1
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Bhandari P, Dorji T, Sharma TR, Mynak ML. Fatal case of meningococcal meningitis in a child from rural Bhutan: A case report. Clin Case Rep 2024; 12:e9396. [PMID: 39210925 PMCID: PMC11358032 DOI: 10.1002/ccr3.9396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Revised: 07/12/2024] [Accepted: 08/16/2024] [Indexed: 09/04/2024] Open
Abstract
N meningiditis remains an important cause of central nervous system infection. A high index of suspicion is required especially in infants. While empirical antibiotics may be initiated, diagnostic measures must be adopted for guided therapy. Notification of such cases contributes to surveillance data and deciding on providing vaccines to the population.
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Affiliation(s)
| | - Thinley Dorji
- Department of Internal MedicineCentral Regional Referral HospitalGelephuBhutan
| | - Tulsi Ram Sharma
- Department of PaediatricsJigme Dorji Wangchuck National Referral HospitalThimphuBhutan
| | - Mimi Lhamu Mynak
- Department of PaediatricsCentral Regional Referral HospitalGelephuBhutan
- Department of Internal MedicineCentral Regional Referral HospitalGelephuBhutan
- Department of PaediatricsJigme Dorji Wangchuck National Referral HospitalThimphuBhutan
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2
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Tanaka Y, Nakayama S, Ueno T, Miura T. Prosthetic Rehabilitation for a Patient With Purpura Fulminans Undergoing Quadruple Amputation: A Case Report. Cureus 2024; 16:e67384. [PMID: 39310561 PMCID: PMC11416141 DOI: 10.7759/cureus.67384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2024] [Indexed: 09/25/2024] Open
Abstract
Purpura fulminans (PF) is a rare and life-threatening syndrome characterized by cutaneous purpura resulting from disseminated intravascular coagulation (DIC) and intravascular thrombosis. PF typically develops as a severe complication of infections and is associated with high mortality rates. Effective treatment involves early recognition, aggressive resuscitation, appropriate antibiotic therapy, and the correction of coagulation abnormalities. Nevertheless, despite effective treatment, patients often ultimately require amputation of the affected limbs. This case report details the rehabilitation process of a patient with PF who underwent quadruple amputation. The patient, a 48-year-old male, underwent quadruple amputation due to PF. After intensive care, he was admitted to a convalescent rehabilitation ward for prosthetic rehabilitation. The rehabilitation process combined physical and occupational therapy to facilitate independent living through the use of upper and lower limb prostheses and assistive devices. The patient presented with ulcerative lesions on the anterior surfaces of both knee joints upon admission. During treatment, he developed osteomyelitis of the right patella, which required intravenous antibiotics and limited rehabilitation to bed-based exercises. Following the administration of intravenous therapy, the prosthetist proceeded with the fabrication of lower limb prostheses. Subsequently, the patient was able to commence standing and gait training, and by the time of discharge, he was able to walk without a cane. Upper limb prostheses enabled independence in activities of daily living (ADLs) such as eating, dressing, and toileting. He was also able to perform cooking-related activities that are part of the instrumental activities of daily living (IADLs). This case highlights the importance and achievable outcomes of rehabilitation for patients with PF who have undergone quadruple amputation. A multidisciplinary approach utilizing both upper and lower limb prostheses, as well as assistive devices, enabled significant functional recovery.
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Affiliation(s)
- Yohei Tanaka
- Rehabilitation Medicine, JR Tokyo General Hospital, Tokyo, JPN
| | | | - Takaaki Ueno
- Rehabilitation Medicine, JR Tokyo General Hospital, Tokyo, JPN
| | - Toshiki Miura
- Orthopedic Surgery, JR Tokyo General Hospital, Tokyo, JPN
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3
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Sweeney PL, Morison DG, Bojanowski CM. Staphylococcus aureus induced purpura fulminans. Am J Med Sci 2024; 367:e56-e57. [PMID: 38219983 DOI: 10.1016/j.amjms.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 11/01/2023] [Accepted: 01/10/2024] [Indexed: 01/16/2024]
Affiliation(s)
- Patrick L Sweeney
- Department of Medicine, Tulane University School of Medicine, New Orleans, LA, USA
| | - Doree G Morison
- Department of Medicine, Tulane University School of Medicine, New Orleans, LA, USA
| | - Christine M Bojanowski
- Department of Medicine, Section of Pulmonary Diseases, Critical Care and Environmental Medicine, Tulane University School of Medicine, New Orleans, LA, USA.
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4
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Okai N, Otsuka Y, Masaki S, Kudo M, Watanabe T. Necrotizing Fasciitis of the Serratus Anterior in a Patient Treated With Infliximab and Prednisolone for Ulcerative Colitis and Rheumatoid Arthritis. Cureus 2024; 16:e59346. [PMID: 38817521 PMCID: PMC11137776 DOI: 10.7759/cureus.59346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 06/01/2024] Open
Abstract
Necrotizing fasciitis (NF) is a rapidly progressive bacterial infection with high mortality. Invasive group A Streptococcus (GAS) infection is the leading cause of NF. Our understanding regarding clinicopathological features and pathogenesis of invasive GAS infection is expanding as the incidence of NF in healthy individuals increases. However, clinicopathological features of NF in the presence of autoimmune diseases have been poorly defined. We experienced NF in a patient treated with infliximab and prednisolone for ulcerative colitis and rheumatoid arthritis. Herein, we present time kinetics findings of clinical symptoms and laboratory data of GAS-associated NF in the presence of immunosuppressant-treated immune disorders.
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Affiliation(s)
- Natsuki Okai
- Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, JPN
| | - Yasuo Otsuka
- Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, JPN
| | - Sho Masaki
- Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, JPN
| | - Masatoshi Kudo
- Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, JPN
| | - Tomohiro Watanabe
- Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, JPN
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5
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Bendapudi PK, Nazeen S, Ryu J, Söylemez O, Robbins A, Rouaisnel B, O’Neil JK, Pokhriyal R, Yang M, Colling M, Pasko B, Bouzinier M, Tomczak L, Collier L, Barrios D, Ram S, Toth-Petroczy A, Krier J, Fieg E, Dzik WH, Hudspeth JC, Pozdnyakova O, Nardi V, Knight J, Maas R, Sunyaev S, Losman JA. Low-frequency inherited complement receptor variants are associated with purpura fulminans. Blood 2024; 143:1032-1044. [PMID: 38096369 PMCID: PMC10950473 DOI: 10.1182/blood.2023021231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 11/15/2023] [Indexed: 03/16/2024] Open
Abstract
ABSTRACT Extreme disease phenotypes can provide key insights into the pathophysiology of common conditions, but studying such cases is challenging due to their rarity and the limited statistical power of existing methods. Herein, we used a novel approach to pathway-based mutational burden testing, the rare variant trend test (RVTT), to investigate genetic risk factors for an extreme form of sepsis-induced coagulopathy, infectious purpura fulminans (PF). In addition to prospective patient sample collection, we electronically screened over 10.4 million medical records from 4 large hospital systems and identified historical cases of PF for which archived specimens were available to perform germline whole-exome sequencing. We found a significantly increased burden of low-frequency, putatively function-altering variants in the complement system in patients with PF compared with unselected patients with sepsis (P = .01). A multivariable logistic regression analysis found that the number of complement system variants per patient was independently associated with PF after controlling for age, sex, and disease acuity (P = .01). Functional characterization of PF-associated variants in the immunomodulatory complement receptors CR3 and CR4 revealed that they result in partial or complete loss of anti-inflammatory CR3 function and/or gain of proinflammatory CR4 function. Taken together, these findings suggest that inherited defects in CR3 and CR4 predispose to the maladaptive hyperinflammation that characterizes severe sepsis with coagulopathy.
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Affiliation(s)
- Pavan K. Bendapudi
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston, MA
- Division of Hematology and Blood Transfusion Service, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Sumaiya Nazeen
- Harvard Medical School, Boston, MA
- Division of Genomic Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Justine Ryu
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Onuralp Söylemez
- Harvard Medical School, Boston, MA
- Division of Genomic Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Alissa Robbins
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Betty Rouaisnel
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Jillian K. O’Neil
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Ruchika Pokhriyal
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Moua Yang
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Meaghan Colling
- Division of Hematology and Blood Transfusion Service, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Bryce Pasko
- Department of Pathology, University of Colorado School of Medicine, Aurora, CO
| | - Michael Bouzinier
- Harvard Medical School, Boston, MA
- Division of Genomic Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Lindsay Tomczak
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston, MA
| | - Lindsay Collier
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston, MA
| | - David Barrios
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Sanjay Ram
- Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester, MA
| | - Agnes Toth-Petroczy
- Harvard Medical School, Boston, MA
- Division of Genomic Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Joel Krier
- Harvard Medical School, Boston, MA
- Division of Genomic Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Elizabeth Fieg
- Division of Genomic Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Walter H. Dzik
- Division of Hematology and Blood Transfusion Service, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - James C. Hudspeth
- Department of Medicine, Boston Medical Center, Boston, MA
- Boston University School of Medicine, Boston, MA
| | - Olga Pozdnyakova
- Harvard Medical School, Boston, MA
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA
| | - Valentina Nardi
- Harvard Medical School, Boston, MA
- Department of Pathology, Massachusetts General Hospital, Boston, MA
| | - James Knight
- Yale Center for Genome Analysis, Yale University, New Haven, CT
| | - Richard Maas
- Harvard Medical School, Boston, MA
- Division of Genomic Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Shamil Sunyaev
- Harvard Medical School, Boston, MA
- Division of Genomic Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Julie-Aurore Losman
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Division of Hematology, Brigham and Women’s Hospital, Boston, MA
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6
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Hussain H, Fadel A, Garcia E, Ruiz MA, Michel G, Saadoon ZF, Sarfraz R, Jayakumar AR. Development of purpura fulminans by Candida glabrata and Mucormycosis infection post-surgery. IDCases 2023; 34:e01918. [PMID: 37954167 PMCID: PMC10638051 DOI: 10.1016/j.idcr.2023.e01918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 10/04/2023] [Accepted: 10/25/2023] [Indexed: 11/14/2023] Open
Abstract
Purpura fulminans (PF) is a disorder with multifactorial causes that lead to acute localize skin microvasculature thrombosis. PF can be classified as one of the manifestations of disseminated vascular coagulation (DIC). Although, there are three types of PF including hereditary (autosomal dominant) due to mutations in single nucleotide polymorphisms (PROC and PROS1) and serpin family C member 1 (SERPINC1) genes. Idiopathic or acquired type of PF is complex and the pathophysiology is ambiguous, however, low levels of protein C and S were observed. The acute infectious form of PF occurs post-bacterial infection (e.g., Neisseria). The clinical presentation is limited to skin findings or systematic manifestation (shock, disseminated intravascular coagulation, or death). We are presenting two cases of PF sharing similar clinical manifestations developed within 12 h post-operatively with distinct micro-organisms infection. The first patient's wound culture grew fluffy mold, and the sequencing confirmed a Mucormycosis, Absidia corymbifera species, while the second patient was infected by cutaneous Candida glabrata which led to the development of PF. Our findings suggest that surgery can trigger local immunological responses in susceptible individuals such as concealed protein C and S deficiency or microorganism toxins that initiated the rapidly developing of PF in those patients.
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Affiliation(s)
- Hussain Hussain
- Larkin Community Hospital Department of Internal Medicine - Infectious Disease, Miami, FL, USA
| | - Aya Fadel
- Hackensack Meridian Health Department of Internal Medicine at Ocean Medical Center, NJ, USA
| | - Efrain Garcia
- Larkin Community Hospital Department of Internal Medicine - Infectious Disease, Miami, FL, USA
| | - Marco A. Ruiz
- Larkin Community Hospital Department of Internal Medicine - Infectious Disease, Miami, FL, USA
| | - George Michel
- Larkin Community Hospital Department of Internal Medicine - Infectious Disease, Miami, FL, USA
| | - Zahraa F. Saadoon
- Larkin Community Hospital Department of Internal Medicine - Infectious Disease, Miami, FL, USA
| | - Rehan Sarfraz
- Larkin Community Hospital Department of Internal Medicine - Infectious Disease, Miami, FL, USA
| | - Arumugam R. Jayakumar
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
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7
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Tew ZY, Johnson D, Louis G, Bhowmick K. Purpura fulminans in a hyposplenic patient arising from pneumococcal sinusitis. BMJ Case Rep 2023; 16:e253043. [PMID: 37460246 PMCID: PMC10357718 DOI: 10.1136/bcr-2022-253043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
We report a previously healthy woman in her 50s who presented with sepsis, rapidly progressive purpuric rash and disseminated intravascular coagulation. She was diagnosed with acute infective purpura fulminans due to invasive pneumococcal infection likely secondary to sinusitis. Our case report discusses our initial diagnostic uncertainty and approach in investigating and treating such a critically unwell patient.
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Affiliation(s)
- Zi Yi Tew
- Department of Anaesthesia, West Suffolk NHS Foundation Trust, Bury Saint Edmunds, UK
| | - Daniel Johnson
- Department of General Medicine, West Suffolk NHS Foundation Trust, Bury Saint Edmunds, UK
| | - Gerard Louis
- Department of Emergency Medicine, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
| | - Kaushik Bhowmick
- Department of Anaesthesia, West Suffolk NHS Foundation Trust, Bury Saint Edmunds, UK
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8
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Temnithikul B, Rungrunanghiranya S, Limtanyakul P, Angkananard T, Wessagowit V. Klebsiella-induced acute infectious purpura fulminans in a Thai woman: Case report and review of literature. SKIN HEALTH AND DISEASE 2023; 3:e186. [PMID: 37275425 PMCID: PMC10233087 DOI: 10.1002/ski2.186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 11/08/2022]
Abstract
Purpura fulminans (PF) is an uncommon syndrome of acute purplish skin eruption characterized by coagulation of the microvasculature, which leads to purplish lesions and skin necrosis. There are three subtypes; idiopathic PF, neonatal PF and, the most common subtype, acute infectious PF (AIPF). Acute infectious PF is related to the thrombotic subtype of disseminated intravascular coagulation (DIC) and usually is superimposed on sepsis. This can rapidly lead to multi-organ failure from thrombotic occlusion of small and medium-sized blood vessels. We report a case of Klebsiella-induced AIPF in a 78-year-old Thai woman and also review other published cases.
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Affiliation(s)
- Bhakinai Temnithikul
- Department of MedicineHRH Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot UniversityOngkharakNakhon NayokThailand
| | - Suthat Rungrunanghiranya
- Department of MedicineHRH Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot UniversityOngkharakNakhon NayokThailand
| | | | - Teeranan Angkananard
- Department of MedicineHRH Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot UniversityOngkharakNakhon NayokThailand
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9
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Perry JC, Pindek RL, Sur A, Kc N, Zeibeq J. Alcohol Abuse as a Silent Risk Factor for Purpura Fulminans and the Importance of Pneumococcal Vaccination. Cureus 2023; 15:e39522. [PMID: 37378100 PMCID: PMC10292072 DOI: 10.7759/cureus.39522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2023] [Indexed: 06/29/2023] Open
Abstract
Purpura fulminans (PF) is a rare presentation of disseminated intravascular coagulopathy (DIC) and a life-threatening complication of septic shock. DIC can present with bleeding and thrombosis in acute settings, making its management exceptionally challenging. Common causative organisms include Neisseria meningitidis, Streptococcus pneumoniae, andHaemophilus influenzae. We report a case of a 47-year-old patient with a history of alcohol abuse and marijuana use with a bizarre presentation of copious diarrhea and altered mental status. The patient was subsequently admitted to the intensive care unit (ICU) for acute respiratory failure and septic shock secondary to Streptococcus pneumoniae bacteremia complicated by DIC. Unfortunately, the patient's condition worsened with multiorgan failure and purpura fulminans, leading to extensive necrosis of all his extremities, with the involvement of his lips, nose, and genitals. Unfortunately, despite aggressive interventions, he continued to deteriorate and ultimately was transitioned to comfort care before he expired. In the literature, there is only one reported case of PF in an individual with alcohol abuse. However, the frequency and severity of pneumococcal infections in individuals with a history of alcohol abuse are much higher than in the general population. PF is a devastating complication of Streptococcus pneumoniae, with a mortality of 43%. We hope that this case will continue highlighting the importance of vaccinating patients with a history of alcohol abuse with the pneumococcal vaccine.
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Affiliation(s)
- Jamal C Perry
- Medicine, Brookdale University Hospital Medical Center, Brooklyn, USA
| | - Rachel L Pindek
- Osteopathic Medicine, New York Institute of Technology College of Osteopathic Medicine, Old Westbury, USA
| | - Avtar Sur
- Internal Medicine, Brookdale University Hospital Medical Center, Brooklyn, USA
| | - Nabin Kc
- Critical Care Medicine, One Brooklyn Health System-Interfaith Medical Center, New York, USA
| | - John Zeibeq
- Pulmonary and Critical Care Medicine, Brookdale University Hospital Medical Center, Brooklyn, USA
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10
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Awad V, Nair P, Roy S, Yalamanchili A, Adapa S, Vemuri N. An Uncommon Presentation of Vasopressin-Induced Purpura Fulminans. J Med Cases 2023; 14:130-136. [PMID: 37188301 PMCID: PMC10181292 DOI: 10.14740/jmc4062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 04/13/2023] [Indexed: 05/17/2023] Open
Abstract
Purpura fulminans (PF) is a rarely encountered rapidly evolving dermatological manifestation of ischemia, particularly in critically ill patients. Considered one of the very few dermatological emergencies, it has high mortality rate where patients often succumb to the illness. It can manifest in three forms: neonatal, idiopathic, and the more commonly infectious variety, which can be secondary to mostly bacterial and rarely viral etiology. It is also reported to be highly associated with disseminated intravascular coagulation (DIC), heparin-induced thrombocytopenia (HIT), and acute hepatic failure (AHF). Hereditary or acquired deficiency of protein C and dysregulation of the coagulation cascade, mainly protein C-thrombomodulin, has been implicated in the pathogenesis. We present a 55-year-old male admitted to the intensive care unit for diabetic ketoacidosis (DKA) and septic shock. Along with initiating management protocol for DKA and broad-spectrum antibiotics, he was initially started on norepinephrine for septic shock. Because of persistent refractory septic shock, he was subsequently initiated on phenylephrine and vasopressin to maintain adequate perfusion. The following day, he was found to have sharply demarcated blackish non-blanching discoloration on bilateral knees, lower limbs, and scrotum, sparing the acral regions. This cutaneous manifestation persisted throughout his hospital course, although it improved after discontinuation of vasopressin while continuing with other pressors. Vasopressin has been implicated in a few instances of skin necrosis; however, PF has rarely been documented and never within 1 day like ours. This case demonstrates a unique development of PF likely from vasopressin after ruling out the diagnoses of DIC, HIT, thrombotic thrombocytopenic purpura, and AHF.
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Affiliation(s)
- Vanessa Awad
- Department of Internal Medicine, Sierra View Medical Center, Porterville, CA, USA
- Corresponding Author: Sasmit Roy, Department of Internal Medicine, University of Virginia, Lynchburg Dialysis Unit, Lynchburg, VA 24501, USA. ; Vanessa Awad, Department of Internal Medicine, Sierra View Medical Center, Porterville, CA 93257, USA.
| | - Preeth Nair
- Department of Internal Medicine, Sierra View Medical Center, Porterville, CA, USA
| | - Sasmit Roy
- Department of Internal Medicine, University of Virginia, Charlottesville, VA, USA
- Corresponding Author: Sasmit Roy, Department of Internal Medicine, University of Virginia, Lynchburg Dialysis Unit, Lynchburg, VA 24501, USA. ; Vanessa Awad, Department of Internal Medicine, Sierra View Medical Center, Porterville, CA 93257, USA.
| | | | - Sreedhar Adapa
- Department of Internal Medicine, Adventist Health, Hanford, CA, USA
| | - Nirupama Vemuri
- Department of Internal Medicine, Sierra View Medical Center, Porterville, CA, USA
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11
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Lin C, Li D, Hu B. Lower Limb Necrosis Secondary to Purpura Fulminans: A Case Report. J Burn Care Res 2023; 44:477-480. [PMID: 36548961 DOI: 10.1093/jbcr/irac186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Indexed: 12/24/2022]
Abstract
Purpura fulminans is a rare and rapidly progressive septic process characterized by the development of hemorrhagic and ecchymotic lesions and skin necrosis. In this work, we report a case of a 52-year-old woman admitted to the Department of Emergency due to progressive purpura. The physical examination demonstrated a decreased skin temperature, unpalpable dorsalis pedis arteries, and ecchymoses covering both lower extremities. Laboratory tests indicated disseminated intravascular coagulation with prolonged activated partial thromboplastin time (APTT), low prothrombin time (PT), elevated d-dimer levels, and a low platelet count. A diagnosis of purpura fulminans was made, and steroids, therapeutic plasma exchange and empiric therapy, including antibiotic and anticoagulation therapy, were initiated immediately. Our treatment resulted in a good and sustained clinical response, as evidenced by the receding of blood blisters and the normalization of the patient's coagulation factors, but bilateral below-knee amputation was inevitable. Finally, the patient recovered well and was discharged home without any complications other than amputation.
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Affiliation(s)
- Chuangqiang Lin
- Department of Emergency Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Shantou University Medical College, China
| | - Dongxin Li
- Department of Emergency Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Bei Hu
- Department of Emergency Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Shantou University Medical College, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
- School of Medicine, South China University of Technology, Guangzhou, China
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12
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Pangburn J, Gibbs J. Two Cases of COVID-19 Patients With Associated Purpura Fulminans. J Burn Care Res 2023; 44:485-486. [PMID: 36402743 DOI: 10.1093/jbcr/irac176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Indexed: 11/21/2022]
Abstract
Purpura fulminans (PF) is a life-threatening emergency involving coagulopathy and widespread skin necrosis. Early treatment, especially surgical management, is imperative as prognosis can be very poor. PF is most commonly associated with severe bacterial illness; however, viral causes are also possible. Currently in the literature, there have only been a handful of PF cases associated with COVID-19. We present two cases of PF in the setting of COVID-19 infection. Both patients had a history of underlying coagulopathies. PF can be a sign of underlying coagulopathy in a COVID-19 patient, who is already at increased risk for thromboembolic events due to the inflammatory nature of COVID itself. Due to how quickly PF can develop into life-threatening necrosis and multiorgan failure, it is imperative that these patients are referred early to a burn center for more advanced care.
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Affiliation(s)
- Jane Pangburn
- Ascension St. Vincent Hospital, Indianapolis, Indiana, USA
| | - Jeffrey Gibbs
- Ascension St. Vincent Hospital, Indianapolis, Indiana, USA
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13
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Gordeeva OB, Dobrotok AV, Selimzianova LR, Deeva VA. Transient deficiency of protein S after past infection process, complications and outcome: clinical case. PEDIATRIC PHARMACOLOGY 2023. [DOI: 10.15690/pf.v20i1.2532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
Background. Purpura fulminans (PF) – is an acute rapidly progressive thrombosis of small-diameter blood vessels located mainly on the skin of the extremities. PF is characterized by high mortality rates. Patients can have serious consequences, including amputations and loss of fingers, foots or even extremities in general.Clinical case description. A clinical case of developing transient deficiency of protein S complicated by idiopathic PF on the 7th day after acute otitis in a 3-year-old boy due to past infection is presented. The progression of the disease developed within a few hours. The patient became hemorrhagic elements on the skin of extremities, and later — tissue necrosis. The conducted therapy facilitated to stop the pathological process in the form of PF, and also prevented the development of severe disabling complications in the child.Conclusion. Differential diagnosis and treatment should be fast and accurate, as the development of PF occurs in mere hours. Diagnostics should include expanded panel of coagulological tests and instrumental examinations, which determines the justifiability of a multidisciplinary approach in the patient management with disorders in the hemostatic system.
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Affiliation(s)
- Olga B. Gordeeva
- Research Institute of Pediatrics and Children’s Health in Petrovsky National Research Centre of Surgery;
Pirogov Russian National Research Medical University
| | - Albina V. Dobrotok
- Research Institute of Pediatrics and Children’s Health in Petrovsky National Research Centre of Surgery
| | - Liliia R. Selimzianova
- Research Institute of Pediatrics and Children’s Health in Petrovsky National Research Centre of Surgery;
Pirogov Russian National Research Medical University;
Sechenov First Moscow State Medical University
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14
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Berlot G, Tomasini A, Zanchi S, Moro E, Pinamonti M, Mohamed S, de Bellis E. Waterhouse-Friderichsen syndrome following a dog bite in an asplenic patient: case report and review of the literature. Int J Emerg Med 2023; 16:12. [PMID: 36823575 PMCID: PMC9947879 DOI: 10.1186/s12245-023-00483-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/12/2023] [Indexed: 02/25/2023] Open
Abstract
The Waterhouse-Friderichsen syndrome represents a critical condition characterized by a septic shock associated with a disseminated intravascular coagulation causing the plugging of the microvascular network virtually all organs and systems, including the skin, the kidneys, the liver, and adrenal glands; the mortality rate is elevated, and survivors often must undergo multiple limb amputations. Here, we describe the uncommon case of an asplenic patient who developed this syndrome after a superficial wound caused by a dog bite causing an initial infection due to Capnocytophaga canimorsus that is part of the normal oral microbiome of pets. The clinical and pathological findings and the current and future therapeutic options are reviewed and discussed.
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Affiliation(s)
- Giorgio Berlot
- Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Integrata Di Trieste, Trieste, 34149, Italy.
| | - Ariella Tomasini
- grid.460062.60000000459364044Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Integrata Di Trieste, Trieste, 34149 Italy
| | - Silvia Zanchi
- grid.460062.60000000459364044Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Integrata Di Trieste, Trieste, 34149 Italy
| | - Edoardo Moro
- grid.460062.60000000459364044Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria Integrata Di Trieste, Trieste, 34149 Italy
| | - Maurizio Pinamonti
- grid.460062.60000000459364044Department of Pathology, Azienda Sanitaria Universitaria Integrata Di Trieste, Trieste, Italy
| | - Sara Mohamed
- grid.460062.60000000459364044Department of Hematology, Azienda Sanitaria Universitaria Integrata Di Trieste, Trieste, Italy
| | - Eleonora de Bellis
- grid.460062.60000000459364044Department of Hematology, Azienda Sanitaria Universitaria Integrata Di Trieste, Trieste, Italy
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15
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Management Strategies in Septic Coagulopathy: A Review of the Current Literature. Healthcare (Basel) 2023; 11:healthcare11020227. [PMID: 36673595 PMCID: PMC9858837 DOI: 10.3390/healthcare11020227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 01/14/2023] Open
Abstract
One of the 'organs' that can be affected by sepsis is the coagulation system. Coagulopathy in sepsis may take the form of sepsis-induced coagulopathy (SIC) or sepsis-associated disseminated intravascular coagulation (DIC). It is important to identify SIC early, as at this stage of coagulopathy anticoagulants may be of the greatest benefit. The most recent diagnostic scoring systems for septic coagulopathy come from the International Society on Thrombosis and Hemostasis and the Japanese Association for Acute Medicine. Recommendations regarding the management of septic coagulopathy differ between organizations. Moreover, septic coagulopathy is an area of intense research in recent years. Therefore we searched three databases to review the most recent management strategies in septic coagulopathy. The mainstream management strategies in septic coagulopathy include the causal treatment of sepsis, unfractionated heparin, low-molecular-weight heparin, antithrombin, and recombinant human thrombomodulin. The last two have been associated with the highest survival benefit. Nevertheless, the indiscriminate use of these anticoagulants should be avoided due to the lack of mortality benefit and increased risk of bleeding. The early diagnosis of SIC and monitoring of coagulation status during sepsis is crucial for the timely management and selection of the most suitable treatment at a time. New directions in septic coagulopathy include new diagnostic biomarkers, dynamic diagnostic models, genetic markers for SIC management, and new therapeutic agents. These new research avenues may potentially result in timelier SIC diagnosis and improved management of all stages of septic coagulopathy by making it more effective, safe, and personalized.
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16
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Kreutz J, Choukeir M, Chatzis G, Schieffer B, Markus B. Hemoadsorption as part of a multimodal therapy concept to treat Capnocytophaga sepsis with thrombocytopenia and multiple organ failure. Int J Artif Organs 2023; 46:52-57. [PMID: 36401351 DOI: 10.1177/03913988221132575] [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: 11/20/2022]
Abstract
BACKGROUND Capnocytophaga, a bacteria native to the oral flora of canines, in rare cases can lead to severe infections resulting in septic shock, respiratory tract infection, and multiple organ failure. In case of trauma following animal bites with rapidly progressing clinical courses, also adjunctive therapeutic measures such as extracorporeal blood purification therapies might be beneficial. CASE PRESENTATION We report on a 68-year-old male who was hospitalized with fever, oliguria and repeated vomiting after suffering a minor bite by his dog. On admission, he was diagnosed with sepsis. In addition, his coagulation status was markedly deranged resulting in the administration of mass transfusions to stabilize his coagulative status. Following detection of Capnocytophaga canimorsus, anti-infective therapy was initiated. In the context of a progressive respiratory deterioration and an increasing vigilance disorder, he had to be intubated. Due to development of renal failure, dialysis was started in conjunction with CytoSorb hemoadsorption therapy to control the hyperinflammatory condition. All of the applied therapeutic measures led to a rapid clinical stabilization, a control of the hyperinflammatory situation, and an improvement in his neurological status. The therapy was well tolerated with no complications encountered. CONCLUSIONS This case supports the clinical recognition of severe Capnocytophaga infection that can lead to critical conditions even in immunocompetent patients. Combined broad spectrum antibiotic therapy, mass transfusions, CRRT, and CytoSorb hemoadsorption therapy resulted in a control of the critical situation. However, further research is needed to fully elucidate the role of hemoadsorption in this rare but life-threatening setting.
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Affiliation(s)
- Julian Kreutz
- Department of Cardiology, Angiology and Critical Care Medicine, University Hospital (UKGM) Marburg, Philipps University, Marburg, Germany
| | - Maryana Choukeir
- Department of Cardiology, Angiology and Critical Care Medicine, University Hospital (UKGM) Marburg, Philipps University, Marburg, Germany
| | - Georgios Chatzis
- Department of Cardiology, Angiology and Critical Care Medicine, University Hospital (UKGM) Marburg, Philipps University, Marburg, Germany
| | - Bernhard Schieffer
- Department of Cardiology, Angiology and Critical Care Medicine, University Hospital (UKGM) Marburg, Philipps University, Marburg, Germany
| | - Birgit Markus
- Department of Cardiology, Angiology and Critical Care Medicine, University Hospital (UKGM) Marburg, Philipps University, Marburg, Germany
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17
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Goshua G, Bendapudi PK, Lee AI. Thrombosis questions from the inpatient wards. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:481-490. [PMID: 36485139 PMCID: PMC9819989 DOI: 10.1182/hematology.2022000384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
The multifaceted pathophysiologic processes that comprise thrombosis and thromboembolic diseases take on a particular urgency in the hospitalized setting. In this review, we explore 3 cases of thrombosis from the inpatient wards: purpura fulminans, cancer-associated thrombosis with thrombocytopenia, and coronavirus disease 2019 (COVID-19) and the use of dose-escalated anticoagulation therapy and antiplatelet agents. We discuss the evaluation and management of purpura fulminans and the roles of plasma transfusion, protein C and antithrombin replacement, and anticoagulation in treating this disease. We present a framework for evaluating the etiologies of thrombocytopenia in cancer and review 2 strategies for anticoagulation management in patients with cancer-associated thrombosis and thrombocytopenia, including recent prospective data supporting the use of dose-modified anticoagulation based on platelet count. Last, we dissect the major clinical trials of therapeutic- and intermediate-dose anticoagulation and antiplatelet therapy in hospitalized patients with COVID-19, reviewing key recommendations from consensus guidelines while highlighting ways in which institutional and patient-tailored practices regarding antithrombotic therapies in COVID-19 may differ. Together, the cases highlight the diverse and dramatic presentations of macro- and microvascular thrombosis as encountered on the inpatient wards.
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Affiliation(s)
- George Goshua
- Section of Hematology, Yale School of Medicine, New Haven, CT
| | - Pavan K Bendapudi
- Division of Hematology, Blood Transfusion Service, Massachusetts General Hospital; Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center; and Harvard Medical School, Boston, MA
| | - Alfred Ian Lee
- Section of Hematology, Yale School of Medicine, New Haven, CT
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18
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Muacevic A, Adler JR, Ngwudike C, Tripathi M. Right Lower Extremity Phlegmasia Cerulea Dolens Due to Iliotibial Vein Thrombosis With Compartment Syndrome and Circulatory Shock: Case Report and Review. Cureus 2022; 14:e32364. [PMID: 36628047 PMCID: PMC9826733 DOI: 10.7759/cureus.32364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2022] [Indexed: 12/13/2022] Open
Abstract
Phlegmasia cerulea dolens (PCD) is a rare and life-threatening complication of extensive deep vein thrombosis (DVT) characterized by severe pain, swelling, and cyanosis of the affected limb. It results from total or near-total occlusion of the deep and superficial veins of a limb, leading to venous congestion and ischemia. It is associated with 40% mortality, more commonly affecting the left lower extremity, with up to 50% of patients requiring limb amputations. PCD complicated by compartment syndrome (CS) with shock and multiorgan failure is very rare. We report the case of a 55-year-old female who presented with sudden onset, severe right lower extremity pain and swelling with associated limb discoloration, paresthesias, and inability to move the toes of her right foot. On examination, there was cyanosis, pulselessness, and tense right leg and thigh compartments. Doppler ultrasonography revealed DVT of the right external iliac extending to the posterior tibial vein. A diagnosis of PCD with CS was made and the patient was immediately started on anticoagulation with unfractionated heparin and emergent decompressive fasciotomies of the right leg and thigh were performed. Following the fasciotomies, she developed circulatory shock and went into cardiac arrest. Despite successful resuscitation, her hemodynamic instability and multiorgan failure precluded further life-saving interventions including thrombolysis or thrombectomy. Limb amputation was declined given her poor prognosis and she passed away shortly thereafter. This case illustrates the rare occurrence of right lower extremity PCD complicated by CS, circulatory shock, and multiorgan failure, which can sometimes occur despite emergency fasciotomy but can be averted with prompt intervention. These complications often preclude immediate thrombolysis and/or thrombectomy. Its recognition, therefore, warrants timely and more aggressive interventions to prevent limb loss or death.
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19
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Ishii J, Haratake D, Ito M, Shime N. Purpura fulminans due to Rickettsia japonica. QJM 2022; 115:758-759. [PMID: 35976146 DOI: 10.1093/qjmed/hcac188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- J Ishii
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - D Haratake
- Department of General Internal Medicine, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - M Ito
- Department of General Internal Medicine, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - N Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
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20
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Symmetrical Peripheral Gangrene: Report of Three Cases. Case Rep Crit Care 2022; 2022:8615420. [PMID: 36278033 PMCID: PMC9581682 DOI: 10.1155/2022/8615420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 09/01/2022] [Accepted: 09/06/2022] [Indexed: 11/07/2022] Open
Abstract
Symmetrical peripheral gangrene (SPG) is a rare clinical syndrome characterized by an acute onset of ischemic damage in two or more extremities without obstruction or vasculitis of supplying vessels. Body parts commonly affected include toes, hands, scrotum, and earlobes, increasing the risk of limb amputation and impairing the quality of life. The vascular injury mechanism is disseminated intravascular coagulation. SPG may manifest unpredictably in conditions associated with septic shock, low output states, vasospastic conditions, myeloproliferative disorders, or hyperviscosity syndrome. A review on the topic is presented based on a 3-case series of SPG that required amputation of fingers and toes after the administration of vasopressors in a septic shock context.
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21
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Molecular Pathogenesis of Endotheliopathy and Endotheliopathic Syndromes, Leading to Inflammation and Microthrombosis, and Various Hemostatic Clinical Phenotypes Based on "Two-Activation Theory of the Endothelium" and "Two-Path Unifying Theory" of Hemostasis. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58091311. [PMID: 36143988 PMCID: PMC9504959 DOI: 10.3390/medicina58091311] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 09/05/2022] [Accepted: 09/14/2022] [Indexed: 12/21/2022]
Abstract
Endotheliopathy, according to the “two-activation theory of the endothelium”, can be triggered by the activated complement system in critical illnesses, such as sepsis and polytrauma, leading to two distinctly different molecular dysfunctions: (1) the activation of the inflammatory pathway due to the release of inflammatory cytokines, such as interleukin 6 and tumor necrosis factor-α, and (2) the activation of the microthrombotic pathway due to the exocytosis of hemostatic factors, such as ultra-large von Willebrand factor (ULVWF) multimers and FVIII. The former promotes inflammation, including inflammatory organ syndrome (e.g., myocarditis and encephalitis) and multisystem inflammatory syndrome (e.g., cytokine storm), and the latter provokes endotheliopathy-associated vascular microthrombotic disease (VMTD), orchestrating thrombotic thrombocytopenic purpura (TTP)-like syndrome in arterial endotheliopathy, and immune thrombocytopenic purpura (ITP)-like syndrome in venous endotheliopathy, as well as multiorgan dysfunction syndrome (MODS). Because the endothelium is widely distributed in the entire vascular system, the phenotype manifestations of endotheliopathy are variable depending on the extent and location of the endothelial injury, the cause of the underlying pathology, as well as the genetic factor of the individual. To date, because the terms of many human diseases have been defined based on pathological changes in the organ and/or physiological dysfunction, endotheliopathy has not been denoted as a disease entity. In addition to inflammation, endotheliopathy is characterized by the increased activity of FVIII, overexpressed ULVWF/VWF antigen, and insufficient ADAMTS13 activity, which activates the ULVWF path of hemostasis, leading to consumptive thrombocytopenia and microthrombosis. Endothelial molecular pathogenesis produces the complex syndromes of inflammation, VMTD, and autoimmunity, provoking various endotheliopathic syndromes. The novel conceptual discovery of in vivo hemostasis has opened the door to the understanding of the pathogeneses of many endotheliopathy-associated human diseases. Reviewed are the hemostatic mechanisms, pathogenesis, and diagnostic criteria of endotheliopathy, and identified are some of the endotheliopathic syndromes that are encountered in clinical medicine.
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22
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Bouzinier MA, Etin D, Trifonov SI, Evdokimova VN, Ulitin V, Shen J, Kokorev A, Ghazani AA, Chekaluk Y, Albertyn Z, Giersch A, Morton CC, Abraamyan F, Bendapudi PK, Sunyaev S, Undiagnosed Diseases Network, Brigham Genomic Medicine, SEQuencing A Baby For An Optimal Outcome, Quantori, Krier JB. AnFiSA: An open-source computational platform for the analysis of sequencing data for rare genetic disease. J Biomed Inform 2022; 133:104174. [PMID: 35998814 DOI: 10.1016/j.jbi.2022.104174] [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: 10/27/2021] [Revised: 07/23/2022] [Accepted: 08/15/2022] [Indexed: 11/28/2022]
Abstract
Despite genomic sequencing rapidly transforming from being a bench-side tool to a routine procedure in a hospital, there is a noticeable lack of genomic analysis software that supports both clinical and research workflows as well as crowdsourcing. Furthermore, most existing software packages are not forward-compatible in regards to supporting ever-changing diagnostic rules adopted by the genetics community. Regular updates of genomics databases pose challenges for reproducible and traceable automated genetic diagnostics tools. Lastly, most of the software tools score low on explainability amongst clinicians. We have created a fully open-source variant curation tool, AnFiSA, with the intention to invite and accept contributions from clinicians, researchers, and professional software developers. The design of AnFiSA addresses the aforementioned issues via the following architectural principles: using a multidimensional database management system (DBMS) for genomic data to address reproducibility, curated decision trees adaptable to changing clinical rules, and a crowdsourcing-friendly interface to address difficult-to-diagnose cases. We discuss how we have chosen our technology stack and describe the design and implementation of the software. Finally, we show in detail how selected workflows can be implemented using the current version of AnFiSA by a medical geneticist.
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Affiliation(s)
- M A Bouzinier
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - D Etin
- Forome Association, Boston, MA, USA; Oracle Corporation, USA.
| | | | - V N Evdokimova
- Forome Association, Boston, MA, USA; SBCS Scientific Biomedical Consulting Services, London, UK
| | - V Ulitin
- Forome Association, Boston, MA, USA
| | - J Shen
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - A Kokorev
- ITMO University, St. Petersburg, Russian Federation
| | - A A Ghazani
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Brigham Genomic Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Y Chekaluk
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Z Albertyn
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - A Giersch
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - C C Morton
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA; Manchester Centre for Audiology and Deafness (ManCAD), School of Health Sciences, University of Manchester, UK
| | - F Abraamyan
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - P K Bendapudi
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston, MA, USA; Division of Hematology and Blood Transfusion Service, Massachusetts General Hospital, Boston, MA, USA
| | - S Sunyaev
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | | | | | | | | | - J B Krier
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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23
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Perinkulam Sathyanarayanan S, Ahmed M, Hericks A. Purpura fulminans due to Streptococcus pneumoniae bacteraemia in an unsplectomised immunocompetent adult without primary hypocomplementaemia. BMJ Case Rep 2022; 15:15/5/e249514. [PMID: 35589268 PMCID: PMC9121414 DOI: 10.1136/bcr-2022-249514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Invasive pneumococcal disease occurs in high-risk patient population which includes patients with asplenia and primary hypocomplementaemia. Pneumococcal sepsis can rarely cause disseminated intravascular coagulation (DIC) and intravascular thrombosis of small and medium sized vessels called purpura fulminans which is associated with a high mortality rate. We present the case of an immunocompetent woman in her 50s with an intact spleen who presented with septic shock from Streptococcus pneumoniae bacteraemia. Her hospital course rapidly progressed to multiorgan dysfunction, DIC and purpura fulminans. She was treated aggressively with broad spectrum antibiotics, coagulation factor replacement, multiple vasopressor support, renal replacement therapy and mechanical ventilator support. Despite aggressive measures, she succumbed to the multiorgan failure.
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Affiliation(s)
| | - Mohammad Ahmed
- Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA.,Department of Internal Medicine, Avera McKennan Hospital and University Health Center, Sioux Falls, South Dakota, USA
| | - Anthony Hericks
- Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA.,Division of Pulmonary Critical Care, Avera McKennan Hospital and University Health Center, Sioux Falls, South Dakota, USA
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24
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Ruiz de Villa A, Charles K, Okonoboh P. A Rare Case of Purpura Fulminans in the Setting of Klebsiella pneumoniae Bacteremia. Cureus 2022; 14:e22921. [PMID: 35399398 PMCID: PMC8986515 DOI: 10.7759/cureus.22921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2022] [Indexed: 12/01/2022] Open
Abstract
A 23-year-old man with circulatory shock associated with severe sepsis and congestive heart failure with an ejection fraction of 10% resulting in anasarca and multiorgan failure was admitted to our hospital's intensive care unit. Hours after admission, he developed a rash on his left inner thigh, which was later diagnosed as purpura fulminans (PF). Blood cultures were consistent with Klebsiella pneumoniae bacteremia, with community-acquired pneumonia being the possible source. PF is a rare and difficult-to-diagnose entity characterized by dysregulated hemostasis that is often associated with poor prognosis and fatal outcomes. To our knowledge, there are limited reports in the literature on K. pneumoniae as a cause of PF. Given the rarity of this presentation, this case will serve as an opportunity to report and discuss the pathophysiology of this disease for the benefit of physicians.
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25
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Liniger S, Dantonello T, Diepold M, Aebi C, Brodard J, Kremer Hovinga JA, Rössler JK, Kartal-Kaess M. Severe acquired purpura fulminans in a child. Arch Dis Child 2022; 107:300. [PMID: 34417189 DOI: 10.1136/archdischild-2021-322379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Sophia Liniger
- Department of Paediatrics, University of Bern, Bern, Switzerland
| | - Tobias Dantonello
- Department for BioMedical Research, University of Bern, Bern, Switzerland.,Division of Paediatric Haematology & Oncology, Department of Paediatrics, Inselspital, University Hospital, University of Bern, Bern, Switzerland
| | - Miriam Diepold
- Department for BioMedical Research, University of Bern, Bern, Switzerland.,Division of Paediatric Haematology & Oncology, Department of Paediatrics, Inselspital, University Hospital, University of Bern, Bern, Switzerland
| | - Christoph Aebi
- Department of Paediatrics, University of Bern, Bern, Switzerland
| | - Justine Brodard
- Department for BioMedical Research, University of Bern, Bern, Switzerland.,Department of Haematology and Central Haematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Johanna A Kremer Hovinga
- Department for BioMedical Research, University of Bern, Bern, Switzerland.,Department of Haematology and Central Haematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jochen Karl Rössler
- Department for BioMedical Research, University of Bern, Bern, Switzerland.,Division of Paediatric Haematology & Oncology, Department of Paediatrics, Inselspital, University Hospital, University of Bern, Bern, Switzerland
| | - Mutlu Kartal-Kaess
- Department for BioMedical Research, University of Bern, Bern, Switzerland .,Division of Paediatric Haematology & Oncology, Department of Paediatrics, Inselspital, University Hospital, University of Bern, Bern, Switzerland
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26
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Williamson SJ, Ruiz-Gaviria R. Pneumococcal purpura fulminans in a 25-year-old patient with liver cirrhosis due to autoimmune hepatitis. IDCases 2022; 30:e01610. [PMID: 36061139 PMCID: PMC9429787 DOI: 10.1016/j.idcr.2022.e01610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 08/19/2022] [Indexed: 11/29/2022] Open
Abstract
Purpura fulminans (PF) is a skin disorder with high morbidity and mortality which is characterized by microvascular thrombosis and development of hemorrhagic necrosis. PF can be caused by acute infection, most commonly due to Neisseria meningitidis, followed by Streptococcus pneumoniae. Prior reports describe cases of pneumococcal PF occurring in patients with asplenia or hyposplenia, though cases have also been reported in otherwise healthy adults without known splenic disease. Herein, we report a young adult patient with cirrhosis due to autoimmune hepatitis who had not received pneumococcal vaccination and developed rapidly progressive fatal S. pneumoniae sepsis with PF.
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27
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Purpura fulminans due to Vibrio vulnificus severe infection. IDCases 2022; 29:e01588. [PMID: 35942256 PMCID: PMC9356192 DOI: 10.1016/j.idcr.2022.e01588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/26/2022] [Accepted: 07/26/2022] [Indexed: 11/21/2022] Open
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28
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Li C, Cao G, Jin F, Ning X. Rare complication of cushing's syndrome in the elderly: a case report. Endocrine 2021; 74:281-284. [PMID: 34448100 DOI: 10.1007/s12020-021-02844-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/31/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Cushing's syndrome (CS) is a rare and severe disease caused by sustained hypercortisolism. The clinical manifestations of CS can be atypical in the elderly, and the diagnosis in these patients is often missed. Infectious Purpura Fulminans (PF) is a life-threating, thrombotic form of disseminated intravascular coagulation with high mortality. To our knowledge, PF occurring in a patient with CS has not been reported previously. METHODS We described an 84-year-old female presented with severe infection, but normal temperature. She suffered from a variety of diseases especially personality change. Physical examination revealed thin skin, general edema, and multiple scattered ecchymosis. Combined with obviously elevated serum cortisol (36.85 ug/dl) and adenoma revealed by adrenal CT scanning, endogenous CS was diagnosed. During hospitalization, the patient developed serious subcutaneous hemorrhage on the right thigh and back. The skin biopsy showed multiple small vessel thrombosis suggesting that the patient developed the rare complication of CS, Purpura Fulminans (PF). RESULTS Chronic hypercortisolism can cause immune suppression, low-grade inflammation, endothelial damage, and a hypercoagulable state, which together increased susceptibility of PF. Fluid resuscitation, antibiotics, infusion of blood product, and debridement were effective treatment measures when CS complicated with infectious PF. CONCLUSION Severe subcutaneous hemorrhage due to PF could occur in the patients of CS, especially in the elderly. Clinicians should be alert to the diagnosis of CS in older adults with cognitive decline and personality change.
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Affiliation(s)
- Cui Li
- Department of Geriatrics, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, Shaanxi, China
| | - Guihua Cao
- Department of Geriatrics, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, Shaanxi, China
| | - Fengzhong Jin
- Department of Geriatrics, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, Shaanxi, China
| | - Xiaoxuan Ning
- Department of Geriatrics, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, Shaanxi, China.
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Maebayashi A, Hayashi N, Kamata S, Sugita A, Tang X, Kawana K. Thrombus formation and ischemic necrosis of the uterus and adnexa due to purpura fulminans: A case report. J Obstet Gynaecol Res 2021; 47:4478-4483. [PMID: 34525489 DOI: 10.1111/jog.15027] [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: 06/25/2021] [Revised: 08/28/2021] [Accepted: 09/01/2021] [Indexed: 11/28/2022]
Abstract
Purpura fulminans (PF) is a syndrome characterized by the sudden onset of progressive skin hemorrhage, necrosis of the extremities, and thrombotic occlusion. Although the cause is believed to be protein C deficiency, many aspects of this syndrome have yet to be clarified. A 45-year-old Japanese woman, G2P2 (vaginal delivery), developed fever and lower abdominal pain. It was her 5th day of menstruation, and a tampon had been in the vagina for a few days. Septic shock and disseminated intravascular coagulation were diagnosed, and multidisciplinary treatment was started. Also, toxic shock syndrome due to tampon use was suspected. The purpura on the limbs turned into blisters and then blackish-purple spots, leading to hemorrhagic necrosis within a few days. Moreover, imaging showed that the uterus and both adnexa had enlarged significantly, and raised suspicion of abscess formation. Total hysterectomy and bilateral adnexectomy were performed, and the histopathological diagnosis was hemorrhagic necrosis due to extensive thrombus formation. In men, PF affects the scrotum and penis, leading to autoamputation of the male genitalia, while there are no reports of PF involving the female genitalia. Regarding the PF, in this case, we considered the possibility of pathologic conditions progressing to the female genitalia.
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Affiliation(s)
- Aki Maebayashi
- Department of Obstetrics and Gynecology, Nihon University Hospital, Tokyo, Japan
| | - Nobuki Hayashi
- Department of Obstetrics and Gynecology, Nihon University Hospital, Tokyo, Japan.,Department of Obstetrics and Gynecology, Nihon University School of Medicine, Tokyo, Japan
| | - Saki Kamata
- Department of Obstetrics and Gynecology, Nihon University Hospital, Tokyo, Japan.,Department of Obstetrics and Gynecology, Nihon University School of Medicine, Tokyo, Japan
| | - Atsunori Sugita
- Department of Emergency and Critical Care Center, Nihon University Hospital, Tokyo, Japan
| | - Xiaoyan Tang
- Department of Pathology and Microbiology, Nihon University Hospital, Tokyo, Japan
| | - Kei Kawana
- Department of Obstetrics and Gynecology, Nihon University School of Medicine, Tokyo, Japan
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Abstract
ABSTRACT Purpura fulminans can result in significant full-thickness wounds, posing a challenge in the pediatric population, given the paucity of donor sites for reconstruction. The authors present the case of an 11-month-old patient for whom a split-thickness skin allograft (TheraSkin) was successfully implemented as a temporizing measure for a large leg wound.
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Bendapudi PK, Whalen MJ, Lahoud-Rahme M, Villalba JA. Case 7-2021: A 19-Year-Old Man with Shock, Multiple Organ Failure, and Rash. N Engl J Med 2021; 384:953-963. [PMID: 33704941 DOI: 10.1056/nejmcpc2027093] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Pavan K Bendapudi
- From the Departments of Medicine (P.K.B.), Pediatrics (M.J.W., M.L.-R.), and Pathology (J.A.V.), Massachusetts General Hospital, and the Departments of Medicine (P.K.B.), Pediatrics (M.J.W., M.L.-R.), and Pathology (J.A.V.), Harvard Medical School - both in Boston
| | - Michael J Whalen
- From the Departments of Medicine (P.K.B.), Pediatrics (M.J.W., M.L.-R.), and Pathology (J.A.V.), Massachusetts General Hospital, and the Departments of Medicine (P.K.B.), Pediatrics (M.J.W., M.L.-R.), and Pathology (J.A.V.), Harvard Medical School - both in Boston
| | - Manuella Lahoud-Rahme
- From the Departments of Medicine (P.K.B.), Pediatrics (M.J.W., M.L.-R.), and Pathology (J.A.V.), Massachusetts General Hospital, and the Departments of Medicine (P.K.B.), Pediatrics (M.J.W., M.L.-R.), and Pathology (J.A.V.), Harvard Medical School - both in Boston
| | - Julian A Villalba
- From the Departments of Medicine (P.K.B.), Pediatrics (M.J.W., M.L.-R.), and Pathology (J.A.V.), Massachusetts General Hospital, and the Departments of Medicine (P.K.B.), Pediatrics (M.J.W., M.L.-R.), and Pathology (J.A.V.), Harvard Medical School - both in Boston
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Kim MC, Patel J. Recognition and Management of Acute Purpura Fulminans: A Case Report of a Complication of Neisseria meningitidis Bacteremia. Cureus 2021; 13:e13704. [PMID: 33824838 PMCID: PMC8012263 DOI: 10.7759/cureus.13704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Purpura fulminans (PF) is a rare, potentially fatal complication of disseminated intravascular coagulation that is commonly associated with severe bacterial infections such as those caused by the bacterium Neisseria meningitidis. With the advent of vaccination, meningococcal disease has become infrequent, with a reported incidence of 1 case per 100,000 people per year. PF is an even rarer phenomenon that is only found in approximately 10 to 20% of patients with meningococcal septicemia. PF can cause irreversible tissue necrosis within 48 hours and, in severe cases, death. Early recognition is crucial as PF has a mortality rate as high as 60% in patients with meningococcal disease. Prompt recognition, treatment of the underlying cause, vigorous skin care, and multispecialty collaboration are required for optimal management of PF, though morbidity and mortality remain high as there is no cure for adult PF. We present a case of acute PF in a patient who presented with septic shock secondary to Neisseria bacteremia.
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Affiliation(s)
- Michael C Kim
- Department of Medicine, Graduate Medical Education, Methodist Dallas Medical Center, Dallas, USA
| | - Jaimin Patel
- Department of Medicine, Graduate Medical Education, Methodist Dallas Medical Center, Dallas, USA
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Morales Hernandez MDM, Carranza M, Patel B, Calvert J, Masri G. Purpura Fulminans in a Patient With Septic Shock due to Escherichia coli Bacteremia With Emphysematous Pyelitis. Cureus 2021; 13:e13249. [PMID: 33717756 PMCID: PMC7952243 DOI: 10.7759/cureus.13249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2021] [Indexed: 11/05/2022] Open
Abstract
Purpura fulminans (PF) is a rapidly fatal disorder predominantly encountered in patients with an acquired deficiency of physiologic anticoagulants due to severe sepsis and septic shock with disseminated intravascular coagulation (DIC). This consumptive process eventually leads to widespread thrombosis, hemorrhagic necrosis, and gangrene. Rapid identification followed by aggressive management of the underlying etiology with a multidisciplinary team is critical to prevent long-term organ dysfunction, disability from amputation, and death. While bleeding is a common finding in DIC, anticoagulation must be considered if PF is present. We report a case of Escherichia coli--associated emphysematous pyelitis leading to bacteremia, septic shock, and PF with small- and medium-sized vessel thrombosis and acral ischemia.
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Affiliation(s)
| | - Michael Carranza
- Internal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Bijal Patel
- Internal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Joshua Calvert
- Internal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Ghania Masri
- Internal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
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Spindel J, Parikh I, Terry M, Cavallazzi R. Leucocytoclastic vasculitis due to acute bacterial endocarditis resolves with antibiotics. BMJ Case Rep 2021; 14:14/1/e239961. [PMID: 33495169 PMCID: PMC7839888 DOI: 10.1136/bcr-2020-239961] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Infective endocarditis is associated with a variety of clinical signs, but its association with multisystem vasculitis is rarely reported. A high index of suspicion is necessary to differentiate a primary autoimmune vasculitis from an infectious cause as the wrong treatment can lead to significant morbidity and mortality. We present a 71-year-old female patient with negative blood cultures, on antibiotics for recent bacteraemia, who presented with cutaneous and renal leucocytoclastic vasculitis. Workup revealed a vegetation adjacent to her right atrial pacemaker lead consistent with infective endocarditis and her vasculitis completely resolved with appropriate antibiotics.
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Affiliation(s)
- Jeffrey Spindel
- Internal Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Ishan Parikh
- Internal Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Merryl Terry
- Pathology, University of Louisville, Louisville, Kentucky, USA
| | - Rodrigo Cavallazzi
- Department of Pulmonary, Critical Care and Sleep Disorders Medicine, University of Louisville, Louisville, Kentucky, USA
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Nguyen V, Myint JA, Philipneri M. Purpura Fulminans in the Setting of Klebsiella Pneumoniae Bacteremia and Acetaminophen Overdose. Cureus 2020; 12:e11633. [PMID: 33376646 PMCID: PMC7755612 DOI: 10.7759/cureus.11633] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Purpura fulminans (PF) is a rare, life-threatening disorder characterized by disseminated intravascular coagulation (DIC), circulatory collapse, and hemorrhagic cutaneous purpura. It typically occurs secondary to acute infections, usually meningococcal septicemia, although there are also congenital and acquired causes. We report a case of a 56-year old female who presented to our institution with clinical signs of PF in the setting of acetaminophen overdose and Klebsiella pneumoniae sepsis. Given the rarity of the disease, we also review cases of PF in similar clinical scenarios that have been described in the literature.
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Affiliation(s)
- Vincent Nguyen
- Department of Medicine, Division of Nephrology, Saint Louis University School of Medicine, Saint Louis, USA
| | - Janine A Myint
- Department of Medicine, Division of Nephrology, Saint Louis University School of Medicine, Saint Louis, USA
| | - Marie Philipneri
- Department of Medicine, Division of Nephrology, Saint Louis University School of Medicine, Saint Louis, USA
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Ghosh SK, Bandyopadhyay D, Dutta A, Jane EP, Biswas SK. A Profile of 23 Indian Patients with Purpura Fulminans: A Retrospective, Descriptive Study. Indian J Dermatol 2020; 65:381-387. [PMID: 33165344 PMCID: PMC7640787 DOI: 10.4103/ijd.ijd_8_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Sudip Kumar Ghosh
- Department of Dermatology, Venereology, and Leprosy, R.G. Kar Medical College, Kolkata, India
| | | | - Abhijit Dutta
- Department of Pediatric Medicine, North Bengal Medical College, West Bengal, India
| | - Esther P Jane
- Department of Dermatology, Venereology, and Leprosy, R.G. Kar Medical College, Kolkata, India
| | - Surajit Kumar Biswas
- Department of Dermatology, Venereology, and Leprosy, R.G. Kar Medical College, Kolkata, India
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Koch C, Taeger C, Geis S, Lonic D, Heidekrueger P, Dolderer J, Bitzinger D, Hirche C, Prantl L, Kehrer A. Early fasciotomies and plastic-surgical reconstruction may enhance preservation of functional extremity length in purpura fulminans. Clin Hemorheol Microcirc 2020; 75:267-278. [PMID: 31524150 DOI: 10.3233/ch-190588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Purpura fulminans (PF) is a distinct form of rare meningococcal septicaemia mostly in childhood which is characterized by high lethality, extensive necroses and mutilations of extremities. Other ethiologies are idiopathic forms or purpura neonatorum, which is marked by deficiency of Protein-C. PF is caused by micro-embolism of the vascular system, followed by quickly spreading necroses of skin and different organs.Modern concepts of intensive care treatment of the acute phase of this disease and early surgical intervention lead to a rising number of surviving patients requiring limb salvage.Aim of this study is to evaluate a possible lower morbidity and the grade of lower loss of function because of early surgical intervention. PATIENTS AND METHODS Between the years 1998 and 2017 eight cases of PF at two large centers for critical wound care, the department of plastic-, hand- and reconstructive surgery of the university hospital of Regensburg and the department of plastic-, hand- and reconstructive surgery of the BG-clinic Ludwigshafen were included into our study.We retrospectively examined patients with PF who were stabilized by intensive care medicine and received surgical interventions. After survival of the acute phase (10 days), patients received plastic surgical reconstructions. RESULTS A total number of eight patients could be included into our study. All patients survived the initial phase (10 days). All patients required plastic-surgical interventions to address extensive skin and soft tissue defects. Flap operations were judged necessary in five cases. Hereby four defects could be reconstructed by free tissue transfer, one with a local flap. Flap survival was 100 percent. One flap required revision of the arterial anastomosis of the flap arteria. Another flap got partial necrosis. One patient died due to multiorgan failure.Early debridements with consequent fasciotomies and secondary plastic-surgical reconstruction achieved good functional results. Limb salvage was accomplished in three patients. One patient died due to fulminant progress of the disease. CONCLUSION Management of PF requires a multidisciplinary approach and close communication between the different subspecialties. Early debridements with consequent fasciotomies showed good results in salvaging subfascial muscle tissue in the extremities with satisfying functional results. Early surgical intervention is an important factor for improved limb salvage and survival.
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Affiliation(s)
- Christoph Koch
- Department of Plastic, Hand, and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Christian Taeger
- Department of Plastic, Hand, and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Sebastian Geis
- Department of Plastic, Hand, and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Daniel Lonic
- Department of Plastic, Hand, and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Paul Heidekrueger
- Department of Plastic, Hand, and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Juergen Dolderer
- Department of Plastic, Hand, and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Diane Bitzinger
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Christoph Hirche
- Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Lukas Prantl
- Department of Plastic, Hand, and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Andreas Kehrer
- Department of Plastic, Hand, and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
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Bagshaw RJ, Stewart AGA, Smith S, Carter AW, Hanson J. The Characteristics and Clinical Course of Patients with Scrub Typhus and Queensland Tick Typhus Infection Requiring Intensive Care Unit Admission: A 23-year Case Series from Queensland, Tropical Australia. Am J Trop Med Hyg 2020; 103:2472-2477. [PMID: 32959771 DOI: 10.4269/ajtmh.20-0780] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Scrub typhus and Queensland tick typhus (QTT)-rickettsial infections endemic to tropical Australia-can cause life-threatening disease. This retrospective study examined the clinical course of all patients with laboratory-confirmed scrub typhus or QTT admitted to the intensive care unit (ICU) of a tertiary referral hospital in tropical Australia between 1997 and 2019. Of the 22 patients, 13 had scrub typhus and nine had QTT. The patients' median (interquartile range [IQR]) age was 50 (38-67) years; 14/22 (64%) had no comorbidity. Patients presented a median (IQR) of seven (5-10) days after symptom onset. Median (IQR) Acute Physiology and Chronic Health Evaluation II scores were 13 (9-17) for scrub typhus and 13 (10-15) for QTT cases (P = 0.61). Following hospital admission, the median (IQR) time to ICU admission was five (2-19) hours. The median (IQR, range) length of ICU stay was 4.4 (2.9-15.9, 0.8-33.8) days. Multi-organ support was required in 11/22 (50%), 5/22 (22%) required only vasopressor support, 2/22 (9%) required only invasive ventilation, and 4/22 (18%) were admitted for monitoring. Patients were ventilated using protective lung strategies, and fluid management was conservative. Standard vasopressors were used, indications for renal replacement therapy were conventional, and blood product usage was restrictive; 9/22 (41%) received corticosteroids. One patient with QTT died, and two (8%) additional patients with QTT developed purpura fulminans requiring digital amputation. Death or permanent disability occurred in 3/9 (33%) QTT and 0/13 scrub typhus cases (P = 0.055). Queensland tick typhus and scrub typhus can cause multi-organ failure requiring ICU care in otherwise well individuals. Queensland tick typhus appears to have a more severe clinical phenotype than previously believed.
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Affiliation(s)
| | | | - Simon Smith
- Department of Medicine, Cairns Hospital, Cairns, Australia
| | - Angus W Carter
- Department of Intensive Care Medicine, Cairns Hospital, Cairns, Australia
| | - Josh Hanson
- The Kirby Institute, University of New South Wales, Sydney, Australia.,Department of Medicine, Cairns Hospital, Cairns, Australia
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Beechar VB, de la Flor C, Medford RJ. Non-typeable Haemophilus influenzae and purpura fulminans. BMJ Case Rep 2020; 13:13/7/e234880. [PMID: 32641317 DOI: 10.1136/bcr-2020-234880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Haemophilus influenzae typically causes illness and infection in the paediatric population. We report a case of a 53-year-old man who developed invasive non-typeable H. influenzae infection associated with purpura fulminans and multiorgan failure. On review of the literature, this is the first reported case of non-typeable H. influenzae causing purpura fulminans. The patient was treated with intravenous ceftriaxone 2 g/day and was eventually discharged from the hospital almost 2 months after admission. We discuss the role that infection/sepsis plays in disturbances to the coagulation cascade leading to purpura fulminans and the virulence factors that make non-typeable H. influenzae unique. Finally, we review other cases of H. influenzae associated with purpura fulminans and discuss the similarities with our case.
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Affiliation(s)
- Vivek Bhika Beechar
- Department of Infectious Disease and Geographic Medicine, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
| | - Carolina de la Flor
- Department of Infectious Disease and Geographic Medicine, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
| | - Richard J Medford
- Department of Infectious Disease and Geographic Medicine, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
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Loberger JM, Aban IB, Prabhakaran P. Exploration of Sepsis-Associated Coagulopathy Severity and Pediatric Septic Shock Outcomes. J Pediatr Intensive Care 2020; 10:38-44. [PMID: 33585060 DOI: 10.1055/s-0040-1713436] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/07/2020] [Indexed: 12/29/2022] Open
Abstract
The objective of this study was to explore correlations between sepsis-associated coagulopathy (SAC) in pediatric septic shock and clinical outcomes. This was a retrospective cohort study of all children admitted to a single, academic pediatric intensive care unit with septic shock over 6 years. The prevalence of SAC was 93.5% with 61% being severe. Those with severe SAC were more likely to have a positive blood culture and have longer median duration of ventilation. All observed mortalities occurred in the severe SAC and indeterminate SAC groups. SAC is highly prevalent in pediatric septic shock and may predict important outcomes.
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Affiliation(s)
- Jeremy M Loberger
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Inmaculada B Aban
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Priya Prabhakaran
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, United States
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Djurdjevic N, Taweesedt PT, Paulson M, LaNou A, Radovanovic M, Patel JN, Veselinovic M, McDermott WR, Dumic I. Septic Shock and Purpura Fulminans Due to Streptococcus pneumoniae Bacteremia in an Unvaccinated Immunocompetent Adult: Case Report and Review. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e923266. [PMID: 32513908 PMCID: PMC7304654 DOI: 10.12659/ajcr.923266] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 05/12/2020] [Accepted: 04/03/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Despite proven efficacy of vaccinations against Streptococcus pneumoniae in preventing infection, only 70% of eligible individuals receive the vaccine in the United States. Pneumococcal bacteremia represents a form of invasive pneumococcal disease and is associated with high mortality, especially in immunocompromised patients and the elderly. Purpura fulminans is a rare complication and manifestation of disseminated intravascular coagulation and sepsis. It is exceedingly rare in the setting of pneumococcal bacteremia, particularly in immunocompetent individuals. CASE REPORT We report a generally healthy 67-year-old male with schizophrenia who refused pneumococcal vaccination. He had an intact and functional spleen with a functional immune system. The patient presented with fever and diarrhea. He subsequently progressed to develop purpura fulminans and septic shock due to S. pneumoniae bacteremia. Despite an extensive search for the primary source of infection, none could not be identified. Due to timely initiation of appropriate antibiotic therapy and aggressive supportive care in an intensive care unit, he recovered despite multi-organ failure that developed throughout his hospitalization. CONCLUSIONS We present a rare manifestation of a potentially preventable disease and emphasize the importance of pneumococcal vaccination in order to decrease the risk of developing invasive pneumococcal disease. Furthermore, we discuss etiology, diagnosis, differential diagnosis, and evidence-based management of purpura fulminans and invasive pneumococcal disease with a literature review. Purpura fulminans due to S. pneumoniae is exceedingly rare in immunocompetent patients and an unusual clinical manifestation of pneumococcal bacteremia.
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Affiliation(s)
| | | | | | - Abigail LaNou
- Mayo Clinic, Alix School of Medicine, Rochester, MN, U.S.A
| | | | - Janki N. Patel
- Mayo Clinic, Alix School of Medicine, Rochester, MN, U.S.A
| | | | | | - Igor Dumic
- Mayo Clinic, Alix School of Medicine, Rochester, MN, U.S.A
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Ou S, Wang X, Huang Y, Zhu YT, Wu ML, Zheng XR, Liu CT. [Acute fever with rash, necrosis, and bullae in both lower extremities in a 12-year-old girl]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2020; 22:651-655. [PMID: 32571467 PMCID: PMC7390209 DOI: 10.7499/j.issn.1008-8830.2002079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 05/07/2020] [Indexed: 06/11/2023]
Abstract
A girl, aged 12 years, was admitted due to fever and rash for 3 days. The child developed recurrent high fever and rash on both lower extremities 3 days before, and the rash on left lower extremity quickly merged into a patch within 24 hours, with hemorrhage and necrosis in black and purple, large vesicles, and blisters in the center. Laboratory examination showed a reduction in platelet count and significant increases in fibrinogen and D-dimer during the course of the disease. The child was diagnosed with purpura flulminans. She was given meropenem combined with linezolid for anti-infection, injection of gamma globulin for immunoregulation, and low-molecular-weight heparin for anticoagulation. The fluid in the rash blisters was drawn and the wound was treated to prevent infection. The child's temperature returned to normal, with improvement in gangrene. She was discharged after platelet count, fibrinogen, and D-dimer had returned to normal. Purpura fulminans is a rare thrombotic hemorrhagic disease with rapid progression and is commonly seen in children. Without timely treatment, it may cause severe sequelae with high disability and mortality rates. Anti-infection, correction of coagulation function, and local management of gangrene skin are of great importance during treatment.
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Affiliation(s)
- Shuang Ou
- Department of Pediatrics, Xiangya Hospital of Central South University, Changsha 410008, China.
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43
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Huang PY, Cheng HT. Pneumococcal Sepsis–Induced Purpura Fulminans in an Asplenic Adult Patient with Disseminated Intravascular Coagulation. Am Surg 2020. [DOI: 10.1177/000313482008600307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Pin-Yi Huang
- School of Medicine China Medical University Taichung, Taiwan
| | - Hsu-Tang Cheng
- Division of Plastic and Reconstructive Surgery Department of Surgery Asia University Hospital Asia University College of Medical and Health Science Taichung, Taiwan
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Kalpatthi R, Kiss JE. Thrombotic Thrombocytopenic Purpura, Heparin-Induced Thrombocytopenia, and Disseminated Intravascular Coagulation. Crit Care Clin 2020; 36:357-377. [PMID: 32172818 DOI: 10.1016/j.ccc.2019.12.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Hemostatic abnormalities are common among critically ill patients and are associated with a high risk of bleeding. The abnormalities range from isolated thrombocytopenia or prolongation of global coagulation assays to complex disease states, such as thrombotic microangiopathic syndromes, and can be associated with a wide range of conditions, including trauma, surgery, acute disease processes, cardiopulmonary bypass, and exposure to drugs and blood products. Prompt identification of underlying causes is important because treatment strategies vary. Moreover, prompt initiation of both supportive and specific treatments is vital to decrease the morbidity and mortality in the intensive care unit.
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Affiliation(s)
- Ram Kalpatthi
- Division of Pediatric Hematology Oncology, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Suite 501A, Pittsburgh, PA 15224, USA
| | - Joseph E Kiss
- Division of Hematology Oncology, Department of Medicine, Clinical Apheresis and Blood Services, Vitalant Northeast Division, University of Pittsburgh School of Medicine, 3636 Boulevard of the Allies, Pittsburgh, PA 15213, USA.
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Note S, Soentjens P, Van Laer M, Meert P, Vanbrabant P. Streptococcal toxic shock syndrome in a returning traveller. Acta Clin Belg 2019; 74:430-434. [PMID: 30369302 DOI: 10.1080/17843286.2018.1539634] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Background: A patient presenting with fever and purpura after a stay in the tropics tempts a physician to make a differential diagnosis mainly focusing on imported diseases. Although the importance of considering a tropical disease is obvious, the fact that cosmopolitan infections account for one third of the cases in a febrile returning traveler must not be overseen. Toxic Shock Syndrome is amongst the most notorious diseases due to the high mortality when inappropriately managed and the association with necrotizing fasciitis. Methods : We present a 60-year old female with fever, shock syndrome and progressive appearance of painful purpura on the lower legs after a 2-week holiday in Zanzibar. Results : The patient was diagnosed with Streptococcal Toxic Shock Syndrome. Treatment focusing on aggressive fluid resuscitation, prompt administration of antibiotics (ceftriaxon, doxycycline and one dose of amikacin) and adjunctive treatment by clindamycin and immunoglobulin was initiated. She was also immediately taken into surgery for a bilateral fasciotomy and surgical exploration of the lower legs. Histology appeared compatible with purpura fulminans, thereby excluding necrotizing fasciitis. No source of infection could be identified. Conclusion: Toxic Shock Syndrome remains a challenging diagnosis and even more in a returning traveler with an extensive differential diagnosis containing both tropical and cosmopolitan diseases. Cornerstones for the treatment of Streptococcal Toxic Shock Syndrome are abrupt administration of antimicrobial therapy comprising beta-lactam antibiotics and clindamycin and surgical exploration to apply source control when indicated.
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Affiliation(s)
- Stéphanie Note
- Medical Component, Royal Military Academy, Brussels, Belgium
- Emergency Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Patrick Soentjens
- Center for Infectious Diseases ID4C, Military Hospital Queen Astrid, Brussels, Belgium
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Marie Van Laer
- Emergency Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Philippe Meert
- Emergency Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Peter Vanbrabant
- Center for Infectious Diseases ID4C, Military Hospital Queen Astrid, Brussels, Belgium
- General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
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Klifto KM, Gurno CF, Grzelak MJ, Seal SM, Asif M, Hultman CS, Caffrey JA. Surgical outcomes in adults with purpura fulminans: a systematic review and patient-level meta-synthesis. BURNS & TRAUMA 2019; 7:30. [PMID: 31641673 PMCID: PMC6798408 DOI: 10.1186/s41038-019-0168-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 08/06/2019] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Kevin M Klifto
- 1Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD USA.,Johns Hopkins Burn Center, 4940 Eastern Avenue, Baltimore, MD 21224 USA
| | - Caresse F Gurno
- 2The Johns Hopkins University School of Nursing, Baltimore, MD USA
| | - Michael J Grzelak
- 1Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Stella M Seal
- 3Welch Medical Library, The Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Mohammed Asif
- 1Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD USA.,Johns Hopkins Burn Center, 4940 Eastern Avenue, Baltimore, MD 21224 USA
| | - C Scott Hultman
- 1Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD USA.,Johns Hopkins Burn Center, 4940 Eastern Avenue, Baltimore, MD 21224 USA
| | - Julie A Caffrey
- 1Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD USA.,Johns Hopkins Burn Center, 4940 Eastern Avenue, Baltimore, MD 21224 USA
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Ader D, Durrani M, Blazar E. Disseminated Intravascular Coagulation With Purpura Fulminans Presentation of Acute Promyelocytic Leukemia. Clin Pract Cases Emerg Med 2019; 3:446-448. [PMID: 31763615 PMCID: PMC6861048 DOI: 10.5811/cpcem.2019.7.43632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 07/13/2019] [Accepted: 07/23/2019] [Indexed: 11/11/2022] Open
Abstract
A 47-year-old male presented to the emergency department with 12 hours of nausea, vomiting, abdominal pain, and a widespread skin eruption with mottled, irregular, purpuric lesions with subsequent rapid decompensation. Laboratory analysis revealed thrombocytopenia, bandemia, elevated metamyelocytes, abnormal coagulation panel, decreased fibrinogen, elevated fibrin split products, renal dysfunction, bacterial rods, dohle bodies, and toxic granulation. Acute promyelocytic leukemia (APML) was confirmed via bone marrow biopsy, flow cytometry, and fluorescence in situ hybridization analysis. Disseminated intravascular coagulation (DIC) may be the initial presentation of APML. When treated promptly, APML can achieve high remission rates; however, conditions such as DIC continue to increase mortality requiring early recognition to improve survival rates.
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Affiliation(s)
- Douglas Ader
- Inspira Medical Center, Department of Emergency Medicine, Vineland, New Jersey
| | - Muhammad Durrani
- Inspira Medical Center, Department of Emergency Medicine, Vineland, New Jersey
| | - Eric Blazar
- Inspira Medical Center, Department of Emergency Medicine, Vineland, New Jersey
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Mader N, Lührs F, Herget-Rosenthal S, Langenbeck M. Being Licked by a Dog Can Be Fatal: Capnocytophaga canimorsus Sepsis with Purpura Fulminans in an Immunocompetent Man. Eur J Case Rep Intern Med 2019; 6:001268. [PMID: 31742204 PMCID: PMC6822668 DOI: 10.12890/2019_001268] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 09/23/2019] [Indexed: 01/13/2023] Open
Abstract
Bite infections caused by Capnocytophaga canimorsus are rare. Severe and fatal infections are more frequently reported in patients with immunodeficiency, splenectomy or alcohol abuse. We describe the case of a 63-year-old man who developed flu-like symptoms and presented after some delay with severe sepsis and purpura fulminans. He was found to be infected with C. canimorsus without a bite injury and did not demonstrate immunodeficiency or any other typical predisposition. Despite extensive intensive care, his conditions deteriorated and he died from multiorgan failure.
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Affiliation(s)
- Naomi Mader
- Department of Medicine, Rotes Kreuz Krankenhaus, Bremen, Germany
| | - Fabian Lührs
- Department of Medicine, Rotes Kreuz Krankenhaus, Bremen, Germany
| | | | - Martin Langenbeck
- Department of Emergency and Intensive Care Medicine, Rotes Kreuz Krankenhaus, Bremen, Germany
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Persistence of endothelial thrombomodulin in a patient with infectious purpura fulminans treated with protein C concentrate. Blood Adv 2019; 2:2917-2921. [PMID: 30396911 DOI: 10.1182/bloodadvances.2018024430] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 10/11/2018] [Indexed: 12/26/2022] Open
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Iba T, Watanabe E, Umemura Y, Wada T, Hayashida K, Kushimoto S, Wada H. Sepsis-associated disseminated intravascular coagulation and its differential diagnoses. J Intensive Care 2019; 7:32. [PMID: 31139417 PMCID: PMC6528221 DOI: 10.1186/s40560-019-0387-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 05/02/2019] [Indexed: 12/19/2022] Open
Abstract
Disseminated intravascular coagulation (DIC) is a common complication in sepsis. Since DIC not only promotes organ dysfunction but also is a strong prognostic factor, its diagnosis at the earliest possible timing is important. Thrombocytopenia is often present in patients with DIC but can also occur in a number of other critical conditions. Of note, many of the rare thrombocytopenic diseases require prompt diagnoses and specific treatments. To differentiate these diseases correctly, the phenotypic expressions must be considered and the different disease pathophysiologies must be understood. There are three major players in the background characteristics of thrombocytopenia: platelets, the coagulation system, and vascular endothelial cells. For example, the activation of coagulation is at the core of the pathogenesis of sepsis-associated DIC, while platelet aggregation is the essential mechanism in thrombotic thrombocytopenic purpura and endothelial damage is the hallmark of hemolytic uremic syndrome. Though each of the three players is important in all thrombocytopenic diseases, one of the three dominant players typically establishes the individual features of each disease. In this review, we introduce the pathogeneses, symptoms, diagnostic measures, and recent therapeutic advances for the major diseases that should be immediately differentiated from DIC in sepsis.
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Affiliation(s)
- Toshiaki Iba
- 1Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421 Japan
| | - Eizo Watanabe
- 2Department of General Medical Science Graduate School of Medicine Chiba University, Chiba, Japan.,Department of Emergency and Critical Care Medicine Eastern Chiba Medical Center, Chiba, Japan
| | - Yutaka Umemura
- 4Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takeshi Wada
- 5Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kei Hayashida
- 6Department of Emergency and Critical Care Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Shigeki Kushimoto
- 7Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | | | - Hideo Wada
- 8Department of Molecular and Laboratory Medicine, Mie University School of Medicine, Tsu, Japan
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