Immunoglobulin classes and subclasses of platelet antibodies in a case of post-transfusion purpura

A multiparous white woman developed severe thrombocytopenia following transfusion of red blood cells. Six ineffective platelet transfusions (a total of 42 random donor concentrates) were given from day 0 to day +6, high-dose steroids from day +1, progressively tapered until day +30, and a total of 150 g of intravenous immunoglobulins from day +2 to day +6. As platelet count had not increased significantly by day +8, four plasma exchange procedures, each consisting of 2,000 ml of plasma exchanged with 5% albumin solution, were performed on days +8, +10, +14 and +18. Platelet count was 5, 50, 100 and 234 x 10(9)/l on days +8, +14, +26 and +32 (discharge), respectively. The patient's acute phase serum contained increased levels of platelet alloantibodies with anti-HPA-1a (PlA1, Zwa) specificity and a titer of 3,200. IgG1, IgG2 and IgG3 subclasses of platelet-reactive antibodies in the patient's serum were elevated, whereas IgG4, IgM and IgA were within the reference values. Levels of IgG1, IgG2 and IgG3 of antiplatelet antibodies showed a marked and parallel reduction during treatment, but were still above the reference values at the end of treatment and 1 year later, when the patient platelet count was normal. Although a failure of intravenous immunoglobulins cannot be proven in this case, plasma exchange seems to have contributed more than intravenous immunoglobulins to clinical remission.

A case of vascular purpura with scurvy

A case of vascular purpura of the lower limbs in a 67 year old man is described. A diagnosis of scurvy was made in consideration of the absence of signs of vasculitis on skin biopsy, the history of a diet extremely poor in vitamin C and the prompt resolution of clinical picture with administration of vitamin C. The authors emphasize the importance of taking into consideration scurvy in the differential diagnosis of vascular purpura: this may spare expensive investigations and a dangerous delay in appropriate therapy.

[Fever and petechial exanthema in children]

In an attempt to determine clinical and analytical predictive parameters of a possible grave disease, we have carried out a retrospective study of 172 children admitted to our hospital with fever and petechiae as initial symptoms. The ages ranged between 1 month and 10 years. Even though we have not found a clinical symptom or analysis sufficiently sensitive as to predict all grave diseases, the general clinical state of the child associated with either a high or low white cell count and an abnormal coagulation study should be alert signals for a serious infectious disease. On the contrary, if the clinical and analytical parameters are within normal limits the risk of a grave disease is low. We emphasize the high incidence of meningococcal disease (26%).

Development of Kasabach-Merritt syndrome following needle aspiration of a hemangioma

A case of Kasabach-Merritt syndrome that developed following needle aspiration in an infant with hemangioma is presented. Enlargement of the tumor leading to severe respiratory distress accompanied by hemorrhages occurred within six to eight hours after this simple intervention. The symptoms continued despite repeated thrombocyte transfusions and prednisolone therapy. Radiotherapy and local intraarterial corticosteroid therapy were attempted and led to some improvement. It took approximately three months for the platelet count and one year for the clinical state to revert to normal. This case illustrates that minor trauma may lead to life-threatening symptoms in a young infant with congenital hemangioma.

Factitious purpura

Factitious purpura may present as a perplexing problem for the dermatologist and can mimic serious disease. This form of mechanical purpura, often caused by suction may be deliberately or unknowingly induced by the patient. Some cases may go unrecognized for a considerable length of time and undergo unnecessary investigation before the diagnosis is realized. Three cases of purpura are reported in which the causative agents were very different.

Suction purpura

BACKGROUND

Purpuric eruptions due to local mechanical causes are commonly seen, particularly in children. These eruptions are not always recognized as isolated purpura, and the patient may be submitted to an unnecessary extensive hematologic workup. We present various causes of suction purpura and outline a logical investigational approach.

OBSERVATIONS

Suction purpura result from an external force exerting negative pressure on a circumscribed area of the skin, producing small grouped petechiae. We present a number of such suction purpura-causing mechanisms: Pressure during the delivery of a neonate, children's habits or play activities, and iatrogenic causes produce similar cutaneous lesions. We also describe the gas mask suction purpura for the first time.

CONCLUSIONS

Once the causative factor is established, there is no need for further investigation or treatment of suction purpura. The lesions will fade completely within a few days.

Brazilian purpuric fever identified in a new region of Brazil. The Brazilian Purpuric Fever Study Group

Brazilian purpuric fever (BPF) is a life-threatening pediatric infection that is preceded by conjunctivitis and caused by Haemophilus influenzae biogroup aegyptius. BPF was first recognized during 1984 in the state of Sao Paulo. BPF was not reported in Brazil outside of Sao Paulo and the neighboring state of Parana until December 1989, when children with BPF were identified in the state of Mato Grosso. By April 1990, 10 children with confirmed BPF were identified from six widely separated cities in Mato Grosso. The overall attack rate for the combined population was 6/100,000 children less than 10 years of age. Six (60%) of the 10 children with BPF died. The recognition of BPF in Mato Grosso suggests that the H. influenzae biogroup aegyptius strain responsible for BPF has a wider geographic distribution than previously appreciated or may be capable of spreading.

Radiation safety: what can happen in an accident

Radiation hazards in dental practice have long been recognized, and the dangers from ionising radiation during dental radiography are discussed elsewhere. Continuing legislation will undoubtedly help reduce the risk of over-exposure and accidents. Nevertheless, it is of some concern that radiation safety is still ignored by some: for example, one recent survey in the UK showed that not all radiography sets conformed to modern safety standards. However, the profession also has reason to be concerned about more public radiation hazards that may affect them, and their families and others, and may, without denying the importance of dental radiation protection, have far greater effects on health. Well-known examples of domestic radon exposure occurred in the UK, particularly in the Lake District and the South West, and the nuclear reactor accidents--notably at Chernobyl in 1986.

Dental considerations for the pediatric oncology patient

A multidisciplinary management approach is required to provide care to the pediatric cancer patient. This article reviews the oral manifestations of cancer therapy, discusses some issues to be considered by the dentist and summarizes some of the treatment modalities available to the dental practitioner.

[Waldenstrm macroglobulinemia presenting in the form of cold urticaria and cold purpura]

A Waldenström macroglobulinemia case, manifested in the form of non-specific skin-symptoms (cold urticaria and cold purpura) is described in a 37 years old female patient. As new skin-symptoms progressive telangiectasia and naevi aranei could be observed. Involvement of skin may be explained by macroglobulins with kryoprotein properties, making early diagnosis possible at the same time.

[Extracorporeal gallbladder lithotripsy: technology, practical methods, results and current value]

Extracorporeal shock wave lithotripsy of gallstones is a safe and well-tolerated procedure. Patients are now treated without general anesthesia and, increasingly, on an outpatient basis. Skin petechiae and transient hematuria are the most common side effects. Episodes of biliary colic are common in the follow-up period, but more serious adverse side effects such as cholecystitis and pancreatitis are distinctly uncommon. It is estimated that only 15% to 20% of all patients with symptomatic cholelithiasis are suitable lithotripsy candidates. As our knowledge of the procedure grows, it seems clear that the best results are obtained in patients with solitary radiolucent stones less than or equal to 20 mm, with stone-free rates at 12 months above 80%, for this selected group of patients. Adjuvant oral bile-acid dissolution therapy should be used in conjunction with gallstone lithotripsy. Gallstone recurrence remains to be established by clinical studies. Therapy for gallstones in 1991 has to be reevaluated by an interdisciplinary approach, taking into account not only open cholecystectomy, but also other modalities such as medical dissolution, laparoscopic surgery, percutaneous cholecystolithotomy and extra-corporeal shock wave lithotripsy. The appeal of the laparoscopic approach will substantially reduce the pool of patients for lithotripsy. Nevertheless, lithotripsy will continue to be a viable treatment option for patients with a single radiolucent stone. It is an outpatient procedure and doesn't require any incision or general anesthesia.

Dermatitis artefacta as the presenting feature of auto-erythrocyte sensitization syndrome and naproxen-induced pseudoporphyria in a single patient

A female patient presented with two episodes of apparent dermatitis artefacta. Although it was clear that self-induced lesions were present on both occasions, there was also strong evidence in support of auto-erythrocyte sensitization syndrome on the first occasion and of naproxen-induced pseudoporphyria on the second occasion. The occurrence of two such rare disorders in a single patient is extremely unusual, and we discuss a possible pathogenetic link between them. The case emphasizes that patients with apparent artefactual lesions, or with a previous history of dermatitis artefacta, still require careful evaluation to identify organic disease.

[Orthostatic purpura: report of two cases]

Two patients with orthostatic purpura were reported. Case 1: A 47-year-old man was admitted to our institution because of multiple purpuric eruptions over the legs after the long periods of sitting or standing. Bleeding time was 4.0 min. Platelet aggregation induced by ADP was disaggregated and no aggregation was observed when induced by collagen and epinephrine. He was diagnosed as having release abnormality of the platelets caused by glutathione administered for treatment of liver damage for several years. Purpura, however, appeared even though platelet function became normal after discontinuing glutathione. Purpura proved to be induced by the long periods of sitting or standing. Case 2: A 37-year-old woman was admitted to our hospital because of purpuric eruptions over the legs for three years. Bleeding time was 2.0 min. Platelet aggregation induced by ADP, epinephrine, collagen and ristocetin was normal. Purpura was caused by long periods of standing without movement. Wearing elastic pantyhose showed reduced appearance of the purpura. Biopsy specimens from both patients revealed no abnormal findings. Both patients had no abnormal results in coagulation studies. Purpura seemed to be caused by the increased capillary pressure after the prolonged periods of standing. No case report concerning orthostatic purpura or mechanical purpura has been published.