Purpura fulminans

Free flap for lower limb salvage in infectious purpura fulminans

BACKGROUND

Infectious purpura fulminans is a disabling disease often leading to amputations. Free flaps preserve limb length, covering exposed areas. We examined the efficacy of free flaps for lower limb salvage in infectious purpura fulminans survivors by evaluating surgical management, walking ability and quality of life.

METHODS

This single-center, observational, descriptive, retrospective study was conducted in from 2016 to 2019. Adult purpura fulminans survivors who received a free flap for lower limb salvage were included. Patient characteristics and data on surgical management and rehabilitation were collected. Quality of life (SF-36 questionnaire), limb function and walking ability were later evaluated post-surgically.

RESULTS

The 6 patients included, mean age 38 years, had all required amputations. Nine free flaps were performed to cover important structures in 7 cases and for stump resurfacing in 2. All flaps were successful. Patients resumed walking at a mean of 204±108 days after the onset of purpura fulminans. Post-surgical evaluation was performed at a mean of 30±9.3 months. Five patients required secondary revision. All were independent for the activities of daily living. Mean physical component score was 37.6±9.4 and mental component score was 44.6±13.2 (minimum 0, maximum 100).

CONCLUSIONS

Use of the free flap in patients with infectious purpura fulminans, after multidisciplinary reflection, is an appropriate procedure that preserves limb length. In spite of secondary complications, preservation of limb length enables patients to resume walking, with relatively good independence and quality of life.

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.

Surgical outcomes in adults with purpura fulminans: a systematic review and patient-level meta-synthesis

Background

Cutaneous manifestations of purpura fulminans (PF) present many challenges for clinicians and surgeons. In a state of septic shock complicated by limb ischemia, surgical interventions are necessary to control the pathological cascade and improve patient outcomes. The objective of this article was to report etiologies and surgical outcomes associated with cutaneous manifestations in adults.

Methods

This systematic review and meta-analysis compared 190 adult patients with etiologies, signs and symptoms, and surgical outcomes associated with cutaneous manifestations of PF. The PubMed, EMBASE, Cochrane Library, Web of Science, and Scopus databases were systematically and independently searched. Patient and clinical characteristics, surgical interventions, outcomes, and complications were recorded.

Results

Seventy-nine studies were eligible for the systematic review, and 77 were eligible for meta-analysis using Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) and Cochrane guidelines. A total of 71/190 (38%) cases reported surgical debridement. Fasciotomies were reported in 12/190 (6%) cases and 20 procedures. Amputations were reported in 154/190 (81%) cases. Reconstruction was reported in 45 cases. Skin grafts were applied in 31 cases. Flaps were used for reconstruction in 28 cases. Median (IQR) surgical procedures per patient were 4 (4, 5) procedures. Infectious organisms causing PF were 32% Neisseria meningitidis (n = 55) and 32% Streptococcus pneumonia (n = 55). Coagulase-negative Staphylococcus (95% confidence interval (CI)(8.2-177.9), p = 0.032), Haemophilus influenza (95%CI (7.2-133), p = 0.029), Streptococcus pneumonia (95% CI (13.3-75.9), p = 0.006), and West Nile Virus (95%CI (8.2-177.9), p = 0.032) were associated with significantly more extensive amputations compared to other organisms.

Conclusion

This systematic review and patient-level meta-analysis found the most common presentation of PF was septic shock from an infectious organism. Neisseria meningitidis and Streptococcus pneumonia were equally the most common organisms associated with PF. The majority of cases were not treated in a burn center. The most common surgeries were amputations, with below-the-knee-amputations being the most common procedure. Skin grafting was the most commonly performed reconstructive procedure. The most common complications were secondary infections. Organisms with significantly more extensive amputations were coagulase-negative Staphylococcus, Haemophilus influenza, Streptococcus pneumonia, and West Nile Virus. Interpretation of findings should be cautioned due to limited sample data.

Pneumococcal sepsis requiring mechanical ventilation: Cohort study in 38 patients with rapid progression to septic shock

BACKGROUND

The aim was to study the course of severe pneumococcal sepsis in patients who rapidly developed septic shock with multiorgan failure.

METHODS

Combined retrospective and prospective cohort study of all patients with pneumococcal sepsis requiring mechanical ventilation admitted to our Medical Intensive Care Unit at Oslo University Hospital Ullevaal, during an 8-year period (01 January 2006 to 31 December 2013). The inclusion criteria were growth of Streptococcus pneumoniae in blood culture and respiratory failure treated with invasive mechanical ventilation.

RESULTS

Thirty-eight patients were included. Median age was 57 years (interquartile range 49-68, range 22-79). For 84% (32/38), it took <24 hours from the first medical evaluation until they were in septic shock. Initial clinical features were variable; none were treated with antibiotics before hospital admission. Median Sequential Organ Failure Assessment (SOFA) score at admission was 11 (range 1-15) and maximum 15 (range 5-22), all patients developed multiorgan failure. Mutilating complications were seen in 47% (18/38) of the patients: six with amputations, 11 had adverse neurological complications and one patient both. In-hospital mortality was 40% (15/38), 20% (8/38) survived with sequelae and 40% (15/38) returned to their habitual state. Poor outcome was associated with meningitis, disseminated intravascular coagulation, and gastrointestinal symptoms.

CONCLUSION

In this patient cohort with pneumococcal sepsis and respiratory failure rapid development of septic shock was seen in all cases, even in young healthy individuals. Initial clinical features were variable; none were treated with antibiotics before admission. Mortality was high (40%), as was morbidity with limb amputations and neurological complications.

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.

Four limb amputations due to peripheral gangrene from inotrope use - Case report and review of the literature

•

Rare case of 4 limb amputations due to peripheral gangrene from inotrope use.

•

Contributing factors include disseminated intravascular coagulation and septic shock.

•

Differential diagnoses include symmetrical peripheral gangrene and purpura fulminans.

•

Some therapeutic agents are beneficial for peripheral ischemia with dopamine use.

•

Single-stage elective amputations led to satisfactory rehabilitation with prosthesis.

INTRODUCTION

We present a rare case of 4 limb amputations due to peripheral gangrene which resulted from the use of inotropes for septic shock.

PRESENTATION OF CASE

A 72-year-old woman with no past medical history presented with fever and pain in bilateral big toes. She was diagnosed with Streptococcal pneumoniae septicaemia and was started on broad spectrum antibiotics, dopamine and noradrenaline in the medical intensive care unit. She developed peripheral gangrene of all 4 extremities due to microvascular spasm from inotrope use and 4 limb amputations were performed electively in a single stage.

DISCUSSION

The gangrene was contributed by the presence of disseminated intravascular coagulation and septic shock. There was no evidence of an autoimmune disorder or vasculitis on laboratory investigations and tissue histology.

CONCLUSION

Microvascular spasm is a rare complication of inotrope use which may lead to extensive peripheral gangrene. Anecdotal reports of reversal agents have been discussed. Four limb amputations are a reasonable option especially if done in an elective setting after the gangrene has demarcated itself. Rehabilitation with prosthesis after 4 limb amputations can result in good functional outcome.

Meningococcal sepsis and purpura fulminans: the surgical perspective

Meningococcal sepsis and purpura fulminans is a rare but highly lethal disease process that requires a multidisciplinary team of experts to optimise morbidity and mortality outcomes due to the breadth of complications of the disease. The surgical perspective involves the critical care management which utilises all currently available measured outcomes of critical care management as well as experimental therapies. Limb loss is common, and is reflective of the high incidence of compartment syndrome compounded by the significant soft tissue loss secondary to purpura and limb ischaemia, presumptively due to digital microemboli. A multidisciplinary approach involving current standards in critical care and early surgical evaluation are important in improving patient outcomes and limb salvage.

Neonatal purpura fulminans secondary to group B streptococcal infection

Purpura fulminans is an acute and frequently fatal disorder characterized by sudden onset of progressive cutaneous hemorrhage and necrosis due to dermal vascular thrombosis and disseminated intravascular coagulation. The authors present a neonate with extensive purpura fulminans due to group B streptoccoccal septicemia and evaluated the attributable clinical mortality and morbidity of this potentially lethal syndrome. Clinicians especially neonatologists should be aware that early-onset sepsis of group B Streptococcus in the newborn infant with purpura fulminans could be a cause of maternal carriage due to colonization of this pathogen microorganism.

Spot diagnosis: An ominous rash in a newborn

Purpura fulminans (PF) is an ominous cutaneous condition usually associated with meningococcemia. PF in the newborn is rarely reported. We report the case of a female preterm infant with extensive PF due to group B streptococcus (GBS) septicemia. She developed multi-organ system failure despite neonatal intensive care support and succumbed 9 days later. GBS, sensitive to penicillin, was isolated from the blood cultures of the mother and the infant. Invasive early GBS infection is common in the newborn and is empirically treated with prompt institution of intravenous antibiotics. PF associated with GBS is a rare cutaneous sign that must not be missed. Mortality remains high despite aggressive treatment and ICU support.

Inpatient rehabilitation of survivors of purpura fulminans with multiple limb amputations: a case series

Purpura fulminans (PF) is a rare, rapidly progressive syndrome characterized by intravascular thrombosis and necrosis of the skin and subcutaneous tissues. Survivors are often left with considerable impairments, including organ dysfunction, adjustment disorder, extensive wounds, and amputations. This retrospective case series presents 4 adult patients who underwent multiple limb amputations secondary to acute infectious PF. All patients underwent acute inpatient rehabilitation, were fitted with prostheses during their stay, and achieved a minimal assistance level for most of their self-care and mobility skills. Rehabilitation management is discussed, including common medical issues, complications, and prosthetic considerations.

Salvaging Limbs in Cases of Severe Purpura Fulminans: Advantages of Free Flaps

BACKGROUND

Purpura fulminans remains a severe and potentially life-threatening disorder, despite advances in intensive care that have led to a significant increase in the survival rate. One major risk is amputation of extremities.

METHODS

The present report concerns a series of four patients (all male; mean age, 19 years) whose lower limb extremities were salvaged by the use of free flaps in the feet. In total, six flaps were performed (mean per patient, 1.7): three latissimus dorsi, two serratus anterior, and one combination latissimus dorsi/serratus anterior.

RESULTS

There were no flap failures, and the results are favorable after a mean follow-up of 25.5 months (range, 18 to 34 months), with all patients able to walk normally.

CONCLUSION

Although microsurgery of this type has been criticized when performed in cases of purpura fulminans, the authors' series indicates that it can be particularly effective.

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.

Plastic surgery management in pediatric meningococcal-induced purpura fulminans

Purpura fulminans associated with meningococcemia is a devastating disease in children. The tissue loss can be extensive and difficult to determine at the outset. The authors suggest a strategy to manage these wounds with the goal of preserving as much tissue and function as possible. At the present time, conservative therapy to the wounds appears to be the best course in the initial, critical phase, as long as no active local purulence is found. Debridement or amputation is performed when the nonviable tissue margins are delineated. Temporary coverage with allograft may be required; definitive coverage is accomplished when the local tissue perfusion has recovered. Future revisions are often necessary to improve these children's quality of life.

Current management of purpura fulminans: a multicenter study

Seven burn centers performed a 10-yr retrospective chart review of patients diagnosed with purpura fulminans. Patient demographics, etiology, presentation, medical and surgical treatment, and outcome were reviewed. A total of 70 patients were identified. Mean patient age was 13 yr. Neisseria meningitidis was the most common etiologic agent in infants and adolescents whereas Streptococcus commonly afflicted the adult population. Acute management consisted of antibiotic administration, volume resuscitation, ventilatory and inotropic support, with occasional use of corticosteroids (38%) and protein C replacement (9%). Full-thickness skin and soft-tissue necrosis was extensive, requiring skin grafting and amputations in 90% of the patients. One fourth of the patients required amputations of all extremities. Fasciotomies when performed early appeared to limit the level of amputation in 6 of 14 patients. Therefore, fasciotomies during the initial management of these patients may reduce the depth of soft-tissue involvement and the extent of amputations.

Surgical interventions in children with meningococcal purpura fulminans--a review of 117 procedures in 21 children

BACKGROUND/PURPOSE

There are few reports describing the surgical management and outcome of children suffering purpura fulminans secondary to meningococcal sepsis. New Zealand is in the grips of a meningococcal epidemic, and, with the attendant sequalae of the disease process, the authors sought to formally review the children who have required surgical involvement.

METHODS

A retrospective case review of children with the sequalae of meningococcal disease presenting to the Orthopedic and Plastic Surgical Units in a university teaching hospital was undertaken.

RESULTS

There were 117 procedures in 21 children performed over a 12-year period. Surgical management was separated into 2 phases-early and late. The mean delay from admission with acute sepsis to the first surgical procedure (ie, early intervention) was 15.9 days. Debridement and autologous skin grafting was the mainstay of managing the necrotic defects; however, allograft skin proved a useful adjunct as a physiologic dressing. Local flaps were used with deep defects down to bone, but in the extremities amputation to viable tissue was required once gangrene was demarcated. Amputations were carried out in 9 of 21 children. Late interventions were related to relief of contractures or fibula overgrowth causing stump ulceration. Clinical follow-up showed that all children interviewed over 5 years of age (9 children) attend ordinary regular school classes and were physically active within the context of their physical disabilities.

CONCLUSIONS

The data would suggest that children requiring surgery for purpura fulminans achieve age-appropriate milestones and are primarily limited by their physical disability related to amputations, scarring, and abnormal bone growth.

Acute Infectious Purpura Fulminans: A 15-Year Retrospective Review of 28 Consecutive Cases

Acute infectious purpura fulminans (AIPF) is a rare syndrome of hemorrhagic infarction of the skin, extremity loss, and intravascular thrombosis. It progresses rapidly and is accompanied by disseminated intravascular coagulation and vascular collapse. The victims often succumb to the disease. Our objective was to investigate the clinical manifestations, outline the clinical course, and delineate factors related to mortality among the patients with AIPF. Patients diagnosed with AIPF over a 15-year period were reviewed retrospectively for patient history, comorbid conditions, progression of clinical course, and medical and surgical management. The vast majority of the patients were under the age of 7; however, the disease process can be seen in adults. The overall mortality rate was 43 per cent. The major predisposing factors were history of recent upper respiratory infection, recent surgery or childbirth, young age, and absence of a spleen. The most common clinical manifestations were skin discoloration, disseminated intravascular coagulation, fever, and septic shock. The most common bacteria cultures were Neisseria meningitidis, Hemophilus influenzae, and Streptococcus pneumoniae. There appears to be a higher mortality in patients who did not undergo a surgical intervention. Compartment syndrome needs to be evaluated early on in the presentation. Rapid diagnosis, intensive care unit management, and prompt surgical consultation and debridement may decrease the mortality.

The protective effect of brachial plexus palsy in purpura fulminans

Acute infectious purpura fulminans is reported in a 16-month-old male with a history of posttraumatic asplenia and complete left brachial plexus palsy. This patient developed peripheral necrosis of both lower extremities and the right upper extremity, whereas the left upper extremity was completely spared from ischemia and tissue damage. Amputation of four digits on the right hand and debridement of both lower extremities were required. This patient demonstrated the protective effect of a traumatic sympathectomy, which suggests the requirement of an intact sympathetic reflex in the development of purpura fulminans.

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 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.

Management strategy in purpura fulminans with multiple organ failure in children

Purpura fulminans (PF), which describes the necrosis of soft tissue secondary to diffuse microvascular thrombosis induced by transient protein C deficiency associated with meningococcal sepsis, is unusual despite the approximately 15000 cases of bacterial meningitis which occur annually in the USA. PF has a reported mortality of 50 per cent secondary to multiple organ failure which commonly accompanies the syndrome and is associated with major long-term morbidity in those who survive. Children who develop multiple organ failure in association with purpura fulminans are difficult management problems and benefit from the unique surgical and critical care resources available in burn centres. We describe our recent experience with three such patients and suggest a management strategy, the key components of which include early excision and closure of deep wounds, aggressive critical care management and long-term follow-up should delayed epiphyseal growth occur.

Symmetrical peripheral gangrene (purpura fulminans) complicating pneumococcal sepsis

Bacterial sepsis is only infrequently accompanied by peripheral ischemia. However, we have managed 10 patients with symmetrical peripheral gangrene (purpura fulminans) accompanying pneumococcal sepsis (Streptococcus pneumoniae) during the past 15 years at a single institution. In only two (20%) of these patients could vasoconstrictor administration be implicated as contributory to gangrene. The clinical scenario was characterized by pneumococcal bacteremia, admission to the medical intensive care unit, normal proximal arterial perfusion, and symmetrical full-thickness digital and distal extremity ischemia leading to cutaneous gangrene. Three (30%) of these patients died. The failure of anticoagulant and antiplatelet agents as therapy and the successful reversal of impending digital gangrene in one patient by sympathetic blockade suggest that the initial underlining pathophysiology is vasoconstrictive rather than thrombotic in nature. Effective management includes appropriate antibiotic therapy, avoidance of early operative intervention, conservative local débridement, and secondary skin grafting.

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.

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.

[Systemic vasculitis associated with non-streptococcal infection. Report of 4 cases]

The responsibility of bacterial agents in the staring of systemic vasculitis is discussed on the basis of four cases: three men and one woman presenting with severe vasculitis which revealed or complicated a focus of infection without hematogenic dissemination. Two patients had gastrointestinal lesions and one had severe renal lesions. The vasculitis affected small caliber vessels, and in two out of four cases it involved arterioles of medium caliber with histological images resembling periarteritis nodosa. Antibiotic therapy alone was immediately effective against vasculitis. However, a purely cutaneous relapse occurred in three patients whose disease had regressed under an adjuvant treatment.

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.

Gangrenous cellulitis associated with gram-negative bacilli in pancytopenic patients: dilemma with respect to effective therapy

INTRODUCTION

Gangrenous (necrotizing) cellulitis is a progressive bacterial infection of skin and soft tissue; the infection can spread into subcutaneous tissue with involvement of superficial and deep fascia (necrotizing fasciitis). We describe two pancytopenic patients with polymicrobial gram-negative bacteremia and fulminating gangrenous cellulitis.

CASE REPORTS

Pseudomonas aeruginosa was isolated from a localized hemorrhagic area of the face in one patient. The chronology of infection in these two patients is documented in a series of dramatic color photographs. Despite appropriate antibiotic therapy, the infections progressed relentlessly and both patients died.

COMMENTS

We discuss the dilemma of establishing the correct diagnosis prior to the appearance of the characteristic cutaneous manifestations of hemorrhagic necrosis and gangrene. Once the diagnosis is established, surgical excision is universally recommended. Unfortunately, bleeding diatheses in pancytopenic patients with co-existing coagulation deficiencies pose logistic obstacles in urgent, real-life situations. The timing and conditions for surgery need to be elucidated in these patients. An approach to this infection is proposed. The utility of frozen-section biopsy of the involved tissue and computed tomographic scans of the involved area remains to be evaluated.

Necrotizing soft-tissue infections

A variety of infections are encountered by the practicing surgeon. Uncommonly, a patient presents with minimal external manifestations of a deep surgical soft-tissue infection. Early aggressive intervention is required to minimize the morbidity in these often debilitated patients.

Current perspectives on septic shock

Although septic shock may be initiated by invading microbes, it is the metabolic and immunologic host responses that determine the true pathophysiology of this common critical care illness. Currently, septic shock therapeutics emphasize empiric and symptomatic treatment. Biochemical elucidation of the septic process will ultimately result in specific interventions for this ominous intensive care syndrome.