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Multiple toxicities: 2 case report In a case series, a 45-year-old woman and a 38-year-old woman were described, who developed symmetric peripheral gangrene secondary to haemodynamic shock with disseminated intravascular coagulation and thrombocytopenia with depletion of natural anticoagulant following treatment with albumin-human or immune-globulin [indications not stated; not all dosages and outcomes stated]. Case 1: A 45-year-old woman developed symmetric peripheral gangrene secondary to septic shock with disseminated intravascular coagulation, thrombocytopenia and natural anticoagulant depletion following the administration of albumin-human and immune-globulin. The woman was hospitalised with culture-negative septicaemia and acute kidney injury. She met the criteria for disseminated intravascular coagulation with severe thrombocytopenia. Laboratory tests showed peak INR of 1.7, fibrin d-dimer >20 µg/mL and slightly elevated ALT levels. Subsequently, she developed bilateral ischaemic limb injury involving both the hands and feet. Additionally, severe depletion of three natural anticoagulants (antithrombin, protein S, and protein C) was noted. It was noted that, she developed ischaemic limb injury shortly after the administration of a high dose of IV immune globulin 700mL. Anamnesis also showed that she had received six IV infusions of albumin-human [albumin] during the 36 hours preceding the onset of limb injury. Eventually, she recovered from septicaemia. However, she required partial amputation of the thumb and three fingers of her right hand. Case 2: A 38-year-old woman developed symmetric peripheral gangrene secondary to septic shock with disseminated intravascular coagulation, thrombocytopenia and natural anticoagulant depletion following treatment with albumin-human. The woman was hospitalised with influenza-B associated pneumonia, which had progressed to haemodynamic shock, respiratory and renal failure. She met the criteria for disseminated intravascular coagulation with severe thrombocytopenia. Laboratory tests showed INR of 2.4, fibrin d-dimer of 13 µg/mL, high albumin levels and slightly elevated ALT level. Subsequently, she developed ischaemic limb injury followed by a documented severe depletion of three natural anticoagulants (antithrombin, protein S, and protein C). It was noted that the ischaemic limb injury involving both feet developed after she received three IV infusions of albuminhuman [albumin] during the 16 hours preceding the onset of limb injury. Thereafter, she was noted with multiple areas of toe necrosis. Eventually, on day 21 of admission, she died [immediate cause of death not stated]. Warkentin TE, et al. Colloid Transfusion, Natural Anticoagulant Depletion, and Symmetric Peripheral Gangrene. New England Journal of Medicine 383: 1592-1594, No. 16, 803518926 15 Oct 2020. Available from: URL: http://doi.org/10.1056/NEJMc2021690

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Reactions 5 Dec 2020 No. 1833