Traumatic asphyxia

Traumatic asphyxia is a distinctive clinical syndrome characterized by cervicofacial cyanosis and edema, multiple petechiae, and subconjunctival hemorrhage after a severe crush injury of the thorax or of the upper part of the abdomen. A case of traumatic asphyxia is reported, and its clinical and pathophysiologic features are discussed.

Meningococcemia and purpura fulminans in adults: acute deficiencies of proteins C and S and early treatment with antithrombin III concentrates

It has been recently suggested that an acquired deficiency of proteins C and S could contribute to the pathogenesis of meningococcemic purpura fulminans (PF) in children. Our study was designed to measure the levels of antithrombin III (AT III), protein C, and protein S during adult PF and to determine the effects of an early infusion of high doses of AT III concentrates on clinical and biological alterations of PF. We studied five consecutive adult patients with meningococcemia (type B) and PF. The levels of AT III, protein C (antigen and activity), and protein S (total and free) were measured at admission and 24 h and 1 month later. The treatment included in each case: amoxycillin, dobutamine and high doses of AT III concentrates. All patients survived and were discharged without any sequelae. At admission, biological data were consistent with severely depressed protein C and protein S levels and moderately decreased AT III levels, without any discrepancy between protein C antigen and activity. After 24 h, AT III and protein S levels were within normal ranges, whereas protein C levels were still depressed. These data are consistent with the theory of a particular imbalance in the anticoagulant systems during meningococcemic PF, contrasting with the usual findings observed during septic disseminated intravascular coagulation. The possibility must be considered that high doses of one anticoagulant (AT III concentrates) could compensate for the acute decrease in the other (protein C system).

Dermatopathology of skin necrosis associated with purpura fulminans

Dermal vascular skin necrosis is associated with a complex group of clinical disorders. Many of these disorders are associated with an underlying abnormality of the PC anticoagulant system or DIC, or both. The clinical appearance and histopathologic features of dermal vascular skin necrosis are similar regardless of the etiology. Acute infectious purpura fulminans is distinct in that an acute vasculitis may be present in addition to microvascular thrombosis. Skin biopsy is a valuable diagnostic tool in the early recognition of these clinical disorders, since skin involvement is frequently an early manifestation of the disease process. Prompt recognition and institution of appropriate therapy at the reversible stages of dermal vascular thrombosis will, it is hoped, reduce the morbidity and mortality currently associated with skin necrosis and purpura fulminans.

Proposed classification and pathologic mechanisms of purpura fulminans and skin necrosis

The syndromes of purpuric lesions associated with a thrombotic mechanism are very rare in the general population. Dermal vascular thrombosis, however, can be devastating and associated with significant morbidity and mortality. These syndromes share common features in their clinical course, pathogenesis, and histology. Although these syndromes can be initiated by either the hemostatic or inflammatory pathways, both pathways center around perturbations of the endothelial cell, which promote thrombosis. If animal models or better testing can be developed, enhanced appreciation of mechanisms underlying purpura fulminans may be deduced. Characterization of the pathophysiology may then allow directed treatment modalities that could limit the course of these syndromes and reduce morbidity and mortality.

Exercise-induced purpura

A 11-year-old boy developed purpura on the back and chest on more than 5 occasions following vigorous exercise. This eruption should be added to the list of differential diagnosis of the dermatosis experienced by athletes.

Fat embolism syndrome after liposuction: a case report and review of the literature

There have been three previous case reports of fat embolism syndrome (FES) after lipectomy. We present a case of FES diagnosed by pulmonary angiography. It seems likely that there is an incidence of subclinical fat embolization after liposuction, but conservative patient selection and aggressive postoperative management can lessen the morbidity and mortality of FES.

[Petechiae, microhematuria, colic-like abdominal pain]

A 46-year-old patient was referred because of recurring bouts of abdominal colics, petechiae and an accompanying nephropathy. The clinical setting pointed towards a cryoglobulinemia, proved by serum cryoprecipitation and electrophoresis and classified as type II. The primary disease was a low-grade non-Hodgkin lymphoma involving bone-marrow and liver. A renal biopsy showed a proliferative glomerulonephritis. Treatment with prednisone and chlorambucil led to improvement of renal function, and the patient became asymptomatic.

Posttransfusion purpura: the therapeutic value of PlA1-negative platelets

A case of PlA1-associated posttransfusion purpura (PTP) is reported, in which a previously sensitized patient developed life-threatening thrombocytopenia, purpura, hematuria, and bronchial bleeding. The patient was transfused with PlA1-negative single-donor apheresis platelets (from four different donors) on four occasions. The first transfusion resulted in a 1-hour posttransfusion increment of 57 x 10(9) per L. The use of two additional PlA1-negative apheresis platelets provided support for a tracheostomy. Bronchial bleeding leading to respiratory arrest was controlled with a fourth transfusion. All PlA1-negative platelet transfusions resulted in transient increases in the patient's platelet count. This is the first reported case of repeated, transiently effective transfusion of PlA1-negative platelets demonstrated during the acute phase of thrombocytopenia.

Utilization patterns of frozen autologous red blood cells. Experience in a referral center and a community hospital

The risks of homologous blood transfusion have motivated some blood centers and private industry to consider providing long-term storage of frozen, autologous red blood cells as a service. The usefulness of this practice is unknown. We performed a retrospective analysis of frozen autologous red blood cell use in two hospitals. Records were available for 21- and 9-year intervals, respectively. A total of 104 autologous units were cryopreserved for 41 patients. Fifteen (37%) of 41 patients received one or more of their stored units of red blood cells. Twenty-two patients had autologous units frozen in anticipation of elective surgery; 11 (50%) of these 22 patients received some or all of their stored units. Sixteen patients had autologous units stored because of potential transfusion problems related to rare blood types or to the presence of multiple blood cell alloantibodies, and another 3 patients had units frozen simply at their personal request. Only 4 (21%) of these latter 19 patients who donated without a specific planned use eventually received their frozen autologous red blood cells. Long-term autologous frozen red blood cell storage can improve medical management of some patients with anticipated surgical procedures or unusual requirements for transfusion. However, our study suggests that most autologous units frozen without specific planned use will not be transfused.

The surgical implications of purpura fulminans

Purpura fulminans is an uncommon catastrophic syndrome that occurs in children, typically one to four weeks after a seemingly benign infectious process. The child usually presents with a high fever, purpuric ecchymosis, hypotension, disseminated intravascular coagulation, and gangrene of the extremities. We have recently treated six children, whose mean age was 22 months; three were male and three were female. Five of the six had a change of mental status upon initial examination. Their mean temperature was 104 degrees F. All six children had purpuric involvement of their extremities; three had involvement of their hands, two had involvement of their faces, and two had involvement of their trunks. All had absent palpable pulses and sluggish capillary refill in the involved hands and feet. Two patients died shortly after admission as a result of severe end-stage sepsis. The platelet counts in these two patients, and the white blood cell counts were markedly depressed. The mean platelet count of the survivors was 370,000 and the mean white blood cell count was 25,000. Lumbar punctures were positive for bacterial meningitis in five patients and viral meningitis in one patient. All patients were treated with intravenous heparin. Of the four survivors, two lost significant tissue and required multiple plastic reconstructive procedures, and two improved on heparin alone with no tissue loss. In addition to systemic support and intravenous antibiotics, the mainstay of treatment is one of immediate heparinization and a continuous heparin drip. Heparin prevents subsequent small vessel thrombosis and limits tissue loss due to ongoing purpura. Conservative management of the purpuric lesions is the treatment of choice until final demarcation occurs.

Protein C and protein S levels in two patients with acquired purpura fulminans

Purpura fulminans (PF) is a cutaneous manifestation of a dramatic and deadly syndrome of systemic disseminated intravascular coagulation (DIC). It is characterized by microvascular thrombosis in the dermis followed by perivascular haemorrhage. Since two other related syndromes involve the protein C (PC) system, we undertook a serial study to investigate the levels of PC and protein S (PS) in two patients with acquired PF. Laboratory findings were consistent with DIC, and both patients were treated with blood replacement and heparin therapy. The levels of PC activity were very low during the initial 24-36 h after onset and gradually increased until returning to normal levels. The total and 'free' PS were also abnormal during the initial onset of PF. The total and free PS increased to normal after 4-6 d. Although the pathogenesis is not fully understood, the infection and sepsis appears to consume PC and PS selectively during the PF and DIC phase. Acquired PF appears to selectively involve the PC system in a similar fashion to two other syndromes of PF-like lesions.