Symmetrical Peripheral Gangrene Without Shock: A Rare Manifestation of Legionella Pneumonia

Abstract

Symmetrical peripheral gangrene (SPG) is a rare and life-threatening condition characterized by symmetrical distal ischemia progressing to gangrene in the absence of large-vessel obstruction or vasculitis. It is most frequently associated with septic shock, disseminated intravascular coagulation, and the use of vasopressors. We describe an unusual case of SPG occurring in a hemodynamically stable patient with Legionella pneumonia. A 43-year-old previously healthy man presented with a four-day history of high-grade fever and productive cough, followed by rapidly progressive blackish discoloration of the fingers and toes. On admission, he was febrile but hemodynamically stable, with preserved peripheral pulses and no history of shock or exposure to vasopressors. Laboratory evaluation revealed neutrophilic leukocytosis and marked thrombocytopenia. Autoimmune, vasculitis, and thrombophilia screening were negative, and Doppler ultrasonography excluded large-vessel occlusion. Blood and pleural fluid cultures were sterile; however, urinary antigen testing confirmed Legionella pneumophila. The patient was treated with intravenous meropenem, clarithromycin, and clindamycin along with supportive care. Following initiation of therapy, his fever resolved, respiratory symptoms improved, and the ischemic changes stabilized without further progression. He was discharged in stable condition without the need for amputation. This case underscores the importance of early recognition and prompt targeted antimicrobial therapy to prevent limb loss in atypical presentations of SPG.