Purpura fulminans

A Profile of 23 Indian Patients with Purpura Fulminans: A Retrospective, Descriptive Study

Background:

Purpura fulminans (PF) is a potentially fatal uncommon disorder of intravascular thrombosis and is clinically characterized by rapidly progressive hemorrhagic infarction of the skin.

Objective:

To describe the clinical feature and outcome of a series of patients with PF.

Materials and Methods:

A descriptive study based on review of case records was carried out at a tertiary care hospital in Kolkata.

Results:

Twenty three consecutive cases seen over a period of 8 years were studied. The age range was 4 days to 78 years (mean 35.6 years) with a male to female ratio of 1:2.8. Hemorrhagic rash was the universal presenting symptom. Other major presenting features included pneumonia (26.1%), sudden-onset shock syndrome (21.7%), and urinary tract infection (17.4%). All patients presented with retiform purpura and lesional necrosis and 8 (34.8%) patients had associated peripheral gangrene. Nineteen (82.6%) patients had sepsis and 60.9% patients had vesiculo-bullous lesion. Pneumococcus was the most common (26.1%) pathogenic organism detected. The precise cause of PF could not be detected in two (8.7%) patients. One patient (4.3%) with neonatal PF had protein C deficiency. All patients had evidence of disseminated intravascular coagulation (DIC). One patient had to undergo a below knee surgical amputation and one patient had autoamputation of the digits. Ten (43.5%) patients succumbed to their illness. Seven of the 8 patients who had peripheral gangrene had a fatal outcome.

Limitations:

Relatively small sample size and a referral bias were a few limitations of the present study.

Conclusion:

The present study emphasizes that PF is a cutaneous marker of DIC. Association of peripheral gangrene, leukopenia and neutropenia may be the reason for the high mortality rate.

Clinical and Histopathologic Characteristics of the Main Causes of Vascular Occlusion - Part I: Thrombi

La patología vascular oclusiva es causante de diversas y variadas manifestaciones clínicas, algunas de las cuales son de catastróficas consecuencias para el paciente. Sin embargo, las causas de tal oclusión son muy variadas, extendiéndose desde trombos por acción descontrolada de los mecanismos de coagulación, hasta anomalías de los endotelios de los vasos u oclusión por materiales extrínsecos. En una serie de dos artículos hacemos una revisión de las principales causas de oclusión vascular, resumiendo sus manifestaciones clínicas principales y los hallazgos histopatológicos fundamentales. Esta primera parte corresponde a las oclusiones vasculares que cursan con trombos.

Acute purpura fulminans-a rare cause of skin necrosis: A single-institution clinicopathological experience

BACKGROUND

Purpura fulminans, an uncommon syndrome of intravascular thrombosis with hemorrhagic infarction of the skin, is often accompanied by disseminated intravascular coagulation (DIC) and multi-organ failure, and may ultimately lead to death.

METHODS

Herein, we document 13 skin biopsies from 11 adult patients with the clinical diagnosis of sepsis and confirmed histopathologic diagnosis of intravascular thrombosis and/or DIC, compatible with acute infectious purpura fulminans (AIPF). Detailed history and clinical examination were performed, and the lesions were correlated with histopathologic findings. Any underlying medical disease was taken into consideration.

RESULTS

There were 5 males and 6 females with lower extremity or peri-incisional purpuric skin lesions. The most important comorbidities identified were a history of surgical procedure or neoplasm, although 4 patients had no relevant underlying history. Most skin biopsies revealed focal epidermal ischemia or necrosis and 3 showed full-thickness epidermal necrosis. In the underlying dermis, there were fibrin thrombi in superficial and deep blood vessels with acute inflammation. Changes of an inflammatory destructive vasculitis were identified in 5 cases. No bacteria or fungi were identified on histopathology.

CONCLUSIONS

AIPF is a rapidly-progressing medical emergency which may be identified by histopathology in culture-negative cases. Biopsies may show neutrophilic infiltrate without infective organisms.

Dermatologic Problems in the Intensive Care Unit: Part III

In this third part of our review of skin problems seen in critically ill patients, we focus on a number of life-threatening systemic disorders in which cutaneous findings are prominent. We discuss purpura fulminans, toxic shock syndrome, systemic lupus erythematosus, acquired immunodeficiency syndrome, Lyme disease, graft-versus-host disease, and Rocky Mountain spotted fever.

Thrombocytopenia in Critical Care Patients

Thrombocytopenia is a common laboratory finding in the intensive care unit (ICU) patient. Because the causes can range from laboratory artifact to life-threatening processes such as thrombotic thrombocytopenic purpura (TTP), identifying the cause of thrombocytopenia is important. In the evaluation of the thrombocytopenia patient, one should incorporate all clinical clues such as why the patient is in the hospital, medications the patient is on, and other abnormal laboratory findings. One should ensure that the patient does not suffer from heparin-induced thrombocytopenia (HIT) or one of the thrombotic microangiopathies (TMs). HIT can present in any patient on heparin and requires specific testing and antithrombotic therapy. TMs cover a spectrum of disease ranging from TTP to pregnancy complications and can have a variety of presentations. Management of disseminated intravascular coagulation depends on the patient’s condition and complication. Other causes of ICU thrombocytopenia include sepsis, medication side effects, post-transfusion purpura, catastrophic anti phospholipid antibody disease, and immune thrombocytopenia.

Purpura Fulminans Secondary to Streptococcus pneumoniae Meningitis

Purpura fulminans (PF) is a rare skin disorder with extensive areas of blueblack hemorrhagic necrosis. Patients manifest typical laboratory signs of disseminated intravascular coagulation (DIC). Our case describes a 37-year-old previously healthy man who presented with 3 days of generalized malaise, headache, vomiting, photophobia, and an ecchymotic skin rash. Initial laboratory workup revealed DIC without obvious infectious trigger including unremarkable cerebrospinal fluid (CSF) biochemical analysis. There was further progression of the skin ecchymosis and multiorgan damage consistent with PF. Final CSF cultures revealed Streptococcus pneumoniae. Despite normal initial CSF biochemical analysis, bacterial meningitis should always be considered in patients with otherwise unexplained DIC as this may be an early manifestation of infection. PF is a clinical diagnosis that requires early recognition and prompt empirical treatment, especially, in patients with progressive altered mental status, ecchymotic skin rash, and DIC.

Varicella-associated purpura fulminans and multiple deep vein thromboses: a case report

Varicella-associated purpura fulminans is a rare syndrome associated with substantial morbidity and mortality. General supportive care, heparinization, and plasma infusions are the mainstays of treatment. A patient aged 8 years and 8 months with purpura fulminans and multiple deep vein thromboses after varicella infection because of deficiencies of proteins C and S is presented in this case report.

Presentation and outcome of purpura fulminans associated with peripheral gangrene in 12 patients at Mayo Clinic

BACKGROUND

Dermatologists may be called to assist in the diagnosis and management of purpura fulminans.

METHODS

This retrospective case series details the clinical presentation and outcomes of patients presenting with purpura fulminans associated with peripheral gangrene between 1989 and 2004.

RESULTS

All 12 patients presented with sudden onset of purpuric patches and evolving gangrene of the extremities in association with a shock syndrome (hypotension, oliguria). Eleven patients had disseminated intravascular coagulation. The cause of purpura fulminans was infectious in 9 patients, surgical in two, and cancer in one. Three patients died (25%) within a week of onset of purpura fulminans. Of the 9 surviving patients, 8 required amputation of at least one limb. Four patients required amputation of all 4 limbs.

LIMITATIONS

Retrospective study design, varying clinical descriptions, and potential referral bias are limitations.

CONCLUSION

Purpura fulminans in association with symmetric peripheral gangrene is an ominous clinical presentation.

Purpura fulminans in an adult patient with Haemophilus influenzae sepsis: case report and review of the literature

Purpura fulminans is a rare complication of a coagulopathy or an infection. Haemophilus influenzae infection, which has decreased since the haemophilus influenzae type B vaccine was initiated, is an unusual initiating cause of purpura fulminans. This case is the first reported in the literature of an adult who developed purpura fulminans after Haemophilus influenzae sepsis. Her elevated beta2 glycoprotein 1 ratio may have contributed to the severity of her disease. Although rare, Haemophilus influenzae may precipitate purpura fulminans. Current therapy is directed at control of precipitating factors, removal of nonviable tissue, treatment of secondary infections, and physiologic support. There also is evidence that patients respond well to hyperbaric oxygen therapy, with decreasing limb and tissue loss.

Staphylococcus aureus sepsis and the Waterhouse-Friderichsen syndrome in children

Staphylococcus aureus has increasingly been recognized as a cause of severe invasive illness. We describe three children who died at our institution after rapidly progressive clinical deterioration from this infection, with necrotizing pneumonia and multiple-organ-system involvement. The identification of bilateral adrenal hemorrhage at autopsy was characteristic of the Waterhouse-Friderichsen syndrome, a constellation of findings usually associated with fulminant meningococcemia. The close genetic relationship among the three responsible isolates of S. aureus, one susceptible to methicillin and two resistant to methicillin, underscores the close relationship between virulent methicillin-susceptible S. aureus and methicillin-resistant S. aureus isolates now circulating in the community.

Critical care clotting catastrophies

Coagulation problems are very common in intensive care patients. It is important to recognize potential problems, perform a rapid assessment, and start therapy. The author reviews general clinical and laboratory approaches to diagnosis and treatment of the bleeding patient and to correction of coagulopathies. This review outlines a set of often catastrophic coagulation problems, which may present both thrombotic and bleeding challenges. These include heparin induced thrombocytopenia, thrombotic thrombocytopenic purpura, and disseminated intravascular coagulation.

Purpura Fulminans Due toStaphylococcus aureus

BACKGROUND

Purpura fulminans is an acute illness commonly associated with meningococcemia or invasive streptococcal disease, and it is typically characterized by disseminated intravascular coagulation (DIC) and purpuric skin lesions. In this article, we report the first 5 cases (to our knowledge) of purpura fulminans directly associated with Staphylococcus aureus strains that produce high levels of the superantigens toxic shock syndrome toxin-1 (TSST-1), staphylococcal enterotoxin serotype B (SEB), or staphylococcal enterotoxin serotype C (SEC).

METHODS

Cases were identified in the Minneapolis-St. Paul, Minnesota, metropolitan area during 2000-2004. S. aureus infection was diagnosed on the basis of culture results, and susceptibility to methicillin was determined. The ability of the isolated organisms to produce TSST-1, SEB, SEC, and Panton-Valentine leukocidin (PVL) was determined. TSST-1, SEB, and SEC levels were also quantified after in vitro growth of the organisms.

RESULTS

In 3 of the 5 cases, the infecting S. aureus strain was isolated from the blood cultures. In 2 of the 5 cases, the infecting S. aureus strain was isolated only from the respiratory tract, indicating that purpura fulminans and toxic shock syndrome resulted from exotoxin and/or other host factors, rather than septicemia. One of these latter 2 patients also had necrotizing pneumonia, and the isolated S. aureus was a methicillin-resistant strain that produced both SEC and PVL. Only 2 of the 5 patients survived, and 1 of the survivors received activated protein C.

CONCLUSIONS

Staphylococcal purpura fulminans may be a newly emerging illness associated with superantigen production. Medical practitioners should be aware of this illness.

Ulcerative colitis presenting as purpura fulminans

A 60-year-old man presented with purpura fulminans involving his chest and flank. He was subsequently found to have active ulcerative colitis (UC) and protein S deficiency. He was treated with heparin and plasma, but because of persistent colitis and progressively worsening purpura, a total colectomy was performed on hospital day 17. This report describes an interesting case of purpura fulminans associated with the hypercoagulable state of active UC that responded dramatically to colectomy.

Massive infectious soft-tissue injury: diagnosis and management of necrotizing fasciitis and purpura fulminans

LEARNING OBJECTIVES

After studying the article, the participant should be able to: 1. Describe the most common bacteriology of necrotizing fasciitis and purpura fulminans. 2. Describe the "finger test" in the diagnosis of necrotizing fasciitis. 3. Discuss the three presentation patterns of necrotizing fasciitis. 4. Discuss the pathophysiology of acute infectious purpura fulminans. 5. Discuss the treatment strategies for necrotizing fasciitis and purpura fulminans, including the use of artificial skin substitutes. Necrotizing fasciitis and purpura fulminans are two destructive processes that involve skin and soft tissues. The plastic and reconstructive surgeon may frequently be called on for assistance in the diagnosis, treatment, and/or reconstruction of patients with these conditions. Understanding the natural history and unique characteristics of these processes is essential for effective surgical management and favorable patient outcome. A comprehensive review of the literature pertaining to these two conditions is presented, outlining the different pathophysiologies, the patterns of presentation, and the treatment strategies necessary for successful management of these massive infectious soft-tissue diseases.

The use of simultaneous free latissimus dorsi tissue transfers for reconstruction of bilateral upper extremities in a case of purpura fulminans

We report a case of extensive purpura fulminans destroying the soft tissue over the posterior aspect of both elbows. Simultaneous, bilateral free latissimus dorsi muscle transfers were used to close both wounds in a single procedure. The wounds resulting from severe purpura fulminans can be extensive and limb threatening. The simultaneous transfer of 2 free flaps can provide expeditious soft tissue repair while minimizing the risk of repeat anesthesia in these critically ill patients. We found that certain details concerning planning and performing the procedure fostered its successful outcome.

Reconstructive surgery in children after meningococcal purpura fulminans

BACKGROUND/PURPOSE

Purpura fulminans (PF) is a serious, often life-threatening disease. As more children are surviving their disease, surgeons are presented with increasing numbers of multiple and complicated wounds as sequelae of PF. The purpose of this paper is to review the management of nine cases of PF, and present the reconstruction method in treating bilateral exposed elbow and knee joints.

METHODS

All cases of pediatric patients with PF and treated by the division of plastic and reconstructive surgery between 1986 and 1998 were reviewed.

RESULTS

Seven children (78%) had meningococcal PF, and one (11%) had PF after Haemophilus influenza septicemia. PF developed in one (11%) but with no growth in either blood or cerebrospinal fluid cultures. Five children (56%) required amputation procedures. Two children (22%) required knee disarticulation. Two patients (22%) had free myocutaneous flap transfers for bone coverage. One (11%) had PF involving the face.

CONCLUSIONS

Meningococcal PF is a rare, often life-threatening disease generally of childhood. More children are surviving their diseases but with devastating sequelae. Successful reconstructive treatment outcome of these children requires a multidisciplinary team approach involving multiple specialties. The goal is to preserve function, maintain maximal length, and salvage limbs when possible. Flexibility and innovation are necessary in treating these multiple and complicated wounds.

Surgical treatment of extensive skin necrosis secondary to purpura fulminans in a patient with meningococcal sepsis

Meningococcal sepsis is associated with a high mortality rate. These patients may show severe disseminated intravascular coagulation (DIC) and skin necrosis. There is very little published experience regarding the surgical treatment of this complication. The similarity between skin necrosis secondary to DIC and full thickness cutaneous burns provides the rationale for its treatment as if it was a deep burn. We report the surgical treatment of extensive skin necrosis in a patient with meningococcal sepsis and DIC. This treatment is similar to that used in full thickness burns, including excision of necrotic tissue and coverage with autografts, as well as amputation of extremities if distal coverage is not possible.

Purpura fulminans in pneumococcal sepsis: case report and review

Purpura fulminans is classically defined by ecchymotic skin lesions, fever, and hypotension. The majority of cases occur in association with bacterial sepsis, and disseminated intravascular coagulation (DIC) is usually present. Prompted by our experience with a patient with pneumococcal sepsis and purpura fulminans in whom hypotension was never observed, we evaluated the important parameters of sepsis in reports of this syndrome. 42 additional cases of pneumococcal bacteremia and purpura fulminans were identified. Hypotension was present in only 51%. Although DIC was present in 85% of patients, hypofibrinogenemia was documented in only 26%. By contrast, both hypotension and hypofibrinogenemia are present in the vast majority of patients described with purpura fulminans in association with meningococcal sepsis. These data confirm that hypotension is not a necessary feature of the syndrome of purpura fulminans associated with pneumococcal sepsis and suggest further that qualitative or quantitative differences exist in the DIC cascade of pneumococcal vs meningococcal sepsis.

Purpura in infants and children

Hemorrhage into the skin (purpura) may result from abnormalities in any of the three components of hemostasis: platelets, plasma coagulation factors, and blood vessels. The morphology, size, and distribution of the hemorrhagic lesions are helpful diagnostic features. The main causes of purpura in the newborn and the more common hemorrhagic disorders in children are reviewed.

Treatment of purpura fulminans in meningococcemia with protein C concentrate

OBJECTIVE

To evaluate the clinical and laboratory effects of protein C concentrate as an adjunct to conventional therapy in the treatment of meningococcemia with purpura fulminans.

DESIGN

Case series (pilot study).

SETTING

Intensive care unit in a tertiary care pediatric hospital.

PATIENTS

Four children (aged 3 months to 15 years) requiring intensive treatment for meningococcemia with shock, disseminated intravascular coagulation, and purpura fulminans.

INTERVENTION

Intravenous administration of a protein C concentrate (100 IU/kg every 6 hours).

MAIN OUTCOME MEASURES

Plasma protein C amidolytic activity, fibrinogen, and D-dimers; evolution of skin and limb lesions.

RESULTS

Treatment with protein C concentrate led to a rise in plasma protein C activity levels to within normal limits in all patients, associated with an increase in plasma fibrinogen and a bimodal decrease in D-dimers. No adverse effects were noted. All patients had reversal of organ dysfunction despite the severity of the initial illness. Two patients recovered completely with no sequelae; two required amputations.

CONCLUSIONS

These encouraging clinical and laboratory results and the absence of side effects warrant the initiation of a double-blind, randomized controlled multicenter trial to determine the role of protein C replacement in the treatment of meningococcemia-associated purpura fulminans.

Severe autoimmune protein S deficiency in a boy with idiopathic purpura fulminans

Idiopathic purpura fulminans usually occurs in young children and is frequently preceded by a preparatory viral or bacterial infection. Following a severe streptococcal pharyngitis, an 8-year-old boy developed purpura fulminans with disseminated intravascular coagulation and severe protein S deficiency (total antigen < 0.05 u/ml). Despite generous plasma infusions, skin necrosis progressed rapidly into compartment syndrome which required fasciotomy and skin grafting and resulted in the loss of three digits of the right foot. Total protein S remained low for over a month despite plasma supplementation and complete normalization of protein C levels. A polyclonal anti-protein S IgG was demonstrated in the patient's plasma, which decreased to 25% of baseline titre after 1 month and was undetectable 6 months after purpura fulminans, when plasma protein S had returned to normal. Transient, isolated and severe deficiencies of protein S have been reported in patients with idiopathic purpura fulminans and a previous preparatory infection. Autoimmune protein S deficiency may play a key role in the aetiopathogenesis of idiopathic purpura fulminans.

Adult respiratory distress syndrome in pregnancy

OBJECTIVE

Our objective was to determine the causes of adult respiratory distress syndrome in pregnancy, the treatment required, and maternal and perinatal outcomes.

STUDY DESIGN

We examined a case series of 16 patients with adult respiratory distress syndrome initially treated in an obstetric intensive care unit. Criteria for the diagnosis were respiratory distress requiring mechanical ventilation and a lung injury score > 2.5.

RESULTS

The incidence of adult respiratory distress syndrome in pregnancy was 1 per 2893 deliveries, occurring primarily in the third trimester. The causes were infection (n = 8), preeclampsia/eclampsia (n = 4), hemorrhage (n = 2), thrombotic thrombocytopenic purpura (n = 1), and smoke inhalation (n = 1). Most patients (69%) were delivered before or soon after admission to our hospital. Multiple organ failure developed in 12 patients (75%). Complications of mechanical ventilation occurred in 81% of cases. Other complications of intensive care unit support were endocarditis, superior vena cava thrombosis, line sepsis, and bacteremia. Maternal mortality was 44%; perinatal mortality was 20%.

CONCLUSIONS

Adult respiratory distress syndrome in pregnancy is associated with a maternal mortality similar to that of studies in the nonpregnant patient. The main causes in pregnancy are hemorrhage, infection, and toxemia. All maternal deaths occurred in patients with multiorgan failure.

Haemophilus influenzae type b purpura fulminans treated with hyperbaric oxygen

We report the case of a 4-month-old child with purpura fulminans caused by Haemophilus influenzae type b. In addition to conventional therapy, she was treated with hyperbaric oxygen, and made a full recovery. Hyperbaric oxygen as an adjunct to other therapy in purpura fulminans is discussed.

Intravascular coagulation necrosis of the skin associated with cryofibrinogenemia, diabetes mellitus, and cardiolipin autoantibodies

Intravascular coagulation necrosis of the skin is rare and appears as hemorrhagic infiltrates that may develop ulcerating necrosis, mainly on the acral areas. The face, arms, and legs were severely involved in our patient. In this patient intravascular coagulation necrosis was associated with cryofibrinogenemia, diabetes mellitus, and IgM cardiolipin autoantibodies. In addition, rheumatoid factor, elevated polyclonal IgA, and haptoglobin were present as risk factors for the vasculopathy. Skin biopsy specimens showed plugging of dermal venules by thrombi formed of fibrin and erythrocytes. Immunohistologic staining revealed a strong positive reaction for fibrinogen, with some positivity for C3, C4, IgG, IgA, and IgM. Erythrocyte extravasation occurred in late lesions without being accompanied by perivascular leukocytic infiltrates. Detailed clinical examination failed to identify an underlying malignancy. Treatment with heparin and prednisolone produced only a brief remission. However, the combination of chlorambucil (7 mg/day orally) with low-dose oral prednisolone (10 mg/day) for several weeks controlled the disease and greatly reduced the cryofibrinogen. No relapse occurred after discontinuation of treatment.

Transient epidermal necrosis associated with disseminated intravascular coagulation in a patient with urticaria

A patient with intermittent erythema developed urticaria and a systemic illness associated with the development of disseminated intravascular coagulation and a widespread bullous eruption. A skin biopsy showed intravascular fibrin and epidermal necrosis with no evidence of vasculitis. The patient made a complete recovery following therapy with fresh frozen plasma and platelets and pulsed intravenous methylprednisolone.

Purpura fulminans secondary to Xanthomonas maltophilia sepsis in an adult with aplastic anemia

Purpura fulminans is a rare disease characterized by purpura ecchymosis, hypotension, and fever associated with disseminated intravascular coagulation. It often begins as a benign infectious process and subsequently progresses to a severe, catastrophic outcome. It is recognized to originate from congenital or acquired protein C deficiency. We present an unusual case of an adult with Xanthomonas maltophilia sepsis that subsequently developed into purpura fulminans with involvement of the four extremities. We discuss the importance of the protein C system in coagulation homeostasis and its relationship to purpura fulminans.

Thrombotic vasculopathy associated with cryofibrinogenemia

Cryofibrinogenemia refers to the presence of cold-precipitable plasma proteins associated with a variety of disorders, including malignancies, inflammatory processes, and thrombohemorrhagic phenomena. Few cases of essential or primary cryofibrinogenemia are reported. We report a case in a 48-year-old man of essential cryofibrinogenemia and hemorrhagic necrosis of the ears and of the upper and lower extremities. Histopathologic studies demonstrated extensive eosinophilic thrombi in the dermal vasculature, with minimal inflammation and no vasculitis. Cryofibrinogenemia should be considered in the investigation of patients with otherwise unexplained cold intolerance and dermal thrombosis associated with minimal or no inflammation.

Unfading acral microlivedo. A discrete marker of thrombotic skin disease associated with antiphospholipid antibody syndrome

Small erythematous or cyanotic lesions on the hands and feet of four patients with antiphospholipid antibodies are described. These discrete lesions outline capillaries and do not disappear when pressure is applied. The histologic features are identical to those described in skin thrombotic syndrome associated with antiphospholipid antibodies, that is, microthrombi in dermal vessels without inflammation. In addition to indicating antiphospholipid antibodies in apparently healthy patients, this sign could be a marker of risk for large-vessel thrombosis.

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.

Purpura fulminans

Purpura fulminans is a rare disease that typically begins as a benign infectious process and subsequently progresses to severe sepsis, hypotension, purpura ecchymosis, and disseminated intravascular coagulation. We present an unusual case of an adult who was seen initially with pneumococcal sepsis that subsequently developed into purpura fulminans with major extremity involvement. A multidisciplinary approach is needed in the treatment of this often catastrophic disease.

Purpura fulminans. A case for heparin therapy

A 6.5-year-old boy developed purpura fulminans. He had no evidence of congenital protein C deficiency. He responded readily to heparin therapy with resolution of his coagulopathy. The coagulopathy resumed rapidly after heparin therapy was interrupted to allow for surgical procedures. Despite correction of his coagulopathy with heparin, surgical amputation of his leg was necessary because of inadequate perfusion.

Histopathologic and immunofluorescence study of skin lesions associated with circulating lupus anticoagulant

We reviewed the histopathologic findings in 28 specimens from 25 patients who had skin lesions associated with lupus anticoagulant. The clinical lesions were ulcers, gangrene, thrombophlebitis, hemorrhage, and cutaneous necrosis. Noninflammatory thrombosis of small dermal vessels was observed in all 8 biopsy specimens from gangrene lesions, 10 of 13 specimens from ulcer lesions, and 2 of 5 specimens from thrombophlebitis lesions. Necrotizing vasculitis was not significant in these biopsy specimens. Immunofluorescence findings included a positive lupus band test in lupus erythematosus-associated disease and nonspecific deposits in occasional cases. Focal noninflammatory intravascular coagulation is responsible for the microscopic and clinical skin lesions in these patients.

Varicella gangrenosa

A four year old girl presented with varicella gangrenosa, and haematological investigations showed a disseminated intravascular coagulation. The child subsequently developed a unilateral deep venous thrombosis. She was treated with oral steroids and intravenous heparin and made a full recovery.