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Warkentin TE. Limb Ischemic Necrosis Secondary to Microvascular Thrombosis: A Brief Historical Review. Semin Thromb Hemost 2024; 50:760-772. [PMID: 38688305 PMCID: PMC11167199 DOI: 10.1055/s-0044-1786356] [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: 05/02/2024]
Abstract
Ischemic limb injury can be broadly classified into arterial (absent pulses) and venous/microvascular (detectable pulses); the latter can be divided into two overlapping disorders-venous limb gangrene (VLG) and symmetrical peripheral gangrene (SPG). Both VLG and SPG feature predominant acral (distal) extremity ischemic necrosis, although in some instances, concomitant nonacral ischemia/skin necrosis occurs. Historically, for coagulopathic disorders with prominent nonacral ischemic necrosis, clinician-scientists implicated depletion of natural anticoagulants, especially involving the protein C (PC) system. This historical review traces the recognition of natural anticoagulant depletion as a key feature of nonacral ischemic syndromes, such as classic warfarin-induced skin necrosis, neonatal purpura fulminans (PF), and meningococcemia-associated PF. However, only after several decades was it recognized that natural anticoagulant depletion is also a key feature of predominantly acral ischemic microthrombosis syndromes-VLG and SPG-even when accompanying nonacral thrombosis is not present. These acquired acral limb ischemic syndromes typically involve the triad of (a) disseminated intravascular coagulation, (b) natural anticoagulant depletion, and (c) a localizing explanation for microthrombosis occurring in one or more limbs, either deep vein thrombosis (helping to explain VLG) or circulatory shock (helping to explain SPG). In most cases of VLG or SPG there are one or more events that exacerbate natural anticoagulant depletion, such as warfarin therapy (e.g., warfarin-associated VLG complicating heparin-induced thrombocytopenia or cancer hypercoagulability) or acute ischemic hepatitis ("shock liver") as a proximate factor predisposing to severe depletion of hepatically synthesized natural anticoagulants (PC, antithrombin) in the setting of circulatory shock.
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Affiliation(s)
- Theodore E. Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Service of Benign Hematology, Hamilton Health Sciences, Hamilton General Hospital, Hamilton, Ontario, Canada
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2
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Duus S, Jespersen S, Wejse C. Infectious purpura fulminans associated with pneumococcal septicaemia in a patient with unacknowledged functional asplenia. BMJ Case Rep 2024; 17:e251397. [PMID: 38531552 PMCID: PMC10966724 DOI: 10.1136/bcr-2022-251397] [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: 03/28/2024] Open
Abstract
Purpura fulminans (PF) is a life-threatening complication of septic shock that can occur due to disseminated infections with Streptococcus pneumoniae The spleen is an important organ in the immunisation process against encapsulated bacteria. Patients with asplenia, either functional or anatomical, are therefore at increased risk of developing serious infections and complications, such as PF, if infected with such bacteria.This case report presents a woman in her late 40s with unacknowledged functional asplenia who was admitted to the hospital with signs of an acute disseminated infection causing septic shock, signs of disseminated intravascular coagulation and infectious PF. A few days after admission, the blood cultures showed growth of S. pneumoniae With early sepsis treatment, the patient survived although with some complications. Clinical presentation, investigations, differential diagnosis, treatment and outcome are presented. Treatment and early recognition of PF are presented and discussed. Relevant recognition and preventative treatment strategies for patients with asplenia are also reviewed and discussed.This case demonstrates the importance of early recognition and treatment of PF in septic patients and the importance of preventive treatment strategies for patients with asplenia to avoid serious infections and complications.
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Affiliation(s)
| | - Sanne Jespersen
- Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Wejse
- Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
- Center for Global Health, Department of Public Health, Aarhus University, Aarhus, Denmark
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3
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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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4
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Abstract
OBJECTIVES This article describes the pathophysiology and causes of disseminated intravascular coagulation (DIC). Implications for nurses are also reviewed. DATA SOURCES Pee-reviewed articles and up-to-date references were used to check accuracy of the information and provide information for current management of this syndrome. CONCLUSION DIC is an oncologic emergency in which bleeding and clotting occur simultaneously. In the cancer population, the syndrome is frequently associated with certain malignancies or sepsis. If not recognized and treated early, mortality can be high. This article describes the risk factors that contribute to DIC, clinical manifestations of DIC, and its treatment. IMPLICATIONS FOR NURSING PRACTICE Nurses need to consider the presenting diagnosis of the patient and understand laboratory abnormalities that signify DIC. The nurse plays a key role in early recognition of this syndrome as prompt treatment can reduce fatality.
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5
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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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6
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Eliwan H, Omer M, McKenna E, Kelly LA, Nolan B, Regan I, Molloy EJ. Protein C Pathway in Paediatric and Neonatal Sepsis. Front Pediatr 2021; 9:562495. [PMID: 35186813 PMCID: PMC8849213 DOI: 10.3389/fped.2021.562495] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 12/20/2021] [Indexed: 11/24/2022] Open
Abstract
Protein C plays a major role in the physiological regulation of coagulation pathways through inactivation of factor Va, factor VIIIa, and plasminogen activator inhibitor. Protein C is involved in the control of inflammation during sepsis, by inhibiting release of pro-inflammatory cytokines, thereby controlling neutrophil, and monocyte effects on injured tissue. Recombinant human activated protein C (rhAPC) reduced mortality in adult sepsis in earlier studies but had no significant benefit in more recent trials. Protein C levels are reduced during paediatric and neonatal sepsis, which may play a major role in the development of disseminated intravascular thrombosis, purpura fulminans, and multiorgan dysfunction. The role of protein C in paediatric sepsis requires further clinical and immunological evaluation to define the patient subgroups who may benefit from this therapy. Newer versions of rhAPC are under development with less risk of haemorrhage potentially broadening the scope of this intervention.
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Affiliation(s)
- Hassan Eliwan
- National Children's Research Centre, Dublin, Ireland.,Department of Paediatrics, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
| | - Murwan Omer
- Department of Paediatrics, Children's Health Ireland at Tallaght, Dublin, Ireland
| | - Ellen McKenna
- Department of Paediatrics, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
| | - Lynne A Kelly
- National Children's Research Centre, Dublin, Ireland.,Department of Paediatrics, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland.,Trinity Research in Childhood Centre, Dublin, Ireland
| | - Beatrice Nolan
- Department of Haematology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Irene Regan
- National Children's Research Centre, Dublin, Ireland.,Department of Haematology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Eleanor J Molloy
- National Children's Research Centre, Dublin, Ireland.,Department of Paediatrics, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland.,Department of Paediatrics, Children's Health Ireland at Tallaght, Dublin, Ireland.,Trinity Research in Childhood Centre, Dublin, Ireland.,Department of Neonatology, Children's Health Ireland at Crumlin, Dublin, Ireland.,Department of Paediatrics, Coombe Women's and Infant's University Hospital, Dublin, Ireland
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7
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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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8
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Alawi SA, Ipaktchi R, Suchodolski K, Jokuszies A. [Treatment failure after postinfectious purpura fulminans despite interdisciplinary surgical and intensive medical therapy]. Med Klin Intensivmed Notfmed 2020; 115:253-259. [PMID: 32055865 DOI: 10.1007/s00063-020-00662-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 12/15/2019] [Accepted: 12/20/2019] [Indexed: 11/29/2022]
Affiliation(s)
- S A Alawi
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover, Deutschland
| | - R Ipaktchi
- Department of Oral and Maxillary and Plastic Facial Surgery, University Hospital Duesseldorf, Düsseldorf, Deutschland
| | - K Suchodolski
- Department of Anesthesiology, Hannover Medical School, Hannover, Deutschland
| | - A Jokuszies
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover, Deutschland. .,Department of Plastic, Aesthetic, Hand and Recosntructive Surgery, Hannover Medical School, Hannover, Deutschland.
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9
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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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10
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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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11
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Kumar A, Shah NP, Menon V, Nissen SE. Purpura fulminans manifesting with Staphylococcus aureus endocarditis: a case report. Eur Heart J Case Rep 2019; 3:5498064. [PMID: 31449632 PMCID: PMC6601163 DOI: 10.1093/ehjcr/ytz077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Revised: 12/28/2018] [Accepted: 04/26/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Purpura fulminans (PF) is a haematologic emergency that can occur in the setting of severe septic shock. Its pathophysiology is not well-understood; however, some evidence suggests it may be mediated by excessive protein C consumption. CASE SUMMARY In this case report, we describe a patient with PF secondary to methicillin-resistant Staphylococcus aureus endocarditis. She presented with severe septic shock and, despite haemodynamic improvement, developed a significant purpuric rash. Diagnostic work-up was notable for severely decreased serum levels of protein C. This patient was successfully treated with protein C concentrate and surgical valve replacement. DISCUSSION While PF is rarely associated with S. aureus infection, this presentation may be more frequently encountered among clinicians in the current opioid epidemic. Quick recognition is crucial and a multidisciplinary approach, including intravenous infusion of protein C, may be considered.
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Affiliation(s)
- Anirudh Kumar
- Heart and Vascular Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Desk J3-5, Cleveland, OH, USA
- Corresponding author. Tel: +1 216 970 7715,
| | - Nishant P Shah
- Heart and Vascular Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Desk J3-5, Cleveland, OH, USA
| | - Venu Menon
- Heart and Vascular Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Desk J3-5, Cleveland, OH, USA
| | - Steven E Nissen
- Heart and Vascular Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Desk J3-5, Cleveland, OH, USA
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12
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Lécuyer H, Virion Z, Barnier JP, Matczak S, Bourdoulous S, Bianchini E, Saller F, Borgel D, Nassif X, Coureuil M. An ADAM-10 dependent EPCR shedding links meningococcal interaction with endothelial cells to purpura fulminans. PLoS Pathog 2018; 14:e1006981. [PMID: 29630665 PMCID: PMC5908201 DOI: 10.1371/journal.ppat.1006981] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 04/19/2018] [Accepted: 03/20/2018] [Indexed: 01/03/2023] Open
Abstract
Purpura fulminans is a deadly complication of Neisseria meningitidis infections due to extensive thrombosis of microvessels. Although a Disseminated Intra-vascular Coagulation syndrome (DIC) is frequently observed during Gram negative sepsis, it is rarely associated with extensive thrombosis like those observed during meningococcemia, suggesting that the meningococcus induces a specific dysregulation of coagulation. Another specific feature of N. meningitidis pathogenesis is its ability to colonize microvessels endothelial cells via type IV pili. Importantly, endothelial cells are key in controlling the coagulation cascade through the activation of the potent anticoagulant Protein C (PC) thanks to two endothelial cell receptors among which the Endothelial Protein C Receptor (EPCR). Considering that congenital or acquired deficiencies of PC are associated with purpura fulminans, we hypothesized that a defect in the activation of PC following meningococcal adhesion to microvessels is responsible for the thrombotic events observed during meningococcemia. Here we showed that the adhesion of N. meningitidis on endothelial cells results in a rapid and intense decrease of EPCR expression by inducing its cleavage in a process know as shedding. Using siRNA experiments and CRISPR/Cas9 genome edition we identified ADAM10 (A Disintegrin And Metalloproteinase-10) as the protease responsible for this shedding. Surprisingly, ADAM17, the only EPCR sheddase described so far, was not involved in this process. Finally, we showed that this ADAM10-mediated shedding of EPCR induced by the meningococcal interaction with endothelial cells was responsible for an impaired activation of Protein C. This work unveils for the first time a direct link between meningococcal adhesion to endothelial cells and a severe dysregulation of coagulation, and potentially identifies new therapeutic targets for meningococcal purpura fulminans. Neisseria meningitidis (meningococcus) is responsible for a severe syndrome called purpura fulminans in which the coagulation system is totally dysregulated, leading to an extensive occlusion of blood microvessels. The pathogenesis of this syndrome is still not understood. Here we show that the meningococcus, when adhering on the apical surface of endothelial cells, induces the activation of membranous protease named ADAM-10, which in turn hydrolyses a cellular receptor called EPCR. The latter is key for the activation of a circulating potent anticoagulant, the Protein C (PC). PC activation is then impaired following meningococcal adhesion on endothelial cells. This work unveils for the first time a specific dysregulation of coagulation induced by the meningococcus and potentially identifies new therapeutic targets for meningococcal purpura fulminans.
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Affiliation(s)
- Hervé Lécuyer
- Institut Necker Enfants Malades, INSERM U1151, CNRS UMR8253, Paris, France
- Université Paris Descartes, Paris, France
- Assistance Publique–Hôpitaux de Paris, Hôpital Universitaire Necker Enfants Malades, Service de Microbiologie Clinique, Paris, France
- * E-mail:
| | - Zoé Virion
- Institut Necker Enfants Malades, INSERM U1151, CNRS UMR8253, Paris, France
- Université Paris Descartes, Paris, France
| | - Jean-Philippe Barnier
- Institut Necker Enfants Malades, INSERM U1151, CNRS UMR8253, Paris, France
- Université Paris Descartes, Paris, France
- Assistance Publique–Hôpitaux de Paris, Hôpital Universitaire Necker Enfants Malades, Service de Microbiologie Clinique, Paris, France
| | - Soraya Matczak
- Institut Necker Enfants Malades, INSERM U1151, CNRS UMR8253, Paris, France
- Université Paris Descartes, Paris, France
| | - Sandrine Bourdoulous
- Université Paris Descartes, Paris, France
- Institut Cochin, INSERM U1016, CNRS UMR8104, Paris, France
| | - Elsa Bianchini
- INSERM UMR-S1176, Université Paris-Sud, Université Paris Saclay, Le Kremlin-Bicêtre, France
| | - François Saller
- INSERM UMR-S1176, Université Paris-Sud, Université Paris Saclay, Le Kremlin-Bicêtre, France
| | - Delphine Borgel
- INSERM UMR-S1176, Université Paris-Sud, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique–Hôpitaux de Paris, Hôpital Universitaire Necker Enfants Malades, Service d’Hématologie Biologique, Paris, France
| | - Xavier Nassif
- Institut Necker Enfants Malades, INSERM U1151, CNRS UMR8253, Paris, France
- Université Paris Descartes, Paris, France
- Assistance Publique–Hôpitaux de Paris, Hôpital Universitaire Necker Enfants Malades, Service de Microbiologie Clinique, Paris, France
| | - Mathieu Coureuil
- Institut Necker Enfants Malades, INSERM U1151, CNRS UMR8253, Paris, France
- Université Paris Descartes, Paris, France
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13
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Lee G, Mak Y, Kam C. Case Report: Meningococcal Meningitis. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790100800209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
A case of meningococcal meningitis in an adult male in March 2000 in Hong Kong is reported. The main features were fever for one day with headache, vomiting, dizziness, diffuse maculo-papular rash, and one purpuric rash on the dorsum of right hand and stable vital signs. Incidentally, there were three other unreported cases of meningococcal infection in the city during that period. It is important for emergency physicians to recognise this life-threatening condition in the initial stable phase to promptly provide the emergency management and to administer the antibiotic treatment to reduce mortality.
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Affiliation(s)
| | | | - Cw Kam
- Tuen Mun Hospital, Accident and Emergency Department, Tsing Chung Koon Road, Tuen Mun, N.T., Hong Kong
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14
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Colling ME, Bendapudi PK. Purpura Fulminans: Mechanism and Management of Dysregulated Hemostasis. Transfus Med Rev 2017; 32:69-76. [PMID: 29157918 DOI: 10.1016/j.tmrv.2017.10.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 08/21/2017] [Accepted: 10/13/2017] [Indexed: 01/30/2023]
Abstract
Purpura fulminans (PF) is a highly thrombotic subtype of disseminated intravascular coagulation that can accompany severe bacterial, and more rarely, viral infections. PF is associated with an extremely high mortality rate, and patients often die of overwhelming multisystemic thrombosis rather than septic shock. Survivors typically experience amputation of involved extremities and significant scarring in affected areas. Despite the devastating clinical course associated with this hemostatic complication of infection, the mechanism of PF remains poorly understood. Severe acquired deficiency of protein C and dysfunction of the protein C-thrombomodulin pathway as well as other systems that exert a negative regulatory effect on coagulation have been implicated. Management of PF involves treatment of the underlying infection, aggressive anticoagulation, and robust transfusion support aimed at correcting acquired deficiencies in natural anticoagulant proteins. In this review, we address the diagnosis and management of PF with a focus on a rational approach to this condition informed by the available data. Proposed mechanisms underlying the dysregulation of coagulation seen in PF are also covered, and implications for therapy are discussed.
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Affiliation(s)
- Meaghan E Colling
- Department of Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Pavan K Bendapudi
- Harvard Medical School, Boston, MA; Division of Hematology, Massachusetts General Hospital, Boston, MA; Blood Transfusion Service, Massachusetts General Hospital, Boston, MA.
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15
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American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock. Crit Care Med 2017; 45:1061-1093. [PMID: 28509730 DOI: 10.1097/ccm.0000000000002425] [Citation(s) in RCA: 381] [Impact Index Per Article: 54.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES The American College of Critical Care Medicine provided 2002 and 2007 guidelines for hemodynamic support of newborn and pediatric septic shock. Provide the 2014 update of the 2007 American College of Critical Care Medicine "Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock." DESIGN Society of Critical Care Medicine members were identified from general solicitation at Society of Critical Care Medicine Educational and Scientific Symposia (2006-2014). The PubMed/Medline/Embase literature (2006-14) was searched by the Society of Critical Care Medicine librarian using the keywords: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation, and American College of Critical Care Medicine guidelines in the newborn and pediatric age groups. MEASUREMENTS AND MAIN RESULTS The 2002 and 2007 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and American Heart Association/Pediatric Advanced Life Support sanctioned recommendations. The review of new literature highlights two tertiary pediatric centers that implemented quality improvement initiatives to improve early septic shock recognition and first-hour compliance to these guidelines. Improved compliance reduced hospital mortality from 4% to 2%. Analysis of Global Sepsis Initiative data in resource rich developed and developing nations further showed improved hospital mortality with compliance to first-hour and stabilization guideline recommendations. CONCLUSIONS The major new recommendation in the 2014 update is consideration of institution-specific use of 1) a "recognition bundle" containing a trigger tool for rapid identification of patients with septic shock, 2) a "resuscitation and stabilization bundle" to help adherence to best practice principles, and 3) a "performance bundle" to identify and overcome perceived barriers to the pursuit of best practice principles.
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Purpura Fulminans in Acute Meningococcemia. J Gen Intern Med 2017; 32:848-849. [PMID: 28236134 PMCID: PMC5481231 DOI: 10.1007/s11606-017-4017-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 11/10/2016] [Accepted: 02/10/2017] [Indexed: 10/20/2022]
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Crochemore T, Nunes Dias Campos F, Menezes Souza Pessoa C, Lima Rocha L, Zanella do Amaral Campos PP, Corrêa TD. Thromboelastometry-guided blood transfusion in septic shock complicated with disseminated intravascular coagulation: a case report. Clin Case Rep 2017; 5:701-706. [PMID: 28469879 PMCID: PMC5412820 DOI: 10.1002/ccr3.912] [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: 09/09/2016] [Revised: 02/22/2017] [Accepted: 02/25/2017] [Indexed: 11/11/2022] Open
Abstract
Approximately 25–50% of septic patients develop disseminated intravascular coagulation. The thromboelastometry evaluates whole blood clot formation and dissolution in real time and has been considered for management of bleeding in diverse clinical conditions. We present a case of thromboelastometry‐guided bleeding management of a septic shock patient with overt disseminated intravascular coagulation (DIC).
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Affiliation(s)
- Tomaz Crochemore
- Intensive Care Unit; Hospital Israelita Albert Einstein; São Paulo SP Brazil
| | | | | | - Leonardo Lima Rocha
- Intensive Care Unit; Hospital Israelita Albert Einstein; São Paulo SP Brazil
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18
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Affiliation(s)
- Louise Elaine Vaz
- Division of Pediatric Infectious Diseases, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR
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19
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Fatal purpura fulminans and Waterhouse-Friderichsen syndrome from fulminant Streptococcus pneumoniae sepsis in an asplenic young adult. IDCases 2016; 6:1-4. [PMID: 27583208 PMCID: PMC4995527 DOI: 10.1016/j.idcr.2016.08.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 08/10/2016] [Accepted: 08/10/2016] [Indexed: 11/23/2022] Open
Abstract
Asplenic patients are at increased risk for sepsis and fulminant infection. Sepsis in these patients is typically secondary to encapsulated bacteria, with Streptococcus pneumoniae being the most frequent pathogen. Rare complications of severe sepsis include purpura fulminans and bilateral adrenal hemorrhage (Waterhouse-Friderichsen syndrome). We present the case of a 36-year-old woman, healthy except for splenectomy years prior for idiopathic thrombocytopenic purpura treatment, who presented with fever. Upon presentation to our hospital, three hours after symptoms onset, she had purpura fulminans and shock. Despite timely antimicrobials and maximal resuscitative efforts, her disease progressed and she expired 12 hours after symptoms onset. Autopsy revealed bilateral adrenal hemorrhage; acute adrenal crisis likely contributed to her refractory shock. Prior to her presentation, she had not received guideline-based post-splenectomy care. Sepsis in asplenic patients can be fulminant and rapidly fatal. Streptococcus pneumoniae remains the most frequent cause, despite decreasing rates in recent years related to widespread pneumococcal vaccination. Guideline-based vaccinations and "pill-in-pocket" therapy can be life-saving for asplenic patients. Purpura fulminans represents an extreme manifestation of disseminated intravascular coagulation, is more common in asplenic patients, and portends a poor prognosis. Waterhouse-Friderichsen syndrome can be seen concurrently with purpura fulminans and further portends a poor prognosis; pre-mortem diagnosis requires a high index of suspicion.
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Abstract
Thrombocytopenia is a common laboratory finding in the intensive care unit (ICU) patient. Because the causes can range from laboratory artifact to life-threatening processes such as thrombotic thrombocytopenic purpura (TTP), identifying the cause of thrombocytopenia is important. In the evaluation of the thrombocytopenia patient, one should incorporate all clinical clues such as why the patient is in the hospital, medications the patient is on, and other abnormal laboratory findings. One should ensure that the patient does not suffer from heparin-induced thrombocytopenia (HIT) or one of the thrombotic microangiopathies (TMs). HIT can present in any patient on heparin and requires specific testing and antithrombotic therapy. TMs cover a spectrum of disease ranging from TTP to pregnancy complications and can have a variety of presentations. Management of disseminated intravascular coagulation depends on the patient’s condition and complication. Other causes of ICU thrombocytopenia include sepsis, medication side effects, post-transfusion purpura, catastrophic anti phospholipid antibody disease, and immune thrombocytopenia.
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Perillo T, Muggeo P, Arcamone G, Leonardis FD, Santoro N. Non Activated Protein C Supplementation in Septic Pediatric Hematological Patients. Pediatr Rep 2016; 8:6488. [PMID: 27433305 PMCID: PMC4933811 DOI: 10.4081/pr.2016.6488] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Revised: 04/17/2016] [Accepted: 05/23/2016] [Indexed: 12/29/2022] Open
Abstract
The purpose of the study was to examine safety and efficacy of non-activated Protein C (PC) supplementation in our cohort of septic pediatric hematological patients. We conducted a retrospective study of 22 septic patients receiving human plasma-derived PC concentrate from 2008 to 2015 at our Pediatric Oncology Center (Bari, Italy). The Surviving sepsis campaign definitions for sepsis, severe sepsis and septic shock were used to define the patients' septic status. For each patient, we calculated Lansky performance status scale (LPSS) and a risk score defined the Hematologic risk score (HRS) that we created in 2007. Patients were defined as High risk for severe sepsis/septic shock in case of HRS>3. HRS<3 identified low risk patients. Baseline serum PC levels, PC administration dosage and duration and days until a 20% improvement in LPSS. Observed baseline serum PC levels (bPC) blood concentrations ranged from 31 to 80%. Patients received PC supplementation in case of low age-related bPC levels or >10% PC concentration decrease within 12 hours from the first evaluation. All patients received 80 U/kg/day PC, intravenously, every twenty-four hours. No drug-related adverse event was observed. The observed sepsis-related mortality rate in our cohort was 9%. PC supplementation in our cohort appeared to be safe, and, probably due to prompt PC administration, we observed an overall mortality that was much lower than expected mortality in cancer severe septic patients.
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Affiliation(s)
- Teresa Perillo
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, University of Bari , Italy
| | - Paola Muggeo
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, University of Bari , Italy
| | - Giampaolo Arcamone
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, University of Bari , Italy
| | - Francesco De Leonardis
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, University of Bari , Italy
| | - Nicola Santoro
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, University of Bari , Italy
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22
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Wojtowicz JM, Jones GL. Streptococcus pneumoniae–induced purpura fulminans in a woman with functional asplenia. CAN J EMERG MED 2015; 16:339-42. [DOI: 10.2310/8000.2013.130990] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
ABSTRACTPurpura fulminans is a rare complication of septic shock, often associated withStreptococcus pneumoniae. Patients with anatomic or functional asplenia are at increased risk for infection because of impairment of their ability to defend against encapsulated pathogens. We report the case of a previously healthy, unimmunized 33-year-old female with functional asplenia who presented in septic shock and purpura fulminans and died in spite of maximal resuscitative measures. The clinical presentation, diagnosis, and management of purpura fulminans are reviewed. Purpura fulminans is a rare condition that requires early diagnosis and aggressive management by emergency physicians.
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Piccin A, O' Marcaigh A, Mc Mahon C, Murphy C, Okafor I, Marcheselli L, Casey W, Claffey L, Smith OP. Non-activated plasma-derived PC improves amputation rate of children undergoing sepsis. Thromb Res 2014; 134:63-7. [PMID: 24821370 DOI: 10.1016/j.thromres.2014.04.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Revised: 04/11/2014] [Accepted: 04/17/2014] [Indexed: 11/24/2022]
Abstract
Low circulating protein C (PC) levels have been observed in sepsis, especially in patients with Neisseriae Meningitides infections. Poor clinical outcome and high limb amputation rates have been associated in infected patients with low circulating PC levels. Published studies using activated PC replacement therapy patients with sepsis have shown reduced mortality rates, however, its use has been associated with severe bleeding events. Paediatric sepsis studies using non-activated plasma-derived PC (Ceprotin®) are lacking. We present a retrospective study in children with sepsis who were treated with Ceprotin® focusing on amputation rate post treatment. Thirty subjects were identified. Median age at diagnosis was 2 years. Twenty-one (70%) were treated for Nesseria Meningitides and one (3%) for Streptococcus-A β-haemolyticus, another 8 (26%) patients with malignancies were treated for neutropenic sepsis. Following Ceprotin® administration, a significant increase in leukocyte count (p=0.004), neutrophil count (p=0.001) and PC (pretreatment=13%, posttreatment=88.5%; p=0.0001) was seen. Prothrombin time (pretreatment =30.3 seconds, posttreatment =16.5; p=0.000) and activated partial thromboplastin time (pretreatment =61.8 sec, postreatment =42.6 sec; p=0.000) were significantly reduced, while fibrinogen levels were significantly elevated (pretreatment =1.9 g/dL, posttreatment =4.4 g/dL; p=0.000). The median time between admission to intensive care and Ceprotin® administration was 10 hrs. Limb amputation rate was reduced (16-23% versus 30-50% from previous studies) and there were no haemorrhagic events observed. This study demonstrates the safe administration of non-activated plasma-derived PC concentrate in patients with sepsis who are coagulopathic and it associated with a reduction in amputation rates.
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Affiliation(s)
- Andrea Piccin
- Hematology Dept, Our Lady's Children's Hospital, Dublin, Ireland; Hematology Dept, San Maurizio Regional Hospital, Bolzano, Italy; Trinity College University, Dublin, Ireland.
| | | | - Corrina Mc Mahon
- Hematology Dept, Our Lady's Children's Hospital, Dublin, Ireland
| | | | - Ikechukwu Okafor
- Hematology Dept, Our Lady's Children's Hospital, Dublin, Ireland
| | - Luigi Marcheselli
- Department of Diagnostic and Clinical Medicine and Public Health University of Modena and Reggio Emilia, Modena Italy
| | - William Casey
- Anesthesiology Dept, Our Lady's Children's Hospital, Dublin, Ireland
| | - Liam Claffey
- Anesthesiology Dept, Temple Street Hospital, Dublin, Ireland
| | - Owen Patrick Smith
- Hematology Dept, Our Lady's Children's Hospital, Dublin, Ireland; Trinity College University, Dublin, Ireland
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24
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Purpura Fulminans following Thermal Injury. Case Rep Emerg Med 2013; 2013:782386. [PMID: 23762660 PMCID: PMC3665217 DOI: 10.1155/2013/782386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 04/19/2013] [Indexed: 11/24/2022] Open
Abstract
Purpura fulminans is a rare syndrome of intravascular thrombosis and hemorrhagic infarction of the skin, which is an unusual cutaneous manifestation of disseminated intravascular coagulation. It often occurs in small children and babies due to infection and/or sepsis, rarely in adults in clinic. We report the first case of deadly purpura fulminans following thermal injury in a 64-year-old Chinese woman. The purpura developed sharply and aggravated multiple organ dysfunction. The patient died of purpura fulminans, disseminated intravascular coagulation, and multiple organ dysfunction syndrome.
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25
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Tamimi-Mariño I, Hidalgo JJ, Perez A, Mendez LI. [Purpura fulminans: functional results in two paediatric patients after suffering multiple amputations]. Rev Esp Cir Ortop Traumatol (Engl Ed) 2013; 56:319-22. [PMID: 23594852 DOI: 10.1016/j.recot.2012.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Revised: 03/02/2012] [Accepted: 03/07/2012] [Indexed: 10/28/2022] Open
Abstract
Purpura fulminans (PF) is an unusual haemorrhagic process that is usually associated with meningococcal sepsis and other infectious processes. It usually affects neonates and young children, and starts with a benign infection that progresses to a high fever, purpura ecchymosis, disseminated intravascular coagulopathy, necrosis and gangrene. The treatment of these children usually requires making difficult decisions, since the surgeon and the families must come to terms with the possibility of following an aggressive line of treatment that could lead to multiple mutilating sequelae, or follow palliative treatment. In this study, we review the clinical presentation, treatment and results of two cases of PF treated in our hospital between the years 2002 and 2005. The children presented in this study had a good long-term functional result and an acceptable quality of life, despite being subjected to multiple amputations.
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Affiliation(s)
- I Tamimi-Mariño
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Carlos Haya, Málaga, España.
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26
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Borgel D, Lerolle N. Quel avenir pour les médicaments de l’hémostase dans le traitement du sepsis sévère après le Xigris® ? MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-013-0665-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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27
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28
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Purpura fulminans: Functional results in two paediatric patients after suffering multiple amputations. Rev Esp Cir Ortop Traumatol (Engl Ed) 2012. [DOI: 10.1016/j.recote.2012.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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29
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Knoebl PN. Severe congenital protein C deficiency: the use of protein C concentrates (human) as replacement therapy for life-threatening blood-clotting complications. Biologics 2011; 2:285-96. [PMID: 19707361 PMCID: PMC2721356 DOI: 10.2147/btt.s1954] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The protein C pathway has an important function in regulating and modulating blood coagulation and ensuring patency of the microcirculation. Protein C deficiency leads to macro- and microvascular thrombosis. Congenital severe protein C deficiency is a life-threatening state with neonatal purpura fulminans and pronounced coagulopathy. Patients with heterozygous protein C deficiency have an increased risk for thromboembolic events or experience coumarin-induced skin necrosis during initiation of coumarin therapy. Replacement with protein C concentrates is an established therapy of congenital protein C deficiency, resulting in rapid resolving of coagulopathy and thrombosis without reasonable side effects. This article summarizes the current knowledge on protein C replacement therapy in congenital protein C deficiency.
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Affiliation(s)
- Paul N Knoebl
- Department of Medicine 1, Division Hematology and Hemostasis, Medical University of Vienna, Vienna, Austria
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30
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Guidance on patient identification and administration of recombinant human activated protein C for the treatment of severe sepsis. Can J Infect Dis 2011; 13:361-72. [PMID: 18159413 DOI: 10.1155/2002/916317] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2002] [Accepted: 08/16/2002] [Indexed: 11/17/2022] Open
Abstract
Approximately one-third of cases of severe sepsis result in death. Endogenous activated protein C (APC) plays a key role in the regulation of the inflammation, fibrinolysis and coagulation associated with severe sepsis. In a recently published phase III trial, Protein C Worldwide Evaluation in Severe Sepsis (PROWESS), intravenous administration of recombinant human APC (rhAPC) 24 mug/kg/h for 96 h to patients with severe sepsis resulted in a 6.1% reduction in absolute mortality and a 19.4% reduction in the relative risk of death from any cause within 28 days (number needed to treat = 16). This dose is now being applied in clinical practice.rhAPC is recommended for the treatment of severe sepsis (sepsis associated with acute organ dysfunction) occurring as a result of all types of infection (Gram-negative bacterial, Gram-positive bacterial and fungal). A panel of Canadian clinicians experienced in the treatment of severe sepsis and the management of critical care patients has developed this consensus document to assist clinicians in appropriate patient selection and management of potential challenges associated with rhAPC therapy.
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Abstract
Infection frequently elicits a coagulation response. Endotoxin triggers the formation of tissue factor initiating coagulation, down regulates anticoagulant mechanisms including the protein C pathway and heparin-like proteoglycans and up regulates plasminogen activator inhibitor. The overall physiological result of this is to promote coagulation through enhancing initiation, suppressing negative regulation and impairing fibrin removal. The response to infection also leads to tissue destruction. Nucleosomes and histones released from the injured cells trigger further inflammation, protection from the pathogen but further tissue injury leading to multi-organ failure. Such a complex response to infection presumably arises due to the role of coagulation in the control and clearance of the infectious agent.
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Affiliation(s)
- Charles T. Esmon
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, University of Oklahoma Health Sciences Center, Oklahoma City, OK
- Howard Hughes Medical Instititute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
- Departments of Pathology and Biochemistry & Molecular Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Jun Xu
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Florea Lupu
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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Continuous renal replacement therapy results in respiratory and hemodynamic beneficial effects in pediatric patients with severe systemic inflammatory response syndrome and multiorgan system dysfunction. Pediatr Crit Care Med 2010; 11:737-40. [PMID: 20068503 DOI: 10.1097/pcc.0b013e3181ce7593] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Proinflammatory mediators have been implicated in the pathogenesis of systemic inflammatory response syndrome and multiorgan system dysfunction. These mediators are of molecular weights that render them amenable to clearance by the hemodiafiltration mode of continuous renal replacement therapy. OBJECTIVE To determine whether a period of 48 hrs of continuous renal replacement therapy in patients with multiorgan system dysfunction secondary to systemic inflammatory response syndrome improves their degree of anasarca as well as their cardiovascular and respiratory systems performances. DATA SOURCE Retrospective chart review. STUDY DESIGN Charts of patients diagnosed with systemic inflammatory response syndrome, who were mechanically ventilated in the pediatric intensive care unit and at the same time were receiving continuous renal replacement therapy, from 2004 to 2008, were reviewed. Patients with preexisting renal failure and/or received extracorporeal membrane oxygenation were excluded. Changes in the patients' body weights, oxygenation indices, and vasopressor scores were used as markers for responsiveness to continuous renal replacement therapy. DATA ANALYSIS AND MAIN RESULTS: Data from twenty-two patients with systemic inflammatory response syndrome and with three to five concomitantly diagnosed organ system dysfunctions, at the time continuous renal replacement therapy was initiated, were analyzed. None of the six patients who had five organ system dysfunctions survived to be discharged from the pediatric intensive care unit. Of the remaining 16 patients with three or four organ system dysfunctions, eight (50%) survived and eight (50%) died. The patients' weight, oxygenation indices, and vasopressor scores did not significantly change with 48 hrs of continuous renal replacement therapy. CONCLUSIONS Mechanically ventilated patients with systemic inflammatory response syndrome and multiorgan system dysfunction demonstrated a precarious and insignificant response to 48 hrs of continuous renal replacement therapy in a hemodiafiltration mode. However, the patients' overall clinical status did not deteriorate during this therapy. More prospective studies are necessary to determine the effectiveness of continuous renal replacement therapy in patients with multiorgan system dysfunction.
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Bektas F, Soyuncu S. Idiopathic purpura fulminans. Am J Emerg Med 2010; 29:475.e5-6. [PMID: 20674230 DOI: 10.1016/j.ajem.2010.04.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2010] [Revised: 04/16/2010] [Accepted: 04/17/2010] [Indexed: 10/19/2022] Open
Affiliation(s)
- Firat Bektas
- Department of Emergency Medicine, Akdeniz University Faculty of Medicine, 07059 Antalya, Turkey.
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Thakkar SC, Streiff MB, Bruley DF, Mears SC. Case report: perioperative use of protein c concentrate for protein C deficiency in THA. Clin Orthop Relat Res 2010; 468:1986-90. [PMID: 20012238 PMCID: PMC2882006 DOI: 10.1007/s11999-009-1189-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2009] [Accepted: 11/23/2009] [Indexed: 01/31/2023]
Abstract
BACKGROUND Perioperative management of patients with heterozygous protein C deficiency is challenging because of the competing risks of bleeding and recurrent thrombosis. CASE DESCRIPTION We report the case of a 74-year-old man with protein C deficiency and heterozygous prothrombin G20210A gene mutation who had a successful left THA with perioperative administration of human zymogen protein C concentrate in addition to anticoagulation with enoxaparin. LITERATURE REVIEW Several studies have reported the use of protein C concentrate in severe sepsis-associated purpura fulminans in patients with severe congenital protein C deficiency who have had thrombotic events. We reviewed studies and case reports pertinent to the treatment of patients with protein C deficiency, especially in the perioperative setting. We report the case of a patient undergoing THA in whom we used human zymogen protein C concentrate. PURPOSES AND CLINICAL RELEVANCE THA, a particularly high-risk procedure, is associated with a 40% to 70% incidence of venographic deep venous thrombosis and a 2% to 3% incidence of symptomatic deep venous thrombosis. These risks are greater in people with thrombophilic defects such as protein C deficiency. The use of human zymogen protein C in our patient with heterozygous protein C deficiency during the perioperative period of a THA was associated with no evidence of excessive bleeding, hematoma, deep venous thrombosis, or pulmonary embolism.
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Affiliation(s)
- Savyasachi C. Thakkar
- Department of Orthopaedic Surgery, The Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, #A665, Baltimore, MD 21224-2780 USA
| | - Michael B. Streiff
- Division of Hematology, Department of Medicine, The Johns Hopkins Hospital, Baltimore, MD USA
| | | | - Simon C. Mears
- Department of Orthopaedic Surgery, The Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, #A665, Baltimore, MD 21224-2780 USA
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Affiliation(s)
- Mukul P Agarwal
- Department of Medicine, University College of Medical Sciences, Delhi, India
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36
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Veldman A. Purpura fulminans und andere komplexe Gerinnungsstörungen bei Kindern. Hamostaseologie 2010. [DOI: 10.1007/978-3-642-01544-1_38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Fischer D, Schloesser RL, Nold-Petry CA, Nold MF, Veldman A. Protein C concentrate in preterm neonates with sepsis. Acta Paediatr 2009; 98:1526-9. [PMID: 19604168 DOI: 10.1111/j.1651-2227.2009.01404.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Doris Fischer
- Department of Pediatrics, Division of Neonatology, JW Goethe-University Hospital Frankfurt, Germany
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Giordano P, Cecinati V, Vecchio GC, Arcamone G, De Leonardis F, Grassi M, Brescia LP, Santoro N, De Mattia D. Successful treatment with Protein C of febrile neutropenia in pediatric patients during cancer therapy. Immunopharmacol Immunotoxicol 2009; 31:293-8. [DOI: 10.1080/08923970802552415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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39
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Brierley J, Carcillo JA, Choong K, Cornell T, Decaen A, Deymann A, Doctor A, Davis A, Duff J, Dugas MA, Duncan A, Evans B, Feldman J, Felmet K, Fisher G, Frankel L, Jeffries H, Greenwald B, Gutierrez J, Hall M, Han YY, Hanson J, Hazelzet J, Hernan L, Kiff J, Kissoon N, Kon A, Irazuzta J, Irazusta J, Lin J, Lorts A, Mariscalco M, Mehta R, Nadel S, Nguyen T, Nicholson C, Peters M, Okhuysen-Cawley R, Poulton T, Relves M, Rodriguez A, Rozenfeld R, Schnitzler E, Shanley T, Kache S, Skache S, Skippen P, Torres A, von Dessauer B, Weingarten J, Yeh T, Zaritsky A, Stojadinovic B, Zimmerman J, Zuckerberg A. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med 2009; 37:666-88. [PMID: 19325359 PMCID: PMC4447433 DOI: 10.1097/ccm.0b013e31819323c6] [Citation(s) in RCA: 649] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND The Institute of Medicine calls for the use of clinical guidelines and practice parameters to promote "best practices" and to improve patient outcomes. OBJECTIVE 2007 update of the 2002 American College of Critical Care Medicine Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock. PARTICIPANTS Society of Critical Care Medicine members with special interest in neonatal and pediatric septic shock were identified from general solicitation at the Society of Critical Care Medicine Educational and Scientific Symposia (2001-2006). METHODS The Pubmed/MEDLINE literature database (1966-2006) was searched using the keywords and phrases: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation (ECMO), and American College of Critical Care Medicine guidelines. Best practice centers that reported best outcomes were identified and their practices examined as models of care. Using a modified Delphi method, 30 experts graded new literature. Over 30 additional experts then reviewed the updated recommendations. The document was subsequently modified until there was greater than 90% expert consensus. RESULTS The 2002 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and AHA sanctioned recommendations. Centers that implemented the 2002 guidelines reported best practice outcomes (hospital mortality 1%-3% in previously healthy, and 7%-10% in chronically ill children). Early use of 2002 guidelines was associated with improved outcome in the community hospital emergency department (number needed to treat = 3.3) and tertiary pediatric intensive care setting (number needed to treat = 3.6); every hour that went by without guideline adherence was associated with a 1.4-fold increased mortality risk. The updated 2007 guidelines continue to recognize an increased likelihood that children with septic shock, compared with adults, require 1) proportionally larger quantities of fluid, 2) inotrope and vasodilator therapies, 3) hydrocortisone for absolute adrenal insufficiency, and 4) ECMO for refractory shock. The major new recommendation in the 2007 update is earlier use of inotrope support through peripheral access until central access is attained. CONCLUSION The 2007 update continues to emphasize early use of age-specific therapies to attain time-sensitive goals, specifically recommending 1) first hour fluid resuscitation and inotrope therapy directed to goals of threshold heart rates, normal blood pressure, and capillary refill 70% and cardiac index 3.3-6.0 L/min/m.
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Lalitha AV, Aruna D, Prakash A, Nanjunda Swamy HM, Subba Rao SD. Spectrum of purpura fulminans. Indian J Pediatr 2009; 76:87-9. [PMID: 19391008 DOI: 10.1007/s12098-009-0034-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2006] [Accepted: 07/08/2008] [Indexed: 11/30/2022]
Abstract
Purpura Fulminans is a severe disorder of acute onset with high morbidity and mortality. It is characterized by DIC with thrombocytopenia, hyofibrinogenemia, hypothrombinemia and anemia. It most often occurs in young with sudden appearance of symmetrical, tender, ecchymotic skin lesions usually involving the lower extremities. An infectious and noninfectious etiology has been proposed. Early recognition and early therapy with appropriate antibiotics and heparin is known to limit both morbidity and mortality. This article reports 5 cases of Purpura Fulminans treated at our centre with review of etiology, pathogenesis, clinical features and treatment.
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Affiliation(s)
- A V Lalitha
- Department of Pediatrics, St John's Medical College Hospital, Bangalore, Karnataka, India.
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Abstract
Multiple organ system extracorporeal support effectively supports brain, heart, lung, liver, kidney, coagulation, red blood cell, and immune cell function in the sickest infants and children who have multiple organ system failure. These therapies have optimum benefit if: (1) the underlying disease is reversible; (2) the therapies are performed expertly and are monitored to prevent and minimize systemic hemolysis; and (3) the therapies are provided in a goal-directed manner. These therapies represent a significant advance in pediatric critical care medicine. This article provides a framework for this multidisciplinary team approach for implementing these therapies.
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Affiliation(s)
- Joseph A Carcillo
- Pediatric Critical Care, Children's Hospital of Pittsburgh, 3705 Fifth Ave., Pittsburgh, PA 15213, USA.
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Davis MDP, Dy KM, Nelson S. Presentation and outcome of purpura fulminans associated with peripheral gangrene in 12 patients at Mayo Clinic. J Am Acad Dermatol 2007; 57:944-56. [PMID: 17719676 DOI: 10.1016/j.jaad.2007.07.039] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2007] [Revised: 07/13/2007] [Accepted: 07/28/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Dermatologists may be called to assist in the diagnosis and management of purpura fulminans. METHODS This retrospective case series details the clinical presentation and outcomes of patients presenting with purpura fulminans associated with peripheral gangrene between 1989 and 2004. RESULTS All 12 patients presented with sudden onset of purpuric patches and evolving gangrene of the extremities in association with a shock syndrome (hypotension, oliguria). Eleven patients had disseminated intravascular coagulation. The cause of purpura fulminans was infectious in 9 patients, surgical in two, and cancer in one. Three patients died (25%) within a week of onset of purpura fulminans. Of the 9 surviving patients, 8 required amputation of at least one limb. Four patients required amputation of all 4 limbs. LIMITATIONS Retrospective study design, varying clinical descriptions, and potential referral bias are limitations. CONCLUSION Purpura fulminans in association with symmetric peripheral gangrene is an ominous clinical presentation.
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Affiliation(s)
- Mark D P Davis
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota 55905, USA.
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44
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Abstract
Severe sepsis is common and increasing in incidence. Mortality rates remain high. Discovery of the link between the coagulation system and the inflammatory response to sepsis led to the development of drotrecogin alpha (activated). This recombinant form of the natural anticoagulant, activated protein C, was shown to reduce 28-day mortality from severe sepsis in a large, randomised, placebo-controlled, multi-centre Phase III study. Although subsequent studies have demonstrated that drotrecogin alpha (activated) is not of benefit to all patients with severe sepsis, it does reduce mortality rates in patients at a high risk of death. Drotrecogin alpha (activated) is associated with an increased risk of bleeding. Recent studies have shed light on its mode of action, which is primarily attributed today to cytoprotective effects especially on the endothelium with improved microcirculation. Ongoing studies will help define which patients are most likely to benefit, perhaps with the help of biochemical markers.
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Affiliation(s)
- Jean-Louis Vincent
- Free University of Brussels, Erasme University Hospital, Department of Intensive Care, Route de Lennik, 808, B-1070 Brussels, Belgium.
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Ahonkai A, Lechtzin N. A case for vaccination. Am J Med 2007; 120:319-21. [PMID: 17398223 DOI: 10.1016/j.amjmed.2007.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2006] [Revised: 02/14/2007] [Accepted: 02/14/2007] [Indexed: 10/23/2022]
Affiliation(s)
- Aima Ahonkai
- Osler Medical Service, Johns Hopkins Hospital, Baltimore, MD, USA
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Abstract
Severe sepsis is a common and frequently fatal condition. Evidence showing a link between the coagulation system and the inflammatory response to sepsis led to the development of drotrecogin alfa (activated) as an agent in the treatment of severe sepsis. Recent studies have shown that the mode of action is actually more complex than initially thought. This recombinant form of the natural anticoagulant, activated protein C, has been demonstrated to reduce mortality in a large randomized controlled, Phase III study involving 1690 patients, even though the results of this and subsequent studies and the licensing of drotrecogin alfa (activated) have generated considerable debate. Administration of drotrecogin alfa (activated) is associated with an increased risk of bleeding and its use is contraindicated in patients with a high risk of bleeding or recent hemorrhagic events.
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Affiliation(s)
- Jean-Louis Vincent
- Erasme University Hospital, Department of Intensive Care, Route de Lennik, 808, B-1070 Brussels, Belgium.
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Schellongowski P, Bauer E, Holzinger U, Staudinger T, Frass M, Laczika K, Locker GJ, Quehenberger P, Rabitsch W, Schenk P, Knöbl P. Treatment of adult patients with sepsis-induced coagulopathy and purpura fulminans using a plasma-derived protein C concentrate (CeprotinR). Vox Sang 2006; 90:294-301. [PMID: 16635072 DOI: 10.1111/j.1423-0410.2006.00760.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES The aim of this study was to document the effects of supplementation with a plasma-derived protein C concentrate in adult patients with infectious purpura fulminans. MATERIALS AND METHODS We report the effect of the administration of a human protein C concentrate (Ceprotin, Baxter, Vienna, Austria) in eight adult patients with purpura fulminans. Five patients received the concentrate as level-adjusted continuous infusion (10 U/kg/h, target protein C activity 100%) and three patients received the concentrate as bolus infusions (100 U/kg every 6 h) in addition to standard sepsis therapy. Heparin, fresh-frozen plasma, antithrombin- and fibrinogen concentrates, low-dose rtPA, and platelet transfusions were given when appropriate. RESULTS Six patients had overt disseminated intravascular coagulation: platelets, 19 g/l; fibrinogen, 60 mg/dl; antithrombin, 47%; prothrombin time, 32%; activated partial thromboplastin time (APTT), 88 s; d-dimer, 66 microg/ml; protein C activity, 29% (medians). Five patients had septic shock, six renal failure and four respiratory failure. Patients received between 5000 and 77,000 U of protein C concentrate over 2.5 days (median); the protein C activity increased to 184% (median) and coagulopathy resolved within 3 days in seven of the eight patients. Six patients survived, one died early from fulminant sepsis, and one died after 14 days from candida sepsis. CONCLUSIONS Our data suggest that treatment with a plasma-derived protein C zymogen concentrate might be a useful support in adult patients with purpura fulminans.
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Affiliation(s)
- Peter Schellongowski
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Vienna, Austria
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Gruber A, Fernández JA, Bush L, Marzec U, Griffin JH, Hanson SR, DI Cera E. Limited generation of activated protein C during infusion of the protein C activator thrombin analog W215A/E217A in primates. J Thromb Haemost 2006; 4:392-7. [PMID: 16420571 DOI: 10.1111/j.1538-7836.2006.01760.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Anticoagulation with activated protein C (APC) reduces the mortality of severe sepsis. We investigated whether the circulating protein C (PC) pool could be utilized for sustained anticoagulation by endogenous APC. To generate APC without procoagulant effects, we administered the anticoagulant thrombin mutant W215A;E217A (WE) to baboons. In preliminary studies, administration of high dose WE (110 microg kg(-1) i.v. bolus every 120 min; n = 2) depleted PC levels by 50% and elicited transient APC bursts and anticoagulation. The response to WE became smaller with each successive injection. Low dose WE infusion (5 microg kg(-1) loading + 5 microg kg(-1) h(-1) infusion; n = 5) decreased plasma PC activity by 15%, from 105% to 90%, to a new equilibrium within 60 min. APC levels increased from 7.5 ng mL(-1) to 86 ng mL(-1) by 40 min, then declined, but remained elevated at 34 ng mL(-1) at 240 min. A 22-fold higher dose WE (n = 5) decreased PC levels to 60% by 60 min without significant further depletion in 5 h. The APC level was 201 ng mL(-1) at 40 min and decreased to 20 ng mL(-1) within 120 min despite continued activator infusion. Co-infusion of WE and equimolar soluble thrombomodulin (n = 5) rapidly consumed about 80% of the PC pool with significant temporal increase in APC generation. In conclusion, low-grade PC activation by WE produced sustained, clinically relevant levels of circulating APC. Limited PC consumption in WE excess was consistent with the rapid depletion of cofactor activity before depletion of the PC zymogen. Reduced utilization of circulating PC might have similar mechanism in some patients.
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Affiliation(s)
- A Gruber
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, OR 97006-8921, USA.
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Abstract
Recombinant human activated protein C (APC) might be the first pharmacological intervention which decreases mortality in the course of severe sepsis. Surviving Sepsis Campaign guidelines have recommended the use of APC with grade B level of proof. During sepsis, the APC pathway serves as a major system for controlling thrombosis inhibiting thrombin formation, limiting inflammatory responses, and potentially decreasing endothelial cell apoptosis. APC use was assessed in the course of severe sepsis 24 microg/kg/h for 96 hours with the aim of inhibiting coagulopathy and inflammation. The PROWESS trial included 1,690 patients and demonstrated a significantly decreased mortality in the treated group. Additional publications have clarified the characteristics of the included patients and tried to outline the potential benefits of APC. The results of ENHANCE, a multicenter open trial, have confirmed the trends reported in the PROWESS trial. Evidence supporting the efficacy of APC in the management of severe sepsis is clearly assessed. However, several issues remain unsolved and require to be addressed as the appropriate use of the drug and its place with other adjunctive therapies directed the sepsis process.
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Affiliation(s)
- P Montravers
- Département d'anesthésie-réanimation, CHU Bichat-Claude-Bernard, Paris, France.
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