725 - Quadruple Limb Amputation after Bacteremia leading to Myonecrosis: A Case Report

Case Diagnosis:
Quadruple Limb Amputation after Bacteremia leading to Myonecrosis

Case Description: The patient is a 55-year-old female from the Republic of the Congo with a recent history of COVID-19, who presented to the emergency department with vomiting and altered mental status. Urine revealed gram-negative bacilli and metabolic acidosis, suggestive of septic shock. She developed large erythematous plaques with associated skin sloughing. Skin biopsies showed evidence of necrotic thrombi and imaging revealed myonecrosis, consistent with purpura fulminans (PF) and disseminated intravascular coagulation (DIC). After failure to respond to empiric antibiotics, she had bilateral trans-radial and below-the-knee amputations. She was referred for physiatry evaluation, where barriers affecting successful rehabilitation were assessed. Such factors included biomechanical limitations, visa restrictions, access to follow-up care, psychological recovery, and financial concerns. Arrangements were made for a pro-bono upper limb prosthesis for the left arm as it was her longest, most functional limb and would aid in her assisting with activities of daily living in any setting.

Discussions:
Quadruple limb amputation is a rare sequelae of PF and DIC. Patients recovering from traumatic amputations require extensive physiotherapy, psychological counseling, and years of follow-up with physiatry. This case highlights the socioeconomic barriers that affect access to rehabilitation and the unique disposition of patients having undergone quadruple limb amputation. Loss of all four limbs inhibits self-prothesis management and makes independent ambulation extremely difficult, such that patients may need motorized mobility, if appropriate.



Conclusions:
PF and DIC are severe complications of sepsis, which may lead to limb necrosis. COVID-19 may contribute to such sequelae as a consequence of vascular compromise. Early intervention and prevention of bacteremia is essential, as the resulting multiorgan dysfunction leads to high levels of morbidity, which affects functional capacity, self-esteem, and mortality.