Herpes simplex virus 2-associated symmetrical peripheral gangrene in an immunocompetent fourteen-year-old girl: a case report.

Background: Symmetrical peripheral gangrene (SPG) is a rare but devastating clinical syndrome marked by symmetrical distal ischemic damage in the absence of large vessel obstruction or vasculitis, usually resulting in high mortality and frequent limb amputations among survivors. The underlying causes are multifactorial, including both infectious and noninfectious factors. However, neither the implicated etiological factors nor the precise mechanisms of pathogenesis have been fully elucidated, making diagnosis and management particularly challenging. Case Description: This report describes a 14-year-old girl who initially exhibited fever, edematous extremities, widespread erythema and small blisters on the trunk and extremities, and subsequent blackening of the fingers and toes. Her condition rapidly progressed to sepsis, shock, disseminated intravascular coagulation (DIC), and early hemophagocytic syndrome, culminating in a diagnosis of SPG. Comprehensive etiological investigations revealed herpes simplex virus 2 (HSV-2) infection as the underlying cause. Through prompt multidisciplinary interventions-including mechanical ventilation, fluid resuscitation, vasopressors, antiviral therapy, anticoagulation, plasma exchange, immunosuppression, and meticulous wound care-the patient achieved a remarkable recovery, with only minor residual pigmentation on her extremities. Conclusions: This case highlights HSV-2 as a rare but potential cause of SPG, broadening the spectrum of known pathogens. Early recognition, rapid diagnostic work-up, and timely multidisciplinary management are essential to improve outcomes and prevent limb loss.