The mneumonic VINDICATE will help formulate a useful list of possible causes of gangrene. V—Vascular. Gangrene is seen in peripheral arteriosclerosis, Buerger disease, thrombosis of the large arteries such as the femoral artery, thrombosis of the terminal aorta, and arterial embolism. I—Infection. Gas gangrene is typically produced by Clostridium perfringens and other clostridia. Streptococci, peptostreptococci, and staphylococci can produce progressive bacteria-synergistic gangrene. N—Neoplasm and neurological. Cryoglobulinemia and multiple myeloma are associated with the Raynaud phenomenon producing gangrene in the fingers. Peripheral neuropathy, syringomyelia, transverse myelitis, and tabes dorsalis may be associated with gangrene. D—Degenerative diseases are not generally associated with gangrene. I—Intoxication should bring to mind the gangrene associated with the use of ergot alkaloids. C—Congenital disorders are not usually associated with gangrene. A—Autoimmune disease. Lupus erythematosus, sclerederma, periarteritis nodosa, and RA may be associated with the Raynaud phenomenon and gangrene.
T—Trauma. Laceration of a major artery to an extremity or pressure from splints may cause gangrene. Extreme cold will produce gangrene from frostbite. E—Endocrinedisorders bring to mind the well-known diabetic gangrene.
All patients should have a CBC, sedimentation rate, venereal disease research laboratory (VDRL) test, chemistry panel, and serum protein electrophorosis. In cases of the Raynaud phenomenon, an ANA and RA titer should also be done. Aerobic and anaerobic cultures of exudates from the wound should also be taken. Plain x-rays of the area involved are recommended. If an embolism or obstruction of the large arteries is suspected, contrast angiography needs to be done. An ice water test, Sia water test, and serum immunoelectrophoresis will be useful in cases of the Raynaud phenomenon. A rheumatology consult is wise.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins MD, FACP Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8 
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