Limb gangrene: What is the best initial approach? A problem with serious controversy among rheumatologists

Critical ischemia of any organ is potentially the most devastating condition threatening all living organs. Gangrene or necrosis of organs is a common problem in routine clinical practice that mostly directed initially to surgical departments due to emergent nature of condition in nearly all cases with one exception of myocardial ischemia or infarction. Basic mechanism for non-traumatic vascular compromise is rather similar in nearly all organs however interestingly clinical approach is highly different in diverse clinical settings. Rather a thorough medical approach is as critical as debridement and revascularization techniques in order to diagnose and treat ongoing underlying pathologies. In this report we analyzed all different approaches of several rheumatologists in a real case scenario of unilateral foot gangrene. In this study, using e-mail questionnaire contacts, we sent the medical history of our patient with unilateral foot gangrene together with predesigned short questions and asked the opinions of 50 experienced rheumatologists from several parts of the world regarding initial management plan to handle the case. The responses were collected and analyzed. Twenty-six physicians (52%) responded of whom 22 (84%) suggested administration of heparin. Thrombolytic therapy was recommended by 3 (11.5%). There were many diverse ideas about starting intravenous (IV) steroid pulse: 15 (57.6%) recommended steroid pulse and 7 (27%) discouraged it. Two rheumatologists believed that this case is actually a surgical case and should not be handled in rheumatology service. We concluded that there is a serious controversy among rheumatologists regarding the management of patients with acute limb ischemia. Also, we suggest that in all uncertain vascular compromise, considering early institution of anti-inflammatory, anti-thrombotic therapies along with vasodilators could be a rational initial approach until further information is obtained from tissue biopsy and full panel laboratory investigation.