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Theron A, Dautremay O, Boissier E, Zerroukhi A, Baleine J, Moulis L, Rodière M, Schved JF, Duraes M, Kanouni T, Cau-Diaz I, Jeziorski E, Biron-Andreani C. Idiopathic purpura fulminans associated with anti-protein S antibodies in children: a multicenter case series and systematic review. Blood Adv 2022; 6:495-502. [PMID: 34788405 PMCID: PMC8791598 DOI: 10.1182/bloodadvances.2021005126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 10/21/2021] [Indexed: 11/30/2022] Open
Abstract
Idiopathic purpura fulminans (IPF) is a rare but severe prothrombotic coagulation disorder that can occur after chickenpox or human herpesvirus 6 (HHV-6) infection. IPF leads to an autoantibody-mediated decrease in the plasma concentration of protein S. We conducted a retrospective multicenter study involving patients with IPF from 13 French pediatric centers and a systematic review of cases in published literature. Eighteen patients were included in our case series, and 34 patients were included as literature review cases. The median age was 4.9 years, and the diagnostic delay after the first signs of viral infection was 7 days. The lower limbs were involved in 49 patients (94%) with typical lesions. In all, 41 patients (78%) had a recent history of varicella-zoster virus infection, and 7 patients (14%) had been infected by HHV-6. Most of the patients received heparin (n = 51; 98%) and fresh frozen plasma transfusions (n = 41; 79%); other treatment options were immunoglobulin infusion, platelet transfusion, corticosteroid therapy, plasmapheresis, and coagulation regulator concentrate infusion. The antithrombin level and platelet count at diagnosis seemed to be associated with severe complications. Given the rarity of this disease, the creation of a prospective international registry is required to consolidate these findings.
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Affiliation(s)
- Alexandre Theron
- Department of Pediatric Oncology and Hematology
- Resource and Competence Center for Hereditary Hemorrhagic Diseases, and
| | - Olivier Dautremay
- Department of Biological Hematology, University of Montpellier, CHU Montpellier, Montpellier, France
- Bioard’aisne Laboratory, Charleville-Mézières, France
| | - Elodie Boissier
- Department of Biological Hematology, University of Montpellier, CHU Montpellier, Montpellier, France
- Laboratory of Hematology, University Hospital, Nantes, France
| | | | - Julien Baleine
- Department of Neonatal Medicine and Pediatric Intensive Care, University of Montpellier, CHU Montpellier, Montpellier, France
| | | | - Michel Rodière
- Department of Pediatrics, Infectious Diseases, and Immunology, University of Montpellier, CHU Montpellier, Montpellier, France
| | - Jean-François Schved
- Resource and Competence Center for Hereditary Hemorrhagic Diseases, and
- Department of Biological Hematology, University of Montpellier, CHU Montpellier, Montpellier, France
| | - Martha Duraes
- Anatomy Laboratory, University of Montpellier, Montpellier, France; and
| | - Tarik Kanouni
- Department of Clinical Hematology, University of Montpellier, CHU Montpellier, Montpellier, France
| | - Isabelle Cau-Diaz
- Department of Biological Hematology, University of Montpellier, CHU Montpellier, Montpellier, France
| | - Eric Jeziorski
- Department of Pediatrics, Infectious Diseases, and Immunology, University of Montpellier, CHU Montpellier, Montpellier, France
| | - Christine Biron-Andreani
- Resource and Competence Center for Hereditary Hemorrhagic Diseases, and
- Department of Biological Hematology, University of Montpellier, CHU Montpellier, Montpellier, France
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Fonkoua LK, Zhang S, Canty E, Fairfull A, Benich S, Knab A, Polimera H, Songdej N. Purpura fulminans from reduced protein S following cytomegalovirus and varicella infection. Am J Hematol 2019; 94:491-495. [PMID: 30585353 DOI: 10.1002/ajh.25386] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 12/04/2018] [Accepted: 12/10/2018] [Indexed: 01/16/2023]
Affiliation(s)
- Lionel Kankeu Fonkoua
- Penn State Health Milton S Hershey Medical Center Penn State College of Medicine Hershey Pennsylvania
| | - Simin Zhang
- Penn State Health Milton S Hershey Medical Center Penn State College of Medicine Hershey Pennsylvania
| | - Ethan Canty
- Penn State Health Milton S Hershey Medical Center Penn State College of Medicine Hershey Pennsylvania
| | - Aubree Fairfull
- Penn State Health Milton S Hershey Medical Center Penn State College of Medicine Hershey Pennsylvania
| | - Sarah Benich
- Penn State Health Milton S Hershey Medical Center Penn State College of Medicine Hershey Pennsylvania
| | - Andrea Knab
- Penn State Health Milton S Hershey Medical Center Penn State College of Medicine Hershey Pennsylvania
| | - Hyma Polimera
- Penn State Health Milton S Hershey Medical Center Penn State College of Medicine Hershey Pennsylvania
| | - Natthapol Songdej
- Penn State Health Milton S Hershey Medical Center Penn State College of Medicine Hershey Pennsylvania
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Abstract
Postvaricella protein S deficiency is a rare and severe disease. We report a case of extensive necrotic skin lesions of acute onset 7 days after varicella in a 4-year-old girl. Protein S antigen and activity were <10%, and antiprotein S antibodies were detected. She was treated with anticoagulation, plasmapheresis and fresh frozen plasma. She survived but required leg amputation.
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Baur A, Pouyau R, Meunier S, Nougier C, Teyssedre S, Javouhey E, Floret D, Gillet Y. Purpura fulminans post-varicelleux et thrombose veineuse : à propos d’un cas pédiatrique. Arch Pediatr 2011; 18:783-6. [DOI: 10.1016/j.arcped.2011.04.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Revised: 01/24/2011] [Accepted: 04/06/2011] [Indexed: 10/18/2022]
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Novel management of post varicella purpura fulminans owing to severe acquired protein S deficiency. Blood Coagul Fibrinolysis 2011; 21:598-600. [PMID: 20625278 DOI: 10.1097/mbc.0b013e32833c2b52] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Acquired protein S deficiency is a rare complication of varicella zoster infection often resulting in purpura fulminans, which is a potentially life-threatening syndrome of intravascular thrombosis and haemorrhagic infarction of the skin. Patients are presumed to develop crossreacting autoantibodies to the virus and protein S. There is no consensus on how best to manage these patients but previous recommendations focus on plasmapheresis and plasma exchange. We report the case of a 3-year-old girl with post varicella purpura fulminans owing to protein S deficiency, who was diagnosed promptly and made a full recovery following immediate treatment with anticoagulation and plasma support. This suggests that if anticoagulation is used, plasma exchange is not always necessary. As recovery occurred without plasmapheresis, we were able to track protein S levels. The timing of protein S recovery was consistent with the waning titre of an acquired immunoglobulin G autoantibody.
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Chickenpox is not always benign: postvaricella purpura fulminans requires prompt and aggressive treatment. Pediatr Emerg Care 2010; 26:932-4. [PMID: 21131808 DOI: 10.1097/pec.0b013e3181fe91cd] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
We present 2 patients, who were admitted owing to rapidly progressing purpuric lesions due to postvaricella purpura fulminans, a coagulopathy leading to life- or limb-threatening thrombosis caused by a severe transient autoimmune protein S deficiency. Laboratory results were being consistent with disseminated intravascular coagulation secondary to protein S deficiency; treatment with fresh frozen plasma, intravenous immunoglobulins, and prednisone was started. In our experience, a prompt therapy may limit the course and the extent of the disease. We present a review of the topic with supporting literature for the therapeutic options. Therefore, we should be reminded that purpura fulminans is a rare but severe complication of chickenpox, which demands quick action.
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Dogan M, Acikgoz M, Bora A, Başaranoğlu M, Oner AF. Varicella-associated purpura fulminans and multiple deep vein thromboses: a case report. J NIPPON MED SCH 2009; 76:165-8. [PMID: 19602824 DOI: 10.1272/jnms.76.165] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Varicella-associated purpura fulminans is a rare syndrome associated with substantial morbidity and mortality. General supportive care, heparinization, and plasma infusions are the mainstays of treatment. A patient aged 8 years and 8 months with purpura fulminans and multiple deep vein thromboses after varicella infection because of deficiencies of proteins C and S is presented in this case report.
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Affiliation(s)
- Murat Dogan
- Department of Pediatrics, Faculty of Medicine, Yuzuncu Yil University, Van, Turkey.
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Boccara O, Lesage F, Regnault V, Lasne D, Dupic L, Bourdon-Lanoy E, Pannier S, Fraitag S, Audat F, Lecompte T, Hubert P, Bodemer C. Nonbacterial purpura fulminans and severe autoimmune acquired protein S deficiency associated with human herpesvirus-6 active replication. Br J Dermatol 2009; 161:181-3. [PMID: 19545295 DOI: 10.1111/j.1365-2133.2009.09264.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Nonbacterial purpura fulminans (PF) is rare, usually follows viral infection in young children, and is characterized by specific coagulation disorders, requiring specific therapy. Following a transient rash, a 2-year-old previously healthy girl developed PF without haemodynamic impairment. Laboratory data revealed disseminated intravascular coagulation and a severe transient protein S deficiency. Antiprotein S autoantibodies and active human herpesvirus-6 (HHV6) replication were demonstrated. Purpuric skin lesions spread very rapidly despite broad-spectrum antibiotics and right leg amputation. Plasmapheresis and intravenous immunoglobulins gave complete clinical recovery and normalization of protein S level within 10 days, with progressive clearance of antiprotein S autoantibodies. Transient severe protein S deficiencies have previously been reported in patients with nonbacterial PF, usually after varicella infection. This is the first documented case of PF after HHV6 infection.
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Affiliation(s)
- O Boccara
- Department of Dermatology, University René DescartesParis V, 75473 Paris cedex 15, France.
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Hernández Blanco A, González Montero R, Urán Moreno MM, Caturla Martínez-Moratalla J, Moya Benavent M. [Post-varicella purpura fulminans: potentially fatal]. An Pediatr (Barc) 2009; 70:379-82. [PMID: 19268637 DOI: 10.1016/j.anpedi.2008.11.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2008] [Revised: 11/27/2008] [Accepted: 11/28/2008] [Indexed: 11/18/2022] Open
Abstract
Although varicella is usually a benign disease, some of its complications, such as post-varicella purpura fulminans, can be fatal. Its pathophysiological mechanism is caused by the production of antibodies to protein C and protein S in the coagulation cascade. This could have fatal consequences for those patients with partial deficiency of these proteins that develop disseminated intravascular coagulation. Treatment is symptomatic: fresh frozen plasma to treat protein depletion, antithrombin III and heparinization against thrombus formation, and anti-inflammatory drugs (steroids). However, new therapies, such as prostaglandin E1 IV and prostacyclin, are being introduced.
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Affiliation(s)
- A Hernández Blanco
- Servicio de Pediatría, Hospital Universitario San Juan, Alicante, España.
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Ngu L, Chooi J, Harmse D, Thomas DW, Davies M. A man with a purple leg. Clin Exp Dermatol 2009; 34:123-4. [DOI: 10.1111/j.1365-2230.2007.02537.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Varicella fulminant hepatitis in an adult patient with Factor V Leiden mutation and trisomy 8 related myelodysplastic syndrome. J Clin Virol 2008; 43:134-5. [PMID: 18539081 DOI: 10.1016/j.jcv.2008.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2008] [Accepted: 04/22/2008] [Indexed: 11/22/2022]
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12
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Bay A, Oner AF, Calka O, Sanli F, Akdeniz N, Dogan M. Purpura fulminans secondary to transient protein C deficiency as a complication of chickenpox infection. Pediatr Dermatol 2006; 23:412-3. [PMID: 16918648 DOI: 10.1111/j.1525-1470.2006.00262.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abdulmalik A, Al-Ateeqi W, Al-Khawari M, Al-Osaimi S. Varicella-associated purpura fulminans: chicken pox is not always benign. Med Princ Pract 2006; 15:232-4. [PMID: 16651842 DOI: 10.1159/000092188] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2004] [Accepted: 01/04/2005] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To report a 6-year-old boy with post-chicken pox purpura fulminans (PF). CLINICAL PRESENTATION AND INTERVENTION A 6-year-old boy presented with purpura of the legs that rapidly progressed to other parts of the limbs and the buttocks. The patient had had chicken pox 10 days prior to presentation. He was afebrile and the chicken pox lesions were dry. He received anti-coagulants, a large volume of fresh frozen plasma, immunoglobulin and steroids. The skin lesions regressed but both hands and parts of the lower limbs remained necrotic; the patient was transferred to an orthopaedic hospital for amputation and skin grafting. CONCLUSION This case report shows that PF can occur as a post-infection syndrome after primary varicella. Early and aggressive treatment of post-chicken pox PF might reduce the mortality and morbidity associated with this condition.
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Affiliation(s)
- A Abdulmalik
- Department of Paediatrics, Al-Amiri Hospital, Safat, Kuwait
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Regnault V, Boehlen F, Ozsahin H, Wahl D, de Groot PG, Lecompte T, de Moerloose P. Anti-protein S antibodies following a varicella infection: detection, characterization and influence on thrombin generation. J Thromb Haemost 2005; 3:1243-9. [PMID: 15946215 DOI: 10.1111/j.1538-7836.2005.01270.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Postinfectious purpura fulminans is a rare disease. Varicella is one of the precipitating conditions and we recently observed such a case. The 4-year-old child was found to have a severe transient protein S deficiency. By enzyme-linked immunosorbent assay and surface plasmon resonance we first demonstrated that anti-protein S antibodies were present and also transient. Next we characterized the epitopes against which these antibodies were directed and found that they predominantly recognized the N-terminal part of protein S. Finally we showed by thrombography a transient dramatic hypercoagulable state as a result of thrombin being unregulated by the dynamic protein C inhibitory system: in vitro thrombin generation, in response to a low concentration of tissue factor, was almost insensitive to activated protein C up to 25 nmol L(-1) on day 4 while it was normally sensitive on day 42. For the first time, we demonstrated a temporal relationship between protein S deficiency, antibodies to protein S and hypercoagulability, thus supporting the pathogenic role of these antibodies.
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Affiliation(s)
- V Regnault
- Inserm 734 and Hospital of Nancy, France
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