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Gouia HF, Duraes M, Delpont M, Herlin C, Biron-Andreani C, Jeziorski E, Captier G, Theron A. Thrombosis in the perforasome in idiopathic purpura fulminans with anti-protein S antibodies: Anatomical and clinical evidence to improve management. Clin Hemorheol Microcirc 2024:CH242162. [PMID: 39031343 DOI: 10.3233/ch-242162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2024]
Abstract
Idiopathic purpura fulminans (IPF) is a rare and severe form of purpura fulminans caused by acquired protein S deficiency. It can lead to severe thrombotic complications, such as large skin necrosis and amputation. The lesions almost exclusively affect the lower limbs, and their distribution is similar among patients with IPF, unlike classical purpura fulminans lesions. Our hypothesis is that vascular structures called perforasomes may be involved in IPF, possibly caused by protein S deficiency. We analyzed all case reports and case series published in the literature that provided sufficient data for an anatomical study of limb injuries. For precise localization of areas of necrosis, we examined each case using descriptions and images to determine whether they overlapped with vascular territories that include perforasomes. We analyzed twelve cases from the literature and identified six vascular territories: the anterolateral, anteromedial, and posterior territories of the upper leg, as well as the anterolateral, anteromedial, and posterolateral territories of the lower leg. For each territory, we described the most probable vascular damage and the corresponding perforasome. IPF is a complex multifactorial disease in which a direct involvement of perforating arteries may be suspected and taken into account in the surgical of lesions.
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Affiliation(s)
- H-F Gouia
- Department of Pediatric Surgery, CHU de Montpellier, University of Montpellier, Montpellier, France
- Department of Plastic, Reconstructive and Aesthetic Surgery, CHU de Montpellier, University of Montpellier, Montpellier, France
| | - M Duraes
- Faculty of Medicine, Anatomy Laboratory, University of Montpellier, Montpellier, France
| | - M Delpont
- Department of Pediatric Surgery, CHU de Montpellier, University of Montpellier, Montpellier, France
| | - C Herlin
- Department of Plastic, Reconstructive and Aesthetic Surgery, CHU de Montpellier, University of Montpellier, Montpellier, France
| | - C Biron-Andreani
- Department of Biological Hematology, CHU de Montpellier, University of Montpellier, Montpellier, France
| | - E Jeziorski
- Department of Pediatric Infectious Disease and Immunology, CHU de Montpellier, University of Montpellier, Montpellier, France
| | - G Captier
- Department of Pediatric Surgery, CHU de Montpellier, University of Montpellier, Montpellier, France
- Faculty of Medicine, Anatomy Laboratory, University of Montpellier, Montpellier, France
| | - A Theron
- Department of Pediatric Oncology and Hematology, CHU de Montpellier, University of Montpellier, Montpellier, France
- IRMB, INSERM, University of Montpellier, Montpellier, France
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Theron A, Dautremay O, Boissier E, Zerroukhi A, Baleine J, Moulis L, Rodière M, Schved JF, Duraes M, Kanouni T, Cau-Diaz I, Jeziorski E, Biron-Andreani C. Idiopathic purpura fulminans associated with anti-protein S antibodies in children: a multicenter case series and systematic review. Blood Adv 2022; 6:495-502. [PMID: 34788405 PMCID: PMC8791598 DOI: 10.1182/bloodadvances.2021005126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 10/21/2021] [Indexed: 11/30/2022] Open
Abstract
Idiopathic purpura fulminans (IPF) is a rare but severe prothrombotic coagulation disorder that can occur after chickenpox or human herpesvirus 6 (HHV-6) infection. IPF leads to an autoantibody-mediated decrease in the plasma concentration of protein S. We conducted a retrospective multicenter study involving patients with IPF from 13 French pediatric centers and a systematic review of cases in published literature. Eighteen patients were included in our case series, and 34 patients were included as literature review cases. The median age was 4.9 years, and the diagnostic delay after the first signs of viral infection was 7 days. The lower limbs were involved in 49 patients (94%) with typical lesions. In all, 41 patients (78%) had a recent history of varicella-zoster virus infection, and 7 patients (14%) had been infected by HHV-6. Most of the patients received heparin (n = 51; 98%) and fresh frozen plasma transfusions (n = 41; 79%); other treatment options were immunoglobulin infusion, platelet transfusion, corticosteroid therapy, plasmapheresis, and coagulation regulator concentrate infusion. The antithrombin level and platelet count at diagnosis seemed to be associated with severe complications. Given the rarity of this disease, the creation of a prospective international registry is required to consolidate these findings.
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Affiliation(s)
- Alexandre Theron
- Department of Pediatric Oncology and Hematology
- Resource and Competence Center for Hereditary Hemorrhagic Diseases, and
| | - Olivier Dautremay
- Department of Biological Hematology, University of Montpellier, CHU Montpellier, Montpellier, France
- Bioard’aisne Laboratory, Charleville-Mézières, France
| | - Elodie Boissier
- Department of Biological Hematology, University of Montpellier, CHU Montpellier, Montpellier, France
- Laboratory of Hematology, University Hospital, Nantes, France
| | | | - Julien Baleine
- Department of Neonatal Medicine and Pediatric Intensive Care, University of Montpellier, CHU Montpellier, Montpellier, France
| | | | - Michel Rodière
- Department of Pediatrics, Infectious Diseases, and Immunology, University of Montpellier, CHU Montpellier, Montpellier, France
| | - Jean-François Schved
- Resource and Competence Center for Hereditary Hemorrhagic Diseases, and
- Department of Biological Hematology, University of Montpellier, CHU Montpellier, Montpellier, France
| | - Martha Duraes
- Anatomy Laboratory, University of Montpellier, Montpellier, France; and
| | - Tarik Kanouni
- Department of Clinical Hematology, University of Montpellier, CHU Montpellier, Montpellier, France
| | - Isabelle Cau-Diaz
- Department of Biological Hematology, University of Montpellier, CHU Montpellier, Montpellier, France
| | - Eric Jeziorski
- Department of Pediatrics, Infectious Diseases, and Immunology, University of Montpellier, CHU Montpellier, Montpellier, France
| | - Christine Biron-Andreani
- Resource and Competence Center for Hereditary Hemorrhagic Diseases, and
- Department of Biological Hematology, University of Montpellier, CHU Montpellier, Montpellier, France
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Pasquesoone L, Belkhou A, Gottrand L, Guerreschi P, Duquennoy-Martinot V. [Management of purpura fulminans lesions in children]. ANN CHIR PLAST ESTH 2016; 61:605-612. [PMID: 27289551 DOI: 10.1016/j.anplas.2016.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 05/05/2016] [Indexed: 11/29/2022]
Abstract
Purpura fulminans is a pediatric life-threatening emergency with a significant mortality, combining: septic shock, extensive purpuric lesions and disseminated intravascular coagulation. The most frequent bacterial pathogen is the meningococcus. The medical management includes antibiotics, corticoids, vascular filling and catecholamines. Purpura fulminans is characterized by the extent of hemorrhagic and mainly thrombotic lesions, attributed to the alteration in the vascular endothelium functions. Damage of soft tissues combines large necrotic areas and more or less extensive distal ischemic lesions. Necrotic lesions can be deep, reaching skin, subcutaneous tissue, fascia, muscle and sometimes even the bone. The importance of the aesthetic and functional sequelae as well as future quality of life, depend on the quality of surgical management for these wide and deep lesions. Fasciotomy is sometimes urgently needed in the case of a clinical compartment syndrome, confirmed by a high-pressure measurement in the muscle compartments. Debridement of necrotic lesions and amputations are only performed after a clear delineation of necrotic areas, between 10 days and 3 weeks of evolution. If an amputation is necessary, it must focus on the residual bone length, considering the child's growth potential. The coverage of tissue loss uses all the plastic surgery techniques, more or less complex, in order to reduce scars to minimum for these children. Rehabilitation follow-up includes physical and psychological care, which are essential until adulthood.
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Affiliation(s)
- L Pasquesoone
- Service de chirurgie plastique, reconstructrice et esthétique, centre de traitement des brûlés, hôpital Roger-Salengro, CHRU de Lille, rue Émile-Laine, 59037 Lille cedex, France.
| | - A Belkhou
- Clinique de chirurgie et orthopédie de l'enfant, hôpital Jeanne-de-Flandre, CHRU de Lille, avenue Eugène-Avinée, 59000 Lille, France
| | - L Gottrand
- Centre de rééducation Marc-Sautelet, 10, rue du Petit-Boulevard, 59650 Villeneuve-d'Ascq, France
| | - P Guerreschi
- Service de chirurgie plastique, reconstructrice et esthétique, centre de traitement des brûlés, hôpital Roger-Salengro, CHRU de Lille, rue Émile-Laine, 59037 Lille cedex, France
| | - V Duquennoy-Martinot
- Service de chirurgie plastique, reconstructrice et esthétique, centre de traitement des brûlés, hôpital Roger-Salengro, CHRU de Lille, rue Émile-Laine, 59037 Lille cedex, France
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