Symmetrical peripheral gangrene (SPG) is a rare disorder leading to ischemic necrosis of extremities. We present a rare case of idiopathic SPG in a 67-year-old male who admitted for left upper limb necrotizing fasciitis, with septic shock and disseminated intravascular coagulation (DIC) secondary to necrotizing fasciitis, over left upper limb was admitted to the intensive care unit. The blood pressure was 70/40 mmHg.

On admission, hemogram showed Total count of 24,000 platelet 1.75 lakh, creatine of 3.2 mg/dl, CRP 72, Procalcitonin >200, ABG showed, metabolic acidosis with a pH of 7.3 Hco3 10 co2 19.9 lactate 7.20. Random blood sugar was less than 120mg/dl Blood and urine culture showed no growth. The patient was treated with empirical antibiotics Colistin, targocid and Meropenem, and fluconazole. Other supportive measures given included vasoactive agents, norepinephrine, and dopamine for nearly 90 hours. Three days after admission, all digits in the four extremities exhibited progressive pallor. On the third day patient underwent debridement of the left upper limb. However, tissue culture of the left upper limb reported significant growth of E-Coli. Patient had constant hypoglycaemia for few hours, despite the treatment with 25 % Dextrose, thereafter, varying of sugar level, patient had severe anaemia transfused with 3unit of PRBC. However right upper limb distal digit unto DIP was gangrened over, and both lower limbs were discoloured, although spared from gangrene due to early intervention. We suspected the gangrene was secondary to vasoactive agents. 

With continued supportive treatments, the patient recovered quickly without additional spread of gangrene. The patient underwent amputation of the affected digits and the left upper limb healed with vacuum dressing. Patient underwent skin grafting for the left upper limb. Patient life saved. SPG can occur as an idiopathic phenomenon. The management requires to control of sugar and infection.