(Kiosk 2) Quadruple-limb Amputation After Legionella Associated Sepsis: A Case Report

Case Diagnosis: Critical limb ischemia with arterial thrombi resulting in quadruple-limb amputation after Legionella Pneumonia-associated sepsis.

Case Description or Program Description: A 65-year-old female with a history of breast cancer s/p mastectomy and chronic hypertension presented to the emergency department with a chief complaint of malaise, weakness, polyuria, diarrhea, and cough associated with shortness of breath for four days. She developed acute respiratory distress and hypoxia requiring emergent endotracheal intubation. Urine Legionella was positive, and her metabolic panel was remarkable for mild hyponatremia. Chest X-Ray displayed bilateral lower lobe opacifications. Echocardiogram showed acute heart failure with an ejection fraction of 15-20%. While on vasopressors, she developed dry gangrene, and distal extremity arterial duplex ultrasound showed arterial thrombi and occlusion of her bilateral distal posterior tibial, dorsalis pedis, radial, and ulnar arteries. She was not a candidate for revascularization. HITT panel was negative. She ultimately underwent bilateral below-knee and trans-radial amputations which were complicated by infection and wound dehiscence requiring debridement and intravenous antibiotics.

Setting: Acute Rehabilitation Hospital

Assessment/Results: The patient was fitted for upper and lower extremity prosthesis while in acute rehabilitation. Prosthesis fitting and training was delayed due to impaired wound healing. She was anticoagulated by subcutaneous enoxaparin for the duration of her inpatient admission.

Discussion (relevance): Cases of quadruple-limb amputation are exceedingly rare. There is scarce documentation of critical limb ischemia in the setting of sepsis secondary to Legionella Pneumonia. Although the patient had previously undergone multiple prior surgeries without complication and reported a negative family history of hypercoagulability, it is suspected that a hypercoagulable state was precipitated by sepsis secondary to Legionella Pneumonia in the setting of prolonged vasopressor utilization. The patient is now followed by hematology in the outpatient setting and hypercoagulable workup is still ongoing.

Conclusions: Physiatrists should understand the complexities of hypercoagulable states and that critical limb ischemia can be precipitated by a myriad of causes including Legionella Pneumonia.