Surgical management of life-threatening and disfiguring sequelae of fulminant meningococcemia

Plastic surgical treatment of purpura fulminans: Long-term follow-up of two patients

Purpura fulminans (PF) is a rapidly progressing, potentially life-threatening condition characterised by disseminated intravascular coagulation (DIC) and haemorrhagic infarction of the skin. Plastic surgical treatment of PF has never been reported in Scandinavia. The aim of this report was to review plastic surgical treatment of PF and the long-term results of two patients treated in our department. Both patients presented to a community hospital with skin lesions looking like simple traumatic skin bleeds a period after a Varicella infection. They were initially treated at the community hospitals with broad-spectrum antibiotics and adjunctive therapies. When their condition permitted, they were transferred to the department of paediatrics of Skåne University Hospital where their DIC was treated further. The patients were transferred to the department of plastic and reconstructive surgery, when medically stable, and operated on with debridement, and amputation of a toe in one patient, and the application of autologous skin grafts. The children made an excellent recovery and were discharged home after 1.5 months and 3 weeks, respectively. At follow-up, 14 years and 8 years later, respectively, the patients were fully recovered and no secondary corrections were indicated. In conclusion, debridement of necrotic tissue should be performed in a department of plastic and reconstructive surgery as soon as the child is clinically stable, and skin grafting when the wound bed permits it. Follow-up should be performed in the same fashion as for full-thickness burns.

Human skin allografts as a useful adjunct in the treatment of purpura fulminans

OBJECTIVE

The aim of this report is to discuss the role of human skin allografts in surgical coverage procedures for patients with purpura fulminans.

METHOD

We describe cases of purpura fulminans in three adults and one infant treated at our burns unit between October 2006 and January 2008.

RESULTS

The application of cryopreserved human skin allografts allowed us to obtain immediate wound closure after necrosis excision and enabled our team to subsequently perform autografts on favourable graft recipient sites.

CONCLUSION

Recourse to human skin allografts must be considered a pertinent therapeutic option in patients with purpura fulminans.

Plastic Surgery Management of Soft Tissue Loss in Meningococcal Septicemia

Soft tissue necrosis associated with meningococcemia is a major challenge for any pediatric plastic surgery service. Records of patients treated by the Department of Plastic and Maxillofacial Surgery, Royal Children's Hospital, Melbourne, Australia, were reviewed. Two hundred fifty patients were treated for meningococcemia at our institution over a 40-year period. Of these, 31 patients suffered soft tissue necrosis. Three groups were identified: lesions that healed with nonoperative management (n = 12); those that required skin grafting, flaps, or minor amputations (n = 14); and those requiring major amputations (n = 5). When compared with a comparable control group of patients with documented meningococcemia who did not suffer tissue loss (n = 35), the best predictors for requiring surgery were the presence of metabolic acidosis on admission (P < 0.0005) and a progressive thrombocytopenia (P < 0.0005). Metabolic acidosis and progressive thrombocytopenia are predictive of the need for surgery for tissue loss and underline the evolving thrombotic nature of the disease.

Early free tissue transfer following gangrene of the feet

Bilateral below knee amputation following septicaemic foot gangrene may be avoided by limited amputation and bilateral immediate free flap reconstruction. This technique results in reduction in morbidity and early mobilisation.

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.

Tissue-engineered skin in the healing of wound stumps from limb amputations secondary to purpura fulminans

Currently wound treatment options of amputation stumps due to purpura fulminans include healing by secondary intention from wound debridement, split-thickness skin grafting, tissue and muscle flaps, plantar skin free transfer, skin expansion, artificial skin, and hyperbaric oxygen therapy. We saw a 6-month-old girl with purpura fulminans as a complication of meningococcemia. She developed necrosis of the distal extremities resulting in bilateral amputation of the lower limbs. Shortly thereafter the leg stumps also became necrosed and she underwent unsuccessful split-thickness grafts of lower limb ulcers. The patient's difficult-to-heal wounds made her an excellent candidate for treatment with tissue-engineered skin. At 10 months of age, this was applied to her previously nonhealing wounds. The tissue-engineered skin induced rapid healing of the patient's chronic amputation stump ulcers and provided her with substantial pain relief. In conclusion, tissue-engineered skin appears to be a potential beneficial treatment for chronic wounds in children with nonhealing amputation stumps.

Mandatory bone scans for the assessment of extremity loss in meningococcal septicaemia?

Meningococcal septicaemia can cause progressive necrosis of skin, soft tissue and bone. Successful limb reconstruction following the disease depends on an accurate assessment of the viability of these tissues and on a multidisciplinary team approach to ensure optimal care. However, bone scanning is not commonly performed in these patients. We present a case of meningococcal septicaemia where bone scanning significantly altered the management by demonstrating an extensive area of bone necrosis proximal to the soft-tissue necrosis. In view of this finding, we propose that bone scanning should be considered in all cases of meningococcal septicaemia where there is tissue necrosis affecting a limb, and that the radiologist should be considered a vital member of the multidisciplinary team.

Meningococcal septicaemia and plastic surgery--a strategy for management

Meningococcal septicaemia is a severe life threatening illness that is part of the spectrum of meningococcal disease. It is of particular concern to the plastic and reconstructive surgeon because as the medical and intensive care of these patients improves, more are surviving the acute phase of the septicaemia and suffering from the associated complications such as skin necrosis and extremity loss. Recently there have been several reports in the literature concerning the management of skin infarction with both skin grafting and free flap surgery. This paper will provide an update on the proposed pathophysiological mechanisms involved, summarise the present data on plastic surgical care and suggest a stratagem for future management of these difficult cases.

Update on meningococcal disease with emphasis on pathogenesis and clinical management

The only natural reservoir of Neisseria meningitidis is the human nasopharyngeal mucosa. Depending on age, climate, country, socioeconomic status, and other factors, approximately 10% of the human population harbors meningococci in the nose. However, invasive disease is relatively rare, as it occurs only when the following conditions are fulfilled: (i) contact with a virulent strain, (ii) colonization by that strain, (iii) penetration of the bacterium through the mucosa, and (iv) survival and eventually outgrowth of the meningococcus in the bloodstream. When the meningococcus has reached the bloodstream and specific antibodies are absent, as is the case for young children or after introduction of a new strain in a population, the ultimate outgrowth depends on the efficacy of the innate immune response. Massive outgrowth leads within 12 h to fulminant meningococcal sepsis (FMS), characterized by high intravascular concentrations of endotoxin that set free high concentrations of proinflammatory mediators. These mediators belonging to the complement system, the contact system, the fibrinolytic system, and the cytokine system induce shock and diffuse intravascular coagulation. FMS can be fatal within 24 h, often before signs of meningitis have developed. In spite of the increasing possibilities for treatment in intensive care units, the mortality rate of FMS is still 30%. When the outgrowth of meningococci in the bloodstream is impeded, seeding of bacteria in the subarachnoidal compartment may lead to overt meningitis within 24 to 36 h. With appropriate antibiotics and good clinical surveillance, the mortality rate of this form of invasive disease is 1 to 2%. The overall mortality rate of meningococcal disease can only be reduced when patients without meningitis, i.e., those who may develop FMS, are recognized early. This means that the fundamental nature of the disease as a meningococcus septicemia deserves more attention.

Update on meningococcal disease with emphasis on pathogenesis and clinical management

The only natural reservoir of Neisseria meningitidis is the human nasopharyngeal mucosa. Depending on age, climate, country, socioeconomic status, and other factors, approximately 10% of the human population harbors meningococci in the nose. However, invasive disease is relatively rare, as it occurs only when the following conditions are fulfilled: (i) contact with a virulent strain, (ii) colonization by that strain, (iii) penetration of the bacterium through the mucosa, and (iv) survival and eventually outgrowth of the meningococcus in the bloodstream. When the meningococcus has reached the bloodstream and specific antibodies are absent, as is the case for young children or after introduction of a new strain in a population, the ultimate outgrowth depends on the efficacy of the innate immune response. Massive outgrowth leads within 12 h to fulminant meningococcal sepsis (FMS), characterized by high intravascular concentrations of endotoxin that set free high concentrations of proinflammatory mediators. These mediators belonging to the complement system, the contact system, the fibrinolytic system, and the cytokine system induce shock and diffuse intravascular coagulation. FMS can be fatal within 24 h, often before signs of meningitis have developed. In spite of the increasing possibilities for treatment in intensive care units, the mortality rate of FMS is still 30%. When the outgrowth of meningococci in the bloodstream is impeded, seeding of bacteria in the subarachnoidal compartment may lead to overt meningitis within 24 to 36 h. With appropriate antibiotics and good clinical surveillance, the mortality rate of this form of invasive disease is 1 to 2%. The overall mortality rate of meningococcal disease can only be reduced when patients without meningitis, i.e., those who may develop FMS, are recognized early. This means that the fundamental nature of the disease as a meningococcus septicemia deserves more attention.

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.

The role of moist wound healing in the management of meningococcal skin lesions

This report describes the management of haemorrhagic skin lesions in a patient with meningococcal meningitis.

Purpura fulminans localising to a recent burn injury

The development of progressive, severe skin changes (purpura fulminans) is a serious complication of septicaemia, particularly meningococcal septicaemia. Purpura fulminans almost invariably leads to some full thickness skin loss and may lead to limb amputation. The pathophysiology may involve microemboli, endotoxins and direct bacterial damage to the vessels. We describe a case of purpura fulminans, probably as a result of meningococcal septicaemia, localising to a recent, healed burn with complete resolution. We can find no other record of the skin manifestations of meningococcal septicaemia localising to a previous injury.

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.

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.

The management of skin infarction after meningococcal septicaemia in children

The clinical course and management of 21 children (12 females, 9 males; mean age 2.4 years) with skin necrosis secondary to meningococcal septicaemia is described. Skin necrosis was most commonly sited in the lower limbs (20 patients). Sixteen patients had multiple areas of involvement and amputation of the digits was required in 5 patients. One required an above knee amputation. Small areas of skin necrosis were managed conservatively (4 patients) but larger areas required debridement and grafting. Skin grafting was delayed in 15 patients and graft loss occurred in 8. Multiple grafting procedures were required in 6 patients. Scar revision was required in 6 patients. Nutritional support is also an important component of management.