitis leading to double transtibial amputation

Abstract

Antineutrophil Cytoplasmic Antibody (ANCA) vasculitis can cause serious complications, leading to bilateral amputations in a young  patient. This is a case of a 23-year-old black African patient with a case of previous pathological history. He was admitted to emergency surgery because of necrotic lesions on his feet extending down his legs. The symptoms progressed rapidly and extensively to necrosis  within three days. The patient also presented with epistaxis. Initially, local care was attempted, but the necrosis spread, reaching the  lower third of the legs. The clinical picture on admission showed almost normal vital signs, with the exception of tachycardia and severe  pain. Physical examination revealed limited necrosis from the feet to the middle third of the legs, with grey to black discolouration of the  skin. The lesions had a putrid odour, loss of cutaneous and muscular substance, and pedal pulses. Biological tests revealed an  inflammatory syndrome. Given this picture, urgent bilateral amputation of the legs was recommended to the patient, who also developed  mild reactive depression. Following amputation, the patient experienced worsening skin necrosis in other areas, leading to a  diagnosis of Granulomatosis with Polyangiitis (GPA) according to the ACR/EULAR 2022 criteria. Despite treatment, the patient suffered a  repetition and died of septic shock following cutaneous sepsis on readmission to emergency, two hours after admission.