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A 56-year-old woman with diabetes mellitus complicated by retinopathy and mild nephropathy and managed with glyburide (glibenclamide) and metformin reported having abdominal pain and fever for the past 48 hours. On admission she was short of breath, hypotensive, and in shock. Her white-cell count was 25,900 per cubic millimeter and she had disseminated intravascular coagulation. She was treated with mechanical ventilation, blood products, hemodynamic support with dopamine and norepinephrine, and broad-spectrum antimicrobial therapy. The next day cyanosis developed in three fingers of the right hand (Panels A and B) and in five toes of the right foot (Panels C and D). She underwent an exploratory laparotomy during which a necrotic gallbladder was found and resected. By the second day after surgery her condition was much improved; inotropic support was not required, laboratory values were normalizing, and coagulopathy was reduced. However, the lesions of the right hand and right foot progressively necrosed, and amputation was required on hospital day 15. She otherwise made a full recovery and was discharged on hospital day 24.
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