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Gordeeva OB, Dobrotok AV, Selimzianova LR, Deeva VA. Transient deficiency of protein S after past infection process, complications and outcome: clinical case. PEDIATRIC PHARMACOLOGY 2023. [DOI: 10.15690/pf.v20i1.2532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
Background. Purpura fulminans (PF) – is an acute rapidly progressive thrombosis of small-diameter blood vessels located mainly on the skin of the extremities. PF is characterized by high mortality rates. Patients can have serious consequences, including amputations and loss of fingers, foots or even extremities in general.Clinical case description. A clinical case of developing transient deficiency of protein S complicated by idiopathic PF on the 7th day after acute otitis in a 3-year-old boy due to past infection is presented. The progression of the disease developed within a few hours. The patient became hemorrhagic elements on the skin of extremities, and later — tissue necrosis. The conducted therapy facilitated to stop the pathological process in the form of PF, and also prevented the development of severe disabling complications in the child.Conclusion. Differential diagnosis and treatment should be fast and accurate, as the development of PF occurs in mere hours. Diagnostics should include expanded panel of coagulological tests and instrumental examinations, which determines the justifiability of a multidisciplinary approach in the patient management with disorders in the hemostatic system.
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Affiliation(s)
- Olga B. Gordeeva
- Research Institute of Pediatrics and Children’s Health in Petrovsky National Research Centre of Surgery;
Pirogov Russian National Research Medical University
| | - Albina V. Dobrotok
- Research Institute of Pediatrics and Children’s Health in Petrovsky National Research Centre of Surgery
| | - Liliia R. Selimzianova
- Research Institute of Pediatrics and Children’s Health in Petrovsky National Research Centre of Surgery;
Pirogov Russian National Research Medical University;
Sechenov First Moscow State Medical University
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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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Sutra P, Pokawattana I. Retinal vasculopathy following varicella zoster virus infection. Curr Opin Ophthalmol 2022; 33:557-563. [PMID: 36165416 DOI: 10.1097/icu.0000000000000899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Varicella zoster virus (VZV) ocular infection can manifest purely as a vasculopathy that leads to retinal arteriole occlusion, without any retinitis or vasculitis. This review summarizes our current knowledge of such VZV ocular infection phenotype, incorporating initial descriptions from 1988. We describe the pathogenesis and VZV's manifestations in the retina using fundus photography, fundus fluorescein angiography, optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA). Laboratory investigations, diagnostic procedures, prognoses, and treatment options are also being reviewed. RECENT FINDINGS Ten case reports where VZV retinal vasculopathy was the primary feature observed after varicella or zoster rash are described. The retinal arteriole, cilioretinal artery, branches of retinal artery, central retinal artery and ophthalmic artery were found to be areas of more rarely affected, neither in the form of vasculitis nor retinitis. Diagnosis is typically made from positive polymerase chain reaction (PCR) for VZV from extracted intraocular fluid or positive serum or cerebrospinal fluid (CSF) anti-VZV immunoglobulin G antibody in the context of compatible ocular findings. In addition, retinal vasculopathy occurring in the setting of confirmed varicella or zoster rashes could be considered potentially pathognomonic. Pathological concepts, including direct VZV infection of affected tissue, persistent inflammation, and/or virus-induced hypercoagulability are also discussed. SUMMARY VZV may produce a wide spectrum of ocular manifestations with isolated VZV retinal vasculopathy being a rarer presentation. A prompt diagnosis followed by an early treatment of systemic acyclovir with or without corticosteroids is the mainstay of treatment.
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Affiliation(s)
- Plern Sutra
- Department of Ophthalmology, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
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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
PURPOSE OF REVIEW Varicella zoster virus (VZV) causes varicella, establishes latency, then reactivates to produce herpes zoster. VZV reactivation can also cause central nervous system (CNS) disease with or without rash. Herein, we review these CNS diseases, pathogenesis, diagnosis, and treatment. RECENT FINDINGS The most common CNS manifestation of VZV infection is vasculopathy that presents as headache, cognitive decline, and/or focal neurological deficits. VZV vasculopathy has also been associated with cerebral amyloid angiopathy and moyamoya syndrome. Rarely, VZV will produce a meningitis, encephalitis, cerebellitis, and myelopathy. Pathogenic mechanisms include direct VZV infection of affected tissue, persistent inflammation, and/or virus-induced hypercoagulability. Diagnosis is confirmed by the temporal association of rash to disease onset, intrathecal synthesis of anti-VZV antibodies, and/or the presence of VZV DNA in CSF. Most cases respond to intravenous acyclovir with corticosteroids. SUMMARY VZV produces a wide spectrum of CNS disorders that may be missed as some cases do not have an associated rash or a CSF pleocytosis. Clinicians must be vigilant in including VZV in their differential diagnosis of CNS infections as VZV is a ubiquitous pathogen; importantly, VZV CNS infections are treatable with intravenous acyclovir therapy and corticosteroids.
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Abstract
: Coronavirus disease 2019 (COVID-19) was officially declared as a pandemic on March 11, 2020. Although most patients with COVID-19 manifest fever and respiratory tract symptoms, extrapulmonary and atypical presentations, such as gastrointestinal, neurologic, and cardiovascular involvement as well as thromboembolic events have been reported amongst COVID-19 patients. Herein, we aim to describe a COVID-19 patient who progressed to purpura fulminans.
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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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Deviley JA, Oldenburg D, Berg LC, Agger WA. Recurrent strokes, central nervous system vasculitis, and acquired protein S deficiency secondary to varicella zoster in a child with AIDS. J Neurovirol 2018; 25:137-140. [PMID: 30478796 DOI: 10.1007/s13365-018-0697-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 10/29/2018] [Accepted: 10/31/2018] [Indexed: 12/21/2022]
Abstract
A child with vertical transmission of human immunodeficiency virus refractory to therapy developed zoster-induced protein S deficiency and recurrent strokes. Extensive carotid arteritis was found postmortem. The carotid tissue was positive for herpes varicella zoster by polymerase chain reaction, as were immunofixation stains of the arterial wall.
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Affiliation(s)
- Jake A Deviley
- Department of Medical Research, Gundersen Health System, Mail Stop C03-006B, 1836 South Avenue, La Crosse, WI, 54601, USA
| | - Darby Oldenburg
- Department of Medical Research, Gundersen Health System, Mail Stop C03-006B, 1836 South Avenue, La Crosse, WI, 54601, USA
| | - Laurence C Berg
- Department of Pathology, Gundersen Health System, La Crosse, WI, USA
| | - William A Agger
- Department of Medical Research, Gundersen Health System, Mail Stop C03-006B, 1836 South Avenue, La Crosse, WI, 54601, USA. .,Department of Infectious Disease, Gundersen Health System, La Crosse, WI, USA.
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Fruchtman Y, Strauss T, Rubinstein M, Ben Harush M, Revel-Vilk S, Kapelushmik J, Paret G, Kenet G. Skin Necrosis and Purpura Fulminans in Children With and Without Thrombophilia--A Tertiary Center's Experience. Pediatr Hematol Oncol 2016; 32:505-10. [PMID: 26436558 DOI: 10.3109/08880018.2015.1068896] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Purpura fulminans (PF) is a very rare clinicopathologic skin disorder comprising dermal microvascular thrombosis associated with perivascular hemorrhage of multiple origins. It may occur as the presenting symptom of severe congenital deficiency of protein C (PC) or protein S (PS) during the newborn period, or later in life following oral anticoagulant therapy with vitamin K antagonists, or of sepsis that may be associated with disseminated intravascular coagulation. Treatment consists of anticoagulants and PC concentrates during acute episodes. We report our experience in the diagnosis and management of pediatric PF. The medical records of the 6 children aged 2-16 years (median: 5 years) who presented with PF to our tertiary care center between 1996 and 2013 were studied. The thrombophilia workup revealed either the presence of congenital homozygous PC deficiency, prothrombotic polymorphisms (factor V Leiden and FIIG20210A heterozygosity), acquired PC/PS deficiency, or no discernible thrombophilia. The skin necrosis resolved following conservative fresh-frozen plasma/anticoagulant therapy in 2 cases, whereas 3 children required interventional plastic surgery. The sixth case, a 10-year-old child with severe PC deficiency, heterozygous factor V Leiden, and FIIG20210A, received recombinant activated PC. PF in childhood is rare and has multiple etiologies. Understanding of the variable pathogenesis and risk factors will facilitate diagnosis and appropriate clinical management.
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Affiliation(s)
- Yariv Fruchtman
- a Department of Pediatric Emergency Care and Pediatric Hematology Unit , Soroka Medical Center , Beer-Sheba , Israel , affiliated to the Ben Gurion University of the Negev , Beer Sheva , Israel.,b Thrombosis Unit, National Hemophilia Center , Safra Children's Hospital, Sheba Medical Center , Tel Hashomer, Israel
| | - Tzipora Strauss
- b Thrombosis Unit, National Hemophilia Center , Safra Children's Hospital, Sheba Medical Center , Tel Hashomer, Israel.,c Department of Neonatology , Safra Children's Hospital, Sheba Medical Center , Tel Hashomer, Israel
| | - Marina Rubinstein
- d Department of Critical Care, Safra Children's Hospital , Sheba Medical Center , Tel Hashomer , Israel , affiliated to the Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Miriam Ben Harush
- a Department of Pediatric Emergency Care and Pediatric Hematology Unit , Soroka Medical Center , Beer-Sheba , Israel , affiliated to the Ben Gurion University of the Negev , Beer Sheva , Israel
| | - Shoshana Revel-Vilk
- e Department of Pediatric Hematology/Oncology , Hadassah Hebrew University Medical Center , Jerusalem , Jerusalem , Israel
| | - Joseph Kapelushmik
- a Department of Pediatric Emergency Care and Pediatric Hematology Unit , Soroka Medical Center , Beer-Sheba , Israel , affiliated to the Ben Gurion University of the Negev , Beer Sheva , Israel
| | - Gideon Paret
- d Department of Critical Care, Safra Children's Hospital , Sheba Medical Center , Tel Hashomer , Israel , affiliated to the Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Gili Kenet
- b Thrombosis Unit, National Hemophilia Center , Safra Children's Hospital, Sheba Medical Center , Tel Hashomer, Israel
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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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