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Samman K, Le CK, Michon B. An Atypical Case of Idiopathic Purpura Fulminans. J Pediatr Hematol Oncol 2022; 44:479-481. [PMID: 35700409 DOI: 10.1097/mph.0000000000002497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 05/08/2022] [Indexed: 11/27/2022]
Abstract
Idiopathic purpura fulminans (PF) is rare but has been reported in pediatric patients, commonly following infections. We present a case of a 5-year-old boy, heterozygous for factor V Leiden, with no history of recent infections, who presented with PF secondary to acquired protein S deficiency. Despite initial supportive treatment, the patient required surgical fasciotomy and extensive skin grafts. The protein S level normalized 4 months following the presentation. In this context, an autoimmune component with transient anti-protein S antibodies was believed to be involved. This case report highlights the course of idiopathic PF due to noninfectious acquired protein S deficiency.
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Affiliation(s)
- Karol Samman
- Department of Pediatrics, Lanaudiere Regional Hospital, Joliette
| | - Cathie-Kim Le
- Department of Emergency Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Bruno Michon
- Department of Hematology and Oncology Laval University Hospital, Quebec, QC
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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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Abstract
Symmetrical peripheral gangrene (SPG) is a disabling complication that affects a small proportion of patients who survive critical illness. Its pathogenesis reflects profoundly disturbed procoagulant-anticoagulant balance in susceptible tissue beds secondary to circulatory shock (cardiogenic, septic). There is a characteristic SPG triad: (a) shock (hypotension, lactic acidemia, normoblastemia, multiple organ dysfunction), (b) disseminated intravascular coagulation (DIC), and (c) natural anticoagulant depletion (protein C, antithrombin). In recent years, risk factors for natural anticoagulant depletion have been identified, most notably acute ischemic hepatitis ("shock liver"), which is seen in at least 90% of patients who develop SPG. Moreover, there is a characteristic time interval (2-5 days, median 3 days) between the onset of shock/shock liver and the beginning of ischemic injury secondary to peripheral microthrombosis ("limb ischemia with pulses"), reflecting the time required to develop severe depletion in hepatically-synthesized natural anticoagulants. Other risk factors for natural anticoagulant depletion include chronic liver disease (e.g., cirrhosis) and, possibly, transfusion of colloids (albumin, high-dose immunoglobulin) lacking coagulation factors. A causal role for vasopressor therapy is unproven and is unlikely; this is because critically ill patients who develop SPG do so usually after at least 36-48 hours of vasopressor therapy, implicating a time-dependent pathophysiological mechanism. The most plausible explanation is a progressive time-dependent decline in key natural anticoagulant factors, reflecting ongoing DIC ("consumption"), proximate liver disease whether acute or chronic ("impaired production"), and colloid administration ("hemodilution"). Given these evolving concepts of pathogenesis, a rationale approach to prevention/treatment of SPG can be developed.
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Affiliation(s)
- Theodore E Warkentin
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Pathology and Molecular Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; McMaster Centre for Transfusion Research, Canada; Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada; Service of Clinical Hematology, Hamilton General Hospital, Hamilton Health Sciences, Hamilton, Ontario, Canada.
| | - Shuoyan Ning
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Pathology and Molecular Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; McMaster Centre for Transfusion Research, Canada; Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada; St. Joseph's Healthcare, Hamilton, Ontario, Canada
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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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Oliveira GN, Basso S, Sevivas T, Neves N. Varicella complicated by cellulitis and deep vein thrombosis. BMJ Case Rep 2017; 2017:bcr-2017-221499. [PMID: 28882940 DOI: 10.1136/bcr-2017-221499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We report a 16-month-old girl with varicella complicated by cellulitis, invasive Group A Streptococcus (GAS) infection and deep vein thrombosis. She presented with varicella lesions, fever and a painful firm tumefaction on the right lower leg (RLL). Ultrasound showed a local subcutaneous tissue thickening suggestive of cellulitis and antibiotics were initiated. Further swelling of the RLL motivated a second ultrasound that showed an obstructive thrombus for which she was started on enoxaparin. The blood culture confirmed GAS infection leading to directed antibiotherapy. Additional studies showed positive lupus anticoagulant, decreased protein S and antithrombin. She completed a 2-week course of intravenous antibiotics and anticoagulation therapy with clinical and laboratory markers improvement. However, 3 days later, a recrudescence of symptoms occurred and the ultrasound revealed a local abscess. Further amoxicillin treatment resulted on a complete resolution of symptoms. Doppler ultrasound after 1 month showed markedly increased vein patency.
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Affiliation(s)
| | - Susana Basso
- Serviço de Radiologia do Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Teresa Sevivas
- Serviço de Sangue e Medicina Transfusional, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Nelson Neves
- Serviço de Internamento do Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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Coagulation disorders and their cutaneous presentations: Diagnostic work-up and treatment. J Am Acad Dermatol 2016; 74:795-804; quiz 805-6. [DOI: 10.1016/j.jaad.2015.08.071] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Revised: 08/19/2015] [Accepted: 08/19/2015] [Indexed: 11/22/2022]
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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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