{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,26]],"date-time":"2025-10-26T15:01:28Z","timestamp":1761490888567,"version":"3.44.0"},"reference-count":17,"publisher":"BMJ","issue":"10","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Case Rep"],"accepted":{"date-parts":[[2019,9,27]]},"published-print":{"date-parts":[[2019,10]]},"abstract":"<jats:p>Peripheral limb ischaemia and gangrene are devastating complications of pneumococcal sepsis. We report a 43-year-old professional pianist who presented with early sepsis and rapid development of this syndrome. No vasopressor medication was ever administered. We urgently reviewed the medical literature on a range of therapies recommended by consulting teams, to ensure he received optimal care. Based on our review and on feedback from the patient himself, we gained valuable insights into this illness and the merits of selected treatment options. His fingers ultimately recovered their function, intact, although several toes were later amputated. More recently published reviews postulate that imbalances in coagulation factors and natural anticoagulants occur as a result of disseminated intravascular coagulopathy and \u2018shock liver\u2019 in the sepsis syndrome, leading to microcirculatory thromboses. We submit this report as we believe it supports this hypothesis and adds further valuable information. We hope our observations will assist other critical care clinicians confronting this serious condition.<\/jats:p>","DOI":"10.1136\/bcr-2019-229659","type":"journal-article","created":{"date-parts":[[2019,10,25]],"date-time":"2019-10-25T12:39:06Z","timestamp":1572007146000},"page":"e229659","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":2,"title":["Sepsis-induced digital ischaemia in a professional pianist, in the absence of vasopressors"],"prefix":"10.1136","volume":"12","author":[{"given":"Vishnu","family":"Kurup","sequence":"first","affiliation":[{"name":"Intensive Care, Barwon Health, Geelong, Victoria, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"R Scott","family":"Simpson","sequence":"additional","affiliation":[{"name":"Intensive Care, Barwon Health, Geelong, Victoria, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2019,10,25]]},"reference":[{"key":"2025082800232962000_12.10.e229659.1","unstructured":"Forrest J , McIntyre P , Burgess M , et al . Pneumococcal disease in Australia Health.gov.au, 2004. Available: http:\/\/health.gov.au\/internet\/main\/publishing.nsf\/content\/cda-pubs-cdi-2000-cdi2404-cdi2404a.htm"},{"key":"2025082800232962000_12.10.e229659.2","doi-asserted-by":"crossref","unstructured":"Toms C , de Kluyver R , Toms C , et al . Invasive pneumoccal disease in Australia 2011 and 2012 Health.gov.au, 2016. Available: http:\/\/www.health.gov.au\/internet\/main\/publishing.nsf\/content\/cda-cdi4002k.htm","DOI":"10.33321\/cdi.2016.40.22"},{"key":"2025082800232962000_12.10.e229659.3","doi-asserted-by":"publisher","DOI":"10.1016\/S0002-9610(05)80452-0"},{"key":"2025082800232962000_12.10.e229659.4","doi-asserted-by":"crossref","first-page":"642","DOI":"10.1056\/NEJMra1316259","article-title":"Ischemic limb gangrene with pulses","volume":"373","author":"Warkentin","year":"2015","journal-title":"N Engl J Med"},{"key":"2025082800232962000_12.10.e229659.5","doi-asserted-by":"crossref","first-page":"114","DOI":"10.1097\/00003246-199101000-00025","article-title":"Digital ischemia complicating pneumococcal sepsis: reversal with sympathetic blockade","volume":"19","author":"Johansen","year":"1991","journal-title":"Crit Care Med"},{"key":"2025082800232962000_12.10.e229659.6","doi-asserted-by":"crossref","first-page":"006","DOI":"10.1055\/s-0038-1676823","article-title":"Microvascular thrombosis and ischaemic limb losses in critically ill patients","volume":"39","author":"Warkentin","year":"2019","journal-title":"Hamostaseologie"},{"key":"2025082800232962000_12.10.e229659.7","doi-asserted-by":"publisher","DOI":"10.1097\/01.BCR.0000066789.79129.C2"},{"key":"2025082800232962000_12.10.e229659.8","doi-asserted-by":"crossref","first-page":"53","DOI":"10.3109\/23320885.2015.1041529","article-title":"Symmetrical peripheral gangrene caused by septic shock","volume":"2","author":"Shimbo","year":"2015","journal-title":"Case Reports Plast Surg Hand Surg"},{"key":"2025082800232962000_12.10.e229659.9","doi-asserted-by":"crossref","first-page":"61","DOI":"10.1097\/CPM.0000000000000253","article-title":"Symmetrical peripheral gangrene: mechanisms for limb loss in the ICU in patients with retained pulses","volume":"25","author":"Warkentin","year":"2018","journal-title":"Clinical Pulmonary Medicine"},{"key":"2025082800232962000_12.10.e229659.10","doi-asserted-by":"publisher","DOI":"10.1016\/S0887-8994(01)00255-7"},{"key":"2025082800232962000_12.10.e229659.11","doi-asserted-by":"publisher","DOI":"10.1136\/postgradmedj-2012-130989"},{"key":"2025082800232962000_12.10.e229659.12","doi-asserted-by":"publisher","DOI":"10.1007\/BF01694349"},{"key":"2025082800232962000_12.10.e229659.13","doi-asserted-by":"crossref","first-page":"619","DOI":"10.1177\/0310057X0403200502","article-title":"The role of microvascular thrombosis in sepsis","volume":"32","author":"Dixon","year":"2004","journal-title":"Anaesth Intensive Care"},{"key":"2025082800232962000_12.10.e229659.14","doi-asserted-by":"crossref","first-page":"879","DOI":"10.1056\/NEJMc1207074","article-title":"Acute hepatic necrosis and ischemic limb necrosis","volume":"367","author":"Siegal","year":"2012","journal-title":"N Engl J Med"},{"key":"2025082800232962000_12.10.e229659.15","doi-asserted-by":"crossref","unstructured":"Gotts JE , Matthay MA . Sepsis: pathophysiology and clinical management. BMJ 2016;353.doi:10.1136\/bmj.i1585","DOI":"10.1136\/bmj.i1585"},{"key":"2025082800232962000_12.10.e229659.16","unstructured":"Worthley LIG . Handbook of emergency laboratory tests. New York: Churchill Livingstone, 1996."},{"key":"2025082800232962000_12.10.e229659.17","doi-asserted-by":"crossref","first-page":"56","DOI":"10.1007\/s12630-015-0503-z","article-title":"Ultrasound-Guided bilateral stellate ganglion blockade to treat digital ischemia in a patient with sepsis: a case report","volume":"63","author":"Bataille","year":"2016","journal-title":"Can J Anesth\/J Can Anesth"}],"container-title":["BMJ Case Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bcr-2019-229659","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,8,28]],"date-time":"2025-08-28T07:23:38Z","timestamp":1756365818000},"score":1,"resource":{"primary":{"URL":"https:\/\/casereports.bmj.com\/lookup\/doi\/10.1136\/bcr-2019-229659"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2019,10]]},"references-count":17,"journal-issue":{"issue":"10","published-online":{"date-parts":[[2019,10,25]]},"published-print":{"date-parts":[[2019,10]]}},"alternative-id":["10.1136\/bcr-2019-229659"],"URL":"https:\/\/doi.org\/10.1136\/bcr-2019-229659","relation":{},"ISSN":["1757-790X"],"issn-type":[{"type":"electronic","value":"1757-790X"}],"subject":[],"published":{"date-parts":[[2019,10]]}}}