1
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Liu Y, Cai M, Chen Y, Wu G, Li S, Chen Z. Validation for the function of protein C in mouse models. PeerJ 2024; 12:e17261. [PMID: 38680896 PMCID: PMC11055512 DOI: 10.7717/peerj.17261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/28/2024] [Indexed: 05/01/2024] Open
Abstract
Objectives Protein C (PC) is an anticoagulant that is encoded by the PROC gene. Validation for the function of PC was carried out in mouse models. Methods In this study, autosomal recessive PC deficiency (PCD) was selected as the target, and the specific mutation site was chromosome 2 2q13-q14, PROC c.1198G>A (p.Gly400Ser) which targets G399S (GGT to AGC) in mouse models. To investigate the role of hereditary PC in mice models, we used CRISPR/Cas9 gene editing technology to create a mouse model with a genetic PCD mutation. Results The two F0 generation positive mice produced using the CRISPR/Cas9 gene editing technique were chimeras, and the mice in F1 and F2 generations were heterozygous. There was no phenotype of spontaneous bleeding or thrombosis in the heterozygous mice, but some of them were blind. Blood routine results showed no significant difference between the heterozygous mice and wild-type mice (P > 0.05). Prothrombin time (PT), activated partial thromboplastin time (APTT), and thrombin time (TT) were prolonged in the heterozygous mice, while the level of fibrinogen content (FIB) decreased, suggesting secondary consumptive coagulation disease. The protein C activity of heterozygous mice was significantly lower than that of wild-type mice (P < 0.001), but there was no significant difference in protein C antigen levels (P > 0.05). H&E staining showed steatosis and hydrodegeneration in the liver of heterozygous mice. Necrosis and exfoliated epithelial cells could be observed in renal tubule lumen, forming cell or granular tubules. Hemosiderin deposition was found in the spleen along with splenic hemorrhage. Immunohistochemistry demonstrated significant fibrin deposition in the liver, spleen, and kidney of heterozygous mice. Conclusion In this study, heterozygotes of the mouse model with a PC mutation were obtained. The function of PC was then validated in a mouse model through genotype, phenotype, and PC function analysis.
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Affiliation(s)
- Ya Liu
- Zhanjiang Institute of Clinical Medicine, Central People’s Hospital of Zhanjiang, Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Maoping Cai
- Zhanjiang Institute of Clinical Medicine, Central People’s Hospital of Zhanjiang, Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Yan Chen
- Zhanjiang Institute of Clinical Medicine, Central People’s Hospital of Zhanjiang, Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Guocai Wu
- Department of Hematology, Central People’s Hospital of Zhanjiang, Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Songyu Li
- Zhanjiang Institute of Clinical Medicine, Central People’s Hospital of Zhanjiang, Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Zhanghui Chen
- Zhanjiang Institute of Clinical Medicine, Central People’s Hospital of Zhanjiang, Guangdong Medical University, Zhanjiang, Guangdong, China
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2
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Antoniadis J, Gomes De Pinho Q, Koubi M, Macagno N, Benyamine A, Granel B. [A bullous eruption]. Rev Med Interne 2024; 45:253-254. [PMID: 38705594 DOI: 10.1016/j.revmed.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/04/2024] [Accepted: 03/07/2024] [Indexed: 05/07/2024]
Affiliation(s)
- J Antoniadis
- Service de médecine interne, hôpital Nord, Assistance publique-Hôpitaux de Marseille (AP-HM), chemin des Bourrely, 13015 Marseille, France
| | - Q Gomes De Pinho
- Service de médecine interne, hôpital Nord, Assistance publique-Hôpitaux de Marseille (AP-HM), chemin des Bourrely, 13015 Marseille, France
| | - M Koubi
- Service de médecine interne, hôpital Nord, Assistance publique-Hôpitaux de Marseille (AP-HM), chemin des Bourrely, 13015 Marseille, France
| | - N Macagno
- Service d'anatomie pathologique et de neuropathologie, hôpital Timone, Assistance publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | - A Benyamine
- Service de médecine interne, hôpital Nord, Assistance publique-Hôpitaux de Marseille (AP-HM), chemin des Bourrely, 13015 Marseille, France
| | - B Granel
- Service de médecine interne, hôpital Nord, Assistance publique-Hôpitaux de Marseille (AP-HM), chemin des Bourrely, 13015 Marseille, France.
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3
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Wettasinghe I, Puthra S, Sugathapala HA, Mendis S. Rapidly Progressive, Symmetrical, Acute Cutaneous Necrosis of Bilateral Lower Limbs: A Rare Presentation of Polyarteritis Nodosa. Cureus 2024; 16:e58649. [PMID: 38770516 PMCID: PMC11103124 DOI: 10.7759/cureus.58649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2024] [Indexed: 05/22/2024] Open
Abstract
Acute cutaneous necrosis is a rare presentation of polyarteritis nodosa (PAN). In this study, we report a presentation with symmetrical cutaneous necrosis of the lower limbs, which ascended upward at a rapid rate. A 47-year-old man presented with a fever of one day and pain in the feet for six days. He had no history of claudication. Upon examination, he was febrile, and subtle bluish discoloration was observed on the sole of his foot. There was a bilateral stocking-type paresthesia up to the ankle joint. His blood pressure on admission was 210/120 mmHg. Eight hours later, the pain subsided, but a left-sided foot drop was noted along with the paresthesia extending up both feet to approximately 10 cm above the medial malleolus. The feet turned black, and dark discoloration spread rapidly upward over the next 16 hours, and the skin became necrosed. A clinical diagnosis of vasculitis was established, and the patient received IV methylprednisolone at a daily dosage of 1 g for three days, effectively stopping the advancement of necrosis. This was followed by treatment with IV cyclophosphamide. A conclusive diagnosis of PAN was made, and the patient underwent wound debridement. After three months of physiotherapy, a successful skin graft was performed. Prompt identification of the underlying etiology is crucial to prevent the advancement of necrosis and save the limbs. When vasculitis is suspected, ruling out infectious causes is essential before starting early immunosuppressive treatment.
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Affiliation(s)
| | - Shiran Puthra
- Internal Medicine, Colombo South Teaching Hospital, Colombo, LKA
| | | | - Suresh Mendis
- Internal Medicine, Colombo South Teaching Hospital, Colombo, LKA
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4
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Okai N, Otsuka Y, Masaki S, Kudo M, Watanabe T. Necrotizing Fasciitis of the Serratus Anterior in a Patient Treated With Infliximab and Prednisolone for Ulcerative Colitis and Rheumatoid Arthritis. Cureus 2024; 16:e59346. [PMID: 38817521 PMCID: PMC11137776 DOI: 10.7759/cureus.59346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 06/01/2024] Open
Abstract
Necrotizing fasciitis (NF) is a rapidly progressive bacterial infection with high mortality. Invasive group A Streptococcus (GAS) infection is the leading cause of NF. Our understanding regarding clinicopathological features and pathogenesis of invasive GAS infection is expanding as the incidence of NF in healthy individuals increases. However, clinicopathological features of NF in the presence of autoimmune diseases have been poorly defined. We experienced NF in a patient treated with infliximab and prednisolone for ulcerative colitis and rheumatoid arthritis. Herein, we present time kinetics findings of clinical symptoms and laboratory data of GAS-associated NF in the presence of immunosuppressant-treated immune disorders.
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Affiliation(s)
- Natsuki Okai
- Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, JPN
| | - Yasuo Otsuka
- Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, JPN
| | - Sho Masaki
- Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, JPN
| | - Masatoshi Kudo
- Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, JPN
| | - Tomohiro Watanabe
- Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, JPN
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5
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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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6
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Bendapudi PK, Nazeen S, Ryu J, Söylemez O, Robbins A, Rouaisnel B, O’Neil JK, Pokhriyal R, Yang M, Colling M, Pasko B, Bouzinier M, Tomczak L, Collier L, Barrios D, Ram S, Toth-Petroczy A, Krier J, Fieg E, Dzik WH, Hudspeth JC, Pozdnyakova O, Nardi V, Knight J, Maas R, Sunyaev S, Losman JA. Low-frequency inherited complement receptor variants are associated with purpura fulminans. Blood 2024; 143:1032-1044. [PMID: 38096369 PMCID: PMC10950473 DOI: 10.1182/blood.2023021231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 11/15/2023] [Indexed: 03/16/2024] Open
Abstract
ABSTRACT Extreme disease phenotypes can provide key insights into the pathophysiology of common conditions, but studying such cases is challenging due to their rarity and the limited statistical power of existing methods. Herein, we used a novel approach to pathway-based mutational burden testing, the rare variant trend test (RVTT), to investigate genetic risk factors for an extreme form of sepsis-induced coagulopathy, infectious purpura fulminans (PF). In addition to prospective patient sample collection, we electronically screened over 10.4 million medical records from 4 large hospital systems and identified historical cases of PF for which archived specimens were available to perform germline whole-exome sequencing. We found a significantly increased burden of low-frequency, putatively function-altering variants in the complement system in patients with PF compared with unselected patients with sepsis (P = .01). A multivariable logistic regression analysis found that the number of complement system variants per patient was independently associated with PF after controlling for age, sex, and disease acuity (P = .01). Functional characterization of PF-associated variants in the immunomodulatory complement receptors CR3 and CR4 revealed that they result in partial or complete loss of anti-inflammatory CR3 function and/or gain of proinflammatory CR4 function. Taken together, these findings suggest that inherited defects in CR3 and CR4 predispose to the maladaptive hyperinflammation that characterizes severe sepsis with coagulopathy.
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Affiliation(s)
- Pavan K. Bendapudi
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston, MA
- Division of Hematology and Blood Transfusion Service, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Sumaiya Nazeen
- Harvard Medical School, Boston, MA
- Division of Genomic Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Justine Ryu
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Onuralp Söylemez
- Harvard Medical School, Boston, MA
- Division of Genomic Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Alissa Robbins
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Betty Rouaisnel
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Jillian K. O’Neil
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Ruchika Pokhriyal
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Moua Yang
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Meaghan Colling
- Division of Hematology and Blood Transfusion Service, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Bryce Pasko
- Department of Pathology, University of Colorado School of Medicine, Aurora, CO
| | - Michael Bouzinier
- Harvard Medical School, Boston, MA
- Division of Genomic Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Lindsay Tomczak
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston, MA
| | - Lindsay Collier
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston, MA
| | - David Barrios
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Sanjay Ram
- Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester, MA
| | - Agnes Toth-Petroczy
- Harvard Medical School, Boston, MA
- Division of Genomic Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Joel Krier
- Harvard Medical School, Boston, MA
- Division of Genomic Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Elizabeth Fieg
- Division of Genomic Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Walter H. Dzik
- Division of Hematology and Blood Transfusion Service, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - James C. Hudspeth
- Department of Medicine, Boston Medical Center, Boston, MA
- Boston University School of Medicine, Boston, MA
| | - Olga Pozdnyakova
- Harvard Medical School, Boston, MA
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA
| | - Valentina Nardi
- Harvard Medical School, Boston, MA
- Department of Pathology, Massachusetts General Hospital, Boston, MA
| | - James Knight
- Yale Center for Genome Analysis, Yale University, New Haven, CT
| | - Richard Maas
- Harvard Medical School, Boston, MA
- Division of Genomic Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Shamil Sunyaev
- Harvard Medical School, Boston, MA
- Division of Genomic Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Julie-Aurore Losman
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Division of Hematology, Brigham and Women’s Hospital, Boston, MA
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7
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Nourbakhsh SMK, Bahadoram M, Rashidi‐Nezhad A, Habibi L, Mansouri F, Akade E. The c.1243T>C mutation in the PROC gene is linked with inherited protein C deficiency and severe purpura fulminans. Clin Case Rep 2023; 11:e8280. [PMID: 38046799 PMCID: PMC10692314 DOI: 10.1002/ccr3.8280] [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: 04/16/2023] [Revised: 10/13/2023] [Accepted: 11/11/2023] [Indexed: 12/05/2023] Open
Abstract
Purpura fulminans is a severe coagulation disorder that often leads to death in neonates. Mutations in the protein C (PROC) gene can cause protein C deficiency, leading to this disorder. This study aimed to investigate a family with a history of coagulopathies, particularly those related to protein C deficiency. The primary objective was to identify any genetic mutations in the PROC gene responsible for the coagulopathies. The study focused on a male neonate with purpura fulminans who ultimately died at 2 months of age. The patient had low protein C activity levels (6%). The entire PROC gene of the patient and his family was analyzed using next-generation sequencing to identify any genetic mutations. Segregation analysis was conducted to determine if the mutation followed an autosomal dominant inheritance pattern. In silico analysis was also conducted to evaluate the pathogenicity of the identified mutation. Analysis revealed a novel homozygous c.1243T>G variant PROC gene. The mutation resulted in a Phe415Val substitution. The mutation was found in at least three generations of the family. Carrier family members had lower protein C activity levels than wild-type homozygotes. Additionally, the mutation may account for the observed reduction in protein C enzyme activity.
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Affiliation(s)
| | - Mohammad Bahadoram
- Thalassemia and Hemoglobinopathy Research Center, Health Research InstituteAhvaz Jundishapur University of Medical SciencesAhvazIran
| | - Ali Rashidi‐Nezhad
- Maternal, Fetal, and Neonatal Research Center, Family Health Research InstituteTehran University of Medical SciencesTehranIran
| | | | - Fatemeh Mansouri
- Department of Genetics and Immunology, Faculty of MedicineUrmia University of Medical SciencesUrmiaIran
| | - Esma'il Akade
- Department of Medical Virology, School of MedicineAhvaz Jundishapur University of Medical SciencesAhvazIran
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8
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Khizroeva J, Makatsariya A, Vorobev A, Bitsadze V, Elalamy I, Lazarchuk A, Salnikova P, Einullaeva S, Solopova A, Tretykova M, Antonova A, Mashkova T, Grigoreva K, Kvaratskheliia M, Yakubova F, Degtyareva N, Tsibizova V, Gashimova N, Blbulyan D. The Hemostatic System in Newborns and the Risk of Neonatal Thrombosis. Int J Mol Sci 2023; 24:13864. [PMID: 37762167 PMCID: PMC10530883 DOI: 10.3390/ijms241813864] [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] [Received: 07/28/2023] [Revised: 09/04/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
Newborns are the most vulnerable patients for thrombosis development among all children, with critically ill and premature infants being in the highest risk group. The upward trend in the rate of neonatal thrombosis could be attributed to progress in the treatment of severe neonatal conditions and the increased survival in premature babies. There are physiological differences in the hemostatic system between neonates and adults. Neonates differ in concentrations and rate of synthesis of most coagulation factors, turnover rates, the ability to regulate thrombin and plasmin, and in greater variability compared to adults. Natural inhibitors of coagulation (protein C, protein S, antithrombin, heparin cofactor II) and vitamin K-dependent coagulation factors (factors II, VII, IX, X) are low, but factor VIII and von Willebrand factor are elevated. Newborns have decreased fibrinolytic activity. In the healthy neonate, the balance is maintained but appears more easily converted into thrombosis. Neonatal hemostasis has less buffer capacity, and almost 95% of thrombosis is provoked. Different triggering risk factors are responsible for thrombosis in neonates, but the most important risk factors for thrombosis are central catheters, fluid fluctuations, liver dysfunction, and septic and inflammatory conditions. Low-molecular-weight heparins are the agents of choice for anticoagulation.
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Affiliation(s)
- Jamilya Khizroeva
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Alexander Makatsariya
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Alexander Vorobev
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Victoria Bitsadze
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Ismail Elalamy
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
- Hematology and Thrombosis Center, Tenon Hospital, Sorbonne University, 4 Rue de la Chine, 75020 Paris, France
| | - Arina Lazarchuk
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Polina Salnikova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Sabina Einullaeva
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Antonina Solopova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Maria Tretykova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Alexandra Antonova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Tamara Mashkova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Kristina Grigoreva
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Margaret Kvaratskheliia
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Fidan Yakubova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Natalia Degtyareva
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Valentina Tsibizova
- Almazov National Medical Research Centre, Health Ministry of Russian Federation, 2 Akkuratova Str., 197341 Saint Petersburg, Russia;
| | - Nilufar Gashimova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - David Blbulyan
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
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9
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Leducq S, Maruani A, Bodemer C, Biscardi S, Boccara O, Chinazzo MF, Mahé E, Plantin P, Fraitag S, Mazereeuw-Hautier J, Chiaverini C, Lemelle I, Bessis D, Bourrat E, Mallet S, Bonniaud B, Grall-Lerosey M, Martin L, Boralevi F, Piram M. Accurate diagnosis of acute hemorrhagic edema of infancy: a French multicenter observational study. Eur J Pediatr 2023; 182:4133-4141. [PMID: 37432503 DOI: 10.1007/s00431-023-05098-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/29/2023] [Accepted: 07/04/2023] [Indexed: 07/12/2023]
Abstract
The purpose of the study is to highlight clinical signs that are either suggestive of or against the diagnosis of AHEI to improve diagnosis and management. The medical records of children under 3 years old diagnosed with AHEI were retrospectively reviewed. Clinical data and photographs were reviewed by three independent experts, and the cases were classified as probable, doubtful, or unclear AHEI. Of the 69 cases of children diagnosed with AHEI included in 22 centers, 40 were classified as probable, 22 as doubtful, and 7 as unclear. The median age of patients with probable AHEI was 11 months [IQR 9-15], and they were in overall good condition (n = 33/40, 82.5%). The morphology of the purpura was targetoid in 75% of cases (n = 30/40) and ecchymotic in 70% of cases (n = 28/40) and affected mostly the legs (n = 39/40, 97%), the arms (n = 34/40, 85%), and the face (n = 33/40, 82.5%). Edema was observed in 95% of cases and affected mostly the hands (n = 36/38, 95%) and feet (n = 28/38, 74%). Pruritus was absent in all patients with probable AHEI and described for 6/21 with doubtful AHEI (29%). AHEI was the original diagnosis in only 24 patients (n = 24/40, 60%). The major differential diagnoses were purpura fulminans and urticaria multiforme. Conclusion: AHEI, which the diagnosis is made on clinical findings, is often misdiagnosed. Purpuric lesions localized on the face/ears, arms/forearms, and thighs/legs with edema of the hands without pruritus in a young child with a good overall condition are highly suggestive of AHEI. What is Known: •Acute hemorrhagic edema of infancy (AHEI) is a cutaneous leukocytoclastic vasculitis affecting children under 3 years old. •Appropriate diagnosis is important to distinguish this benign disease from more serious diseases to avoid investigations and treatments, iatrogenic harm and unnecessary follow-up. What is New: •AHEI is an uncommon disorder often misdiagnosed by pediatricians and dermatologists. •Purpuric lesions localized on the face/ears, arms/forearms, and thighs/legs with edema of the hands without pruritus in an infant with a good overall condition are highly suggestive of AHEI.
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Affiliation(s)
- Sophie Leducq
- Department of Dermatology and Reference Center for Rare Diseases and Vascular Malformations (MAGEC), Unit of Pediatric Dermatology, CHRU Tours, Tours, France.
- Universities of Tours and Nantes, INSERM 1246-SPHERE, , Tours, France.
| | - Annabel Maruani
- Department of Dermatology and Reference Center for Rare Diseases and Vascular Malformations (MAGEC), Unit of Pediatric Dermatology, CHRU Tours, Tours, France
- Universities of Tours and Nantes, INSERM 1246-SPHERE, , Tours, France
| | - Christine Bodemer
- Department of Dermatology and Reference Center for Genodermatoses and Rare Skin Diseases (MAGEC), APHP, Paris University, Necker-Enfants Malades Hospital, Paris Centre University, Imagine Institute, Paris, France
| | | | - Olivia Boccara
- Department of Dermatology and Reference Center for Genodermatoses and Rare Skin Diseases (MAGEC), APHP, Paris University, Necker-Enfants Malades Hospital, Paris Centre University, Imagine Institute, Paris, France
| | | | - Emmanuel Mahé
- Department of Dermatology, Hôpital Victor Dupouy, Argenteuil, France
| | | | - Sylvie Fraitag
- Pathology Department, Necker-Enfants Malades Hospital, APHP, Paris, France
| | | | | | - Irene Lemelle
- Paediatric Onco-Haematology, Brabois Hospital, University Hospital of Nancy, Vandoeuvre-Lès-Nancy, France
| | - Didier Bessis
- Department of Dermatology, University Hospital of Montpellier, Montpellier, France
| | - Emmanuelle Bourrat
- Department of General Pediatrics, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Stéphanie Mallet
- Department of Dermatology, Hôpital Timone, Aix-Marseille Université, Marseille, France
| | - Bertille Bonniaud
- Department of Dermatology and Genetics of Developmental Anomalies, UMR Inserm 1231, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079, Dijon, France
| | | | | | - Franck Boralevi
- Pediatric Dermatology Unit, Hôpital Pellegrin-Enfants, CHU de Bordeaux, France
| | - Maryam Piram
- Department of Pediatrics, CHU Sainte Justine Research Centre, Sainte Justine University Hospital, University of Montreal, Montreal, QC, Canada
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10
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Tew ZY, Johnson D, Louis G, Bhowmick K. Purpura fulminans in a hyposplenic patient arising from pneumococcal sinusitis. BMJ Case Rep 2023; 16:e253043. [PMID: 37460246 PMCID: PMC10357718 DOI: 10.1136/bcr-2022-253043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
We report a previously healthy woman in her 50s who presented with sepsis, rapidly progressive purpuric rash and disseminated intravascular coagulation. She was diagnosed with acute infective purpura fulminans due to invasive pneumococcal infection likely secondary to sinusitis. Our case report discusses our initial diagnostic uncertainty and approach in investigating and treating such a critically unwell patient.
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Affiliation(s)
- Zi Yi Tew
- Department of Anaesthesia, West Suffolk NHS Foundation Trust, Bury Saint Edmunds, UK
| | - Daniel Johnson
- Department of General Medicine, West Suffolk NHS Foundation Trust, Bury Saint Edmunds, UK
| | - Gerard Louis
- Department of Emergency Medicine, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
| | - Kaushik Bhowmick
- Department of Anaesthesia, West Suffolk NHS Foundation Trust, Bury Saint Edmunds, UK
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11
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Perry JC, Pindek RL, Sur A, Kc N, Zeibeq J. Alcohol Abuse as a Silent Risk Factor for Purpura Fulminans and the Importance of Pneumococcal Vaccination. Cureus 2023; 15:e39522. [PMID: 37378100 PMCID: PMC10292072 DOI: 10.7759/cureus.39522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2023] [Indexed: 06/29/2023] Open
Abstract
Purpura fulminans (PF) is a rare presentation of disseminated intravascular coagulopathy (DIC) and a life-threatening complication of septic shock. DIC can present with bleeding and thrombosis in acute settings, making its management exceptionally challenging. Common causative organisms include Neisseria meningitidis, Streptococcus pneumoniae, andHaemophilus influenzae. We report a case of a 47-year-old patient with a history of alcohol abuse and marijuana use with a bizarre presentation of copious diarrhea and altered mental status. The patient was subsequently admitted to the intensive care unit (ICU) for acute respiratory failure and septic shock secondary to Streptococcus pneumoniae bacteremia complicated by DIC. Unfortunately, the patient's condition worsened with multiorgan failure and purpura fulminans, leading to extensive necrosis of all his extremities, with the involvement of his lips, nose, and genitals. Unfortunately, despite aggressive interventions, he continued to deteriorate and ultimately was transitioned to comfort care before he expired. In the literature, there is only one reported case of PF in an individual with alcohol abuse. However, the frequency and severity of pneumococcal infections in individuals with a history of alcohol abuse are much higher than in the general population. PF is a devastating complication of Streptococcus pneumoniae, with a mortality of 43%. We hope that this case will continue highlighting the importance of vaccinating patients with a history of alcohol abuse with the pneumococcal vaccine.
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Affiliation(s)
- Jamal C Perry
- Medicine, Brookdale University Hospital Medical Center, Brooklyn, USA
| | - Rachel L Pindek
- Osteopathic Medicine, New York Institute of Technology College of Osteopathic Medicine, Old Westbury, USA
| | - Avtar Sur
- Internal Medicine, Brookdale University Hospital Medical Center, Brooklyn, USA
| | - Nabin Kc
- Critical Care Medicine, One Brooklyn Health System-Interfaith Medical Center, New York, USA
| | - John Zeibeq
- Pulmonary and Critical Care Medicine, Brookdale University Hospital Medical Center, Brooklyn, USA
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12
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Pangburn J, Gibbs J. Two Cases of COVID-19 Patients With Associated Purpura Fulminans. J Burn Care Res 2023; 44:485-486. [PMID: 36402743 DOI: 10.1093/jbcr/irac176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Indexed: 11/21/2022]
Abstract
Purpura fulminans (PF) is a life-threatening emergency involving coagulopathy and widespread skin necrosis. Early treatment, especially surgical management, is imperative as prognosis can be very poor. PF is most commonly associated with severe bacterial illness; however, viral causes are also possible. Currently in the literature, there have only been a handful of PF cases associated with COVID-19. We present two cases of PF in the setting of COVID-19 infection. Both patients had a history of underlying coagulopathies. PF can be a sign of underlying coagulopathy in a COVID-19 patient, who is already at increased risk for thromboembolic events due to the inflammatory nature of COVID itself. Due to how quickly PF can develop into life-threatening necrosis and multiorgan failure, it is imperative that these patients are referred early to a burn center for more advanced care.
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Affiliation(s)
- Jane Pangburn
- Ascension St. Vincent Hospital, Indianapolis, Indiana, USA
| | - Jeffrey Gibbs
- Ascension St. Vincent Hospital, Indianapolis, Indiana, USA
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13
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Goodall RJ, Roberts J, Correia MD, Frew Q, Barnes D, Dziewulski P, Shelley O, El-Muttardi N. Management of purpura fulminans skin loss at a regional burns centre: Sixteen-year experience. J Plast Reconstr Aesthet Surg 2023; 79:23-29. [PMID: 36842284 DOI: 10.1016/j.bjps.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 01/29/2023] [Indexed: 02/10/2023]
Abstract
INTRODUCTION Purpura fulminans (PF) is a rare syndrome of cutaneous purpura which is the consequence of severe circulatory shock causing intravascular thrombosis, haemorrhagic necrosis, and consequent tissue loss. The aim of this study was to present our 16-year experience of managing PF in a regional burns centre. METHODS We performed a single-centre retrospective case series of all patients admitted to the St Andrews Burns Centre at Broomfield Hospital, Chelmsford, Essex, UK, between June 2006 and July 2022 with a diagnosis of PF. Data were extracted by retrospectively searching hospital case notes. RESULTS Thirteen individuals were identified [five children (mean age 5, range 1-14) and eight adults (mean age 39, range 24-54)]. The total body surface area of cutaneous necrosis ranged from 5% to 80%, with a mean of 27.2%. Patients were treated with an established surgical sequence of total wound debridement and immediate coverage with a cadaveric allograft, followed by staged wound autografting. The mean time from disease onset to wound autografting was 37.3 days (range 20-64 days). Eight individuals (61.6%) required major amputation of at least one limb (proximal to the ankle or wrist joint). Only one mortality (of 80% total body surface area skin loss) was observed in the identified cohort. CONCLUSIONS The large body surface areas often involved in PF cases make management of these wounds well suited for burns centres, wherein established facilities and multidisciplinary teams exist that are familiar with managing large cutaneous burns. We provide a suggested algorithm to aid the management of PF.
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Affiliation(s)
- R J Goodall
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK.
| | - J Roberts
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
| | - M D Correia
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
| | - Q Frew
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
| | - D Barnes
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
| | - P Dziewulski
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
| | - O Shelley
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
| | - N El-Muttardi
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
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14
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Management Strategies in Septic Coagulopathy: A Review of the Current Literature. Healthcare (Basel) 2023; 11:healthcare11020227. [PMID: 36673595 PMCID: PMC9858837 DOI: 10.3390/healthcare11020227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 01/14/2023] Open
Abstract
One of the 'organs' that can be affected by sepsis is the coagulation system. Coagulopathy in sepsis may take the form of sepsis-induced coagulopathy (SIC) or sepsis-associated disseminated intravascular coagulation (DIC). It is important to identify SIC early, as at this stage of coagulopathy anticoagulants may be of the greatest benefit. The most recent diagnostic scoring systems for septic coagulopathy come from the International Society on Thrombosis and Hemostasis and the Japanese Association for Acute Medicine. Recommendations regarding the management of septic coagulopathy differ between organizations. Moreover, septic coagulopathy is an area of intense research in recent years. Therefore we searched three databases to review the most recent management strategies in septic coagulopathy. The mainstream management strategies in septic coagulopathy include the causal treatment of sepsis, unfractionated heparin, low-molecular-weight heparin, antithrombin, and recombinant human thrombomodulin. The last two have been associated with the highest survival benefit. Nevertheless, the indiscriminate use of these anticoagulants should be avoided due to the lack of mortality benefit and increased risk of bleeding. The early diagnosis of SIC and monitoring of coagulation status during sepsis is crucial for the timely management and selection of the most suitable treatment at a time. New directions in septic coagulopathy include new diagnostic biomarkers, dynamic diagnostic models, genetic markers for SIC management, and new therapeutic agents. These new research avenues may potentially result in timelier SIC diagnosis and improved management of all stages of septic coagulopathy by making it more effective, safe, and personalized.
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15
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Salah E. TEN mimics: Classification and practical approach to toxic epidermal necrolysis-like dermatoses. Indian J Dermatol Venereol Leprol 2022; 89:337-346. [PMID: 36688885 DOI: 10.25259/ijdvl_244_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 08/01/2022] [Indexed: 12/15/2022]
Abstract
Toxic epidermal necrolysis (TEN) is an acute life-threatening dermatologic emergency. However, many dermatoses can present with a TEN-like eruption. Those "TEN-mimics" are a true diagnostic challenge and an alarming differential diagnosis to such a serious condition. Herein, we will expose and classify the landscape of TEN-mimics. Also, the key differentiating clinical and/or laboratory points will be highlighted to help an accurate diagnosis of either a TEN or a TEN-like presentation.
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Affiliation(s)
- Eman Salah
- Department of Dermatology, Venereology & Andrology, Faculty of Medicine, Zagazig University, Egypt
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16
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Muacevic A, Adler JR, Ngwudike C, Tripathi M. Right Lower Extremity Phlegmasia Cerulea Dolens Due to Iliotibial Vein Thrombosis With Compartment Syndrome and Circulatory Shock: Case Report and Review. Cureus 2022; 14:e32364. [PMID: 36628047 PMCID: PMC9826733 DOI: 10.7759/cureus.32364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2022] [Indexed: 12/13/2022] Open
Abstract
Phlegmasia cerulea dolens (PCD) is a rare and life-threatening complication of extensive deep vein thrombosis (DVT) characterized by severe pain, swelling, and cyanosis of the affected limb. It results from total or near-total occlusion of the deep and superficial veins of a limb, leading to venous congestion and ischemia. It is associated with 40% mortality, more commonly affecting the left lower extremity, with up to 50% of patients requiring limb amputations. PCD complicated by compartment syndrome (CS) with shock and multiorgan failure is very rare. We report the case of a 55-year-old female who presented with sudden onset, severe right lower extremity pain and swelling with associated limb discoloration, paresthesias, and inability to move the toes of her right foot. On examination, there was cyanosis, pulselessness, and tense right leg and thigh compartments. Doppler ultrasonography revealed DVT of the right external iliac extending to the posterior tibial vein. A diagnosis of PCD with CS was made and the patient was immediately started on anticoagulation with unfractionated heparin and emergent decompressive fasciotomies of the right leg and thigh were performed. Following the fasciotomies, she developed circulatory shock and went into cardiac arrest. Despite successful resuscitation, her hemodynamic instability and multiorgan failure precluded further life-saving interventions including thrombolysis or thrombectomy. Limb amputation was declined given her poor prognosis and she passed away shortly thereafter. This case illustrates the rare occurrence of right lower extremity PCD complicated by CS, circulatory shock, and multiorgan failure, which can sometimes occur despite emergency fasciotomy but can be averted with prompt intervention. These complications often preclude immediate thrombolysis and/or thrombectomy. Its recognition, therefore, warrants timely and more aggressive interventions to prevent limb loss or death.
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17
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Temnithikul B, Rungrunanghiranya S, Limtanyakul P, Angkananard T, Wessagowit V. Klebsiella‐induced acute infectious purpura fulminans in a Thai woman: Case report and review of literature. SKIN HEALTH AND DISEASE 2022. [DOI: 10.1002/ski2.186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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18
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Gunasekaran K, Elangovan D, Perumalla S, Abhilash KPP, Prakash JAJ. Purpura Fulminans and Spotted Fever: A Case Series from South India. J Glob Infect Dis 2022; 14:162-164. [PMID: 36636298 PMCID: PMC9831211 DOI: 10.4103/jgid.jgid_297_21] [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: 11/11/2021] [Revised: 05/03/2022] [Accepted: 06/03/2022] [Indexed: 12/12/2022] Open
Abstract
Purpura fulminans (PF) is associated with acute infections such as meningococcal, staphylococcal, streptococcal, and rickettsial infections. However, there are only a few reports of association of PF with rickettsial fever from India. In this case series of seven adults with PF, four were definitive cases of spotted fever as the ompA real-time polymerase chain reaction was positive. The other three adults were probable cases of spotted fever, as they were positive by immunoglobulin M enzyme-linked immunosorbent assay, and their fever subsided within 72 h of rickettsia-specific therapy. Three of the seven patients had peripheral gangrene. These patients, despite presenting with severe spotted fever, had a favorable outcome. This is attributed to the high index of suspicion and early treatment supported by diagnostic assays.
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Affiliation(s)
- Karthik Gunasekaran
- Department of Internal Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Divyaa Elangovan
- Department of Clinical Microbiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Susmitha Perumalla
- Department of Clinical Microbiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Kundavaram Paul Prabhakar Abhilash
- Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India,Address for correspondence: Dr. Kundavaram Paul Prabhakar Abhilash, Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India. E-mail:
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19
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Symmetrical Peripheral Gangrene: Report of Three Cases. Case Rep Crit Care 2022; 2022:8615420. [PMID: 36278033 PMCID: PMC9581682 DOI: 10.1155/2022/8615420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 09/01/2022] [Accepted: 09/06/2022] [Indexed: 11/07/2022] Open
Abstract
Symmetrical peripheral gangrene (SPG) is a rare clinical syndrome characterized by an acute onset of ischemic damage in two or more extremities without obstruction or vasculitis of supplying vessels. Body parts commonly affected include toes, hands, scrotum, and earlobes, increasing the risk of limb amputation and impairing the quality of life. The vascular injury mechanism is disseminated intravascular coagulation. SPG may manifest unpredictably in conditions associated with septic shock, low output states, vasospastic conditions, myeloproliferative disorders, or hyperviscosity syndrome. A review on the topic is presented based on a 3-case series of SPG that required amputation of fingers and toes after the administration of vasopressors in a septic shock context.
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20
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Nepal D, Aryal E, Parajuli S, Bhattarai AM, Nepal K, Himanshu, Shah B. Purpura fulminans in probable scrub typhus group of rickettsioses from hilly region in Nepal - A case report. Ann Med Surg (Lond) 2022; 82:104701. [PMID: 36268303 PMCID: PMC9577652 DOI: 10.1016/j.amsu.2022.104701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/06/2022] [Accepted: 09/10/2022] [Indexed: 11/26/2022] Open
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21
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Minford A, Brandão LR, Othman M, Male C, Abdul-Kadir R, Monagle P, Mumford AD, Adcock D, Dahlbäck B, Miljic P, DeSancho MT, Teruya J. Diagnosis and management of severe congenital protein C deficiency (SCPCD): Communication from the SSC of the ISTH. J Thromb Haemost 2022; 20:1735-1743. [PMID: 35570324 DOI: 10.1111/jth.15732] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 04/11/2022] [Accepted: 04/13/2022] [Indexed: 02/04/2023]
Abstract
Severe congenital protein C deficiency (SCPCD) is rare and there is currently substantial variation in the management of this condition. A joint project by three Scientific and Standardization Committees of the ISTH: Plasma Coagulation Inhibitors, Pediatric/Neonatal Thrombosis and Hemostasis, and Women's Health Issues in Thrombosis and Hemostasis, was developed to review the current evidence and help guide on diagnosis and management of SCPCD. We provide a summary of the clinical presentations, differential diagnoses, appropriate investigations to confirm the diagnosis, approaches for management of the acute situation, and options for long-term management including subsequent pregnancies. We finally provide a set of recommendations to help in this regard.
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Affiliation(s)
- Adrian Minford
- Department of Paediatrics, Bradford Royal Infirmary, West Yorkshire, UK
| | - Leonardo R Brandão
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Maha Othman
- School of Medicine, Queen's University, Kingston, ON, Canada
- School of Baccalaureate Nursing, St. Lawrence College, Kingston, ON, Canada
| | - Christoph Male
- Department of Paediatrics, Medical University of Vienna, Vienna, Austria
| | - Rezan Abdul-Kadir
- Katharine Dormandy Haemophilia and Thrombosis Centre and Department of Obstetrics and Gynaecology, The Royal Free NHS Foundation Hospital, London, London, UK
- Institute for Women's Health, University College London, London, UK
| | - Paul Monagle
- Kids Cancer Centre, Department of Haematology, Sydney Children's Hospital, Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew D Mumford
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Dorothy Adcock
- Laboratory Corporation of America, Burlington, North Carolina, USA
| | - Björn Dahlbäck
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Predrag Miljic
- Faculty of Medicine, Clinic of Hematology, Clinical Center of Serbia, University in Belgrade, Belgrade, Serbia
| | - Maria T DeSancho
- Division of Hematology-Oncology, Department of Medicine, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Jun Teruya
- Departments of Pathology & Immunology, Pediatrics, and Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
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22
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Li XL, Luan CY, Fan YJ, Lin XY, Jiang D, Su MX, Wang G, Yang X. A Rare Case of Acute Infectious Purpura Fulminans Caused by Klebsiella Pneumoniae and Human Herpesvirus Type 5. J Inflamm Res 2022; 15:4251-4260. [PMID: 35923907 PMCID: PMC9340174 DOI: 10.2147/jir.s369986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/29/2022] [Indexed: 11/23/2022] Open
Abstract
Background Purpura fulminans (PF), a rare, life-threatening disorder, is a hematological emergency in which there is skin necrosis, disseminated intravascular coagulation (DIC), and protein C deficiency. In PF, the skin necrosis and DIC are secondary to protein C deficiency. This may progress rapidly to multiorgan failure caused by the thrombotic occlusion of small- and medium-sized blood vessels. Case Report This article presents the case of a 22-year-old male with fever as well as necrotic and purpuric skin lesions. The ultrasound and computed tomography scans revealed infections in the skin wounds as well as venous microthrombosis and thrombosis in multiple intracranial and pulmonary vessels. The laboratory tests showed signs of sepsis, thrombocytopenia, an abnormal decrease in protein C and antithrombin III, DIC, multiple organ and system failures, gastric varices, and gastrointestinal hemorrhage. The blood, sputum, and secretions under the skin lesions were cultured and were positive for Klebsiella pneumoniae. The results of the high-throughput genetic testing of the pathogenic microorganism DNA were consistent. In addition, human herpesvirus type 5 was detected. The histopathological examination of the skin lesions revealed pathological features consistent with PF. After successful treatment by the departments of Dermatology, Emergency Critical Care Medicine, and the Intensive Care Unit, the patient was discharged after 67 days of hospitalization. Conclusion Adults with acquired protein C and/or S deficiency states, including certain bacterial and viral infections, who drink alcohol and take varieties of non-steroidal anti-inflammatory analgesics at the same time, may develop acute infectious PF. Clinicians should be aware of this for early diagnosis and treatment.
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Affiliation(s)
- Xiao-Lan Li
- Department of Dermatology, The Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, People’s Republic of China
- Correspondence: Xiao-Lan Li, Department of Dermatology, The Second Affiliated Hospital of Kunming Medical University, No. 374 of Dian-Mian Avenue, Wu-Hua District, Kunming, 650101, People’s Republic of China, Tel +86 871 63402212, Fax +86 871 65334416, Email
| | - Chun-Yan Luan
- Department of Dermatology, The Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, People’s Republic of China
| | - Ying-Jun Fan
- Department of Rheumatology, The Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, People’s Republic of China
| | - Xiao-Ying Lin
- Department of Dermatology, The Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, People’s Republic of China
| | - Dong Jiang
- Department of Dermatology, The Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, People’s Republic of China
| | - Mei-Xian Su
- Department of Emergency Critical Care Medicine, The Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, People’s Republic of China
| | - Gang Wang
- Department of Intensive Care Unit, The Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, People’s Republic of China
| | - Xu Yang
- Laboratory Bacteria Room, The Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, People’s Republic of China
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23
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Perinkulam Sathyanarayanan S, Ahmed M, Hericks A. Purpura fulminans due to Streptococcus pneumoniae bacteraemia in an unsplectomised immunocompetent adult without primary hypocomplementaemia. BMJ Case Rep 2022; 15:15/5/e249514. [PMID: 35589268 PMCID: PMC9121414 DOI: 10.1136/bcr-2022-249514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Invasive pneumococcal disease occurs in high-risk patient population which includes patients with asplenia and primary hypocomplementaemia. Pneumococcal sepsis can rarely cause disseminated intravascular coagulation (DIC) and intravascular thrombosis of small and medium sized vessels called purpura fulminans which is associated with a high mortality rate. We present the case of an immunocompetent woman in her 50s with an intact spleen who presented with septic shock from Streptococcus pneumoniae bacteraemia. Her hospital course rapidly progressed to multiorgan dysfunction, DIC and purpura fulminans. She was treated aggressively with broad spectrum antibiotics, coagulation factor replacement, multiple vasopressor support, renal replacement therapy and mechanical ventilator support. Despite aggressive measures, she succumbed to the multiorgan failure.
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Affiliation(s)
| | - Mohammad Ahmed
- Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA.,Department of Internal Medicine, Avera McKennan Hospital and University Health Center, Sioux Falls, South Dakota, USA
| | - Anthony Hericks
- Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA.,Division of Pulmonary Critical Care, Avera McKennan Hospital and University Health Center, Sioux Falls, South Dakota, USA
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24
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Ruiz de Villa A, Charles K, Okonoboh P. A Rare Case of Purpura Fulminans in the Setting of Klebsiella pneumoniae Bacteremia. Cureus 2022; 14:e22921. [PMID: 35399398 PMCID: PMC8986515 DOI: 10.7759/cureus.22921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2022] [Indexed: 12/01/2022] Open
Abstract
A 23-year-old man with circulatory shock associated with severe sepsis and congestive heart failure with an ejection fraction of 10% resulting in anasarca and multiorgan failure was admitted to our hospital's intensive care unit. Hours after admission, he developed a rash on his left inner thigh, which was later diagnosed as purpura fulminans (PF). Blood cultures were consistent with Klebsiella pneumoniae bacteremia, with community-acquired pneumonia being the possible source. PF is a rare and difficult-to-diagnose entity characterized by dysregulated hemostasis that is often associated with poor prognosis and fatal outcomes. To our knowledge, there are limited reports in the literature on K. pneumoniae as a cause of PF. Given the rarity of this presentation, this case will serve as an opportunity to report and discuss the pathophysiology of this disease for the benefit of physicians.
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25
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Tang X, Zhang Z, Yang H, Xiao J, Wen X, Dou Y, Yu J, Hu Y. Clinical and genetic features of Chinese pediatric patients with severe congenital protein C deficiency who first presented with purpura fulminans: A case series study and literature review. Thromb Res 2022; 210:70-77. [PMID: 35026611 DOI: 10.1016/j.thromres.2021.12.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/05/2021] [Accepted: 12/27/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Purpura fulminans (PF) is a hematological emergency that can be caused by severe congenital protein C (PC) deficiency. It has been rarely reported in the Chinese population. We aimed to characterize the clinical and genetic features of Chinese pediatric patients with severe congenital PC deficiency who first presented with PF. MATERIALS AND METHODS Twelve pediatric patients were diagnosed with severe congenital PC deficiency with PF, which was diagnosed based on our hospital records and previous reports from 1988 to July 2021 in China. We evaluated the clinical and genetic features of these patients. RESULTS Nine patients (9/12, 75%) had onsets that were observed within the first 48 h after birth. Six patients had a family history of thromboembolism. There was no consanguinity. Other symptoms were intracranial thrombosis or hemorrhage (4, 33.3%), ocular lesions (2, 16.7%), gastrointestinal hemorrhage (2, 16.7%) and kidney infarction before birth (1, 8.3%). All but one of the patients (one case not detected) had a plasma PC activity of <10%. The genetic study indicated that in the eight patients with inherited PC deficiency, two were homozygous, five were compound heterozygous and one was heterozygous for PC deficiency. CONCLUSION This is the first and largest case series of Chinese pediatric patients with severe congenital PC deficiency who first presented with PF. It has been shown that treatment with both fresh frozen plasma and anticoagulants is recommended when PC concentrate is not easily available, especially in developing countries.
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Affiliation(s)
- Xue Tang
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Shenzhen, Guangdong, China
| | - Zhiyong Zhang
- Department of Rheumatology and Immunology, Children's Hospital of Chongqing Medical University, Chongqing, China; National Clinical Research Center for Child Health and Disorders, Chongqing, China; Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China; Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Hui Yang
- Department of Hematology and Oncology, Children's Hospital of Chongqing Medical University, Chongqing, China; National Clinical Research Center for Child Health and Disorders, Chongqing, China; Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China; Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Jianwen Xiao
- Department of Hematology and Oncology, Children's Hospital of Chongqing Medical University, Chongqing, China; National Clinical Research Center for Child Health and Disorders, Chongqing, China; Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China; Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Xianhao Wen
- Department of Hematology and Oncology, Children's Hospital of Chongqing Medical University, Chongqing, China; National Clinical Research Center for Child Health and Disorders, Chongqing, China; Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China; Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Ying Dou
- Department of Hematology and Oncology, Children's Hospital of Chongqing Medical University, Chongqing, China; National Clinical Research Center for Child Health and Disorders, Chongqing, China; Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China; Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Jie Yu
- Department of Hematology and Oncology, Children's Hospital of Chongqing Medical University, Chongqing, China; National Clinical Research Center for Child Health and Disorders, Chongqing, China; Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China; Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Yanni Hu
- Department of Hematology and Oncology, Children's Hospital of Chongqing Medical University, Chongqing, China; National Clinical Research Center for Child Health and Disorders, Chongqing, China; Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China; Chongqing Key Laboratory of Pediatrics, Chongqing, China.
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26
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Fukuta K, Shiozaki K, Nakanishi R, Inai T, Izaki H, Yamamura R, Nakataki E, Kudo E, Kanda K. Sepsis-associated purpura fulminans caused by emphysematous cystitis. IJU Case Rep 2021; 4:403-406. [PMID: 34755068 PMCID: PMC8560431 DOI: 10.1002/iju5.12359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 07/28/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Emphysematous cystitis is a rare pathology characterized by gas bubbles within the bladder wall and lumen from gas-producing bacteria. Sepsis-associated purpura fulminans is also rare and shows poor clinical outcomes. CASE PRESENTATION A 73-year-old man was hospitalized at a nearby hospital due to chronic subdural hematoma, symptomatic epilepsy, and diabetes mellitus. He was transferred to our hospital with fever, low blood pressure, and cyanosis of the legs, and was diagnosed with septic shock due to emphysematous cystitis with purpura fulminans. He underwent intensive treatment, including retroperitoneal drainage. Urine culture was positive for Citrobacter freundii. His general condition gradually improved and diffuse air decreased after surgery, but progressive purpuric skin necrosis became evident on the legs, which could not be salvaged. He died on the 25th hospital day. CONCLUSION Sepsis-associated purpura fulminans caused by emphysematous cystitis shows a very poor prognosis irrespective of intensive treatment, including retroperitoneal drainage.
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Affiliation(s)
- Kyotaro Fukuta
- Departments ofUrologyTokushima Prefectural Central HospitalTokushimaJapan
| | - Keito Shiozaki
- Departments ofUrologyTokushima Prefectural Central HospitalTokushimaJapan
| | - Ryoichi Nakanishi
- Departments ofUrologyTokushima Prefectural Central HospitalTokushimaJapan
| | - Tohru Inai
- Departments ofUrologyTokushima Prefectural Central HospitalTokushimaJapan
| | - Hirofumi Izaki
- Departments ofUrologyTokushima Prefectural Central HospitalTokushimaJapan
| | - Rie Yamamura
- Department ofDermatologyTokushima Prefectural Central HospitalTokushimaJapan
| | - Emiko Nakataki
- Department ofIntensive Care UnitTokushima Prefectural Central HospitalTokushimaJapan
| | - Eiji Kudo
- Department ofPathologyTokushima Prefectural Central HospitalTokushimaJapan
| | - Kazuya Kanda
- Departments ofUrologyTokushima Prefectural Central HospitalTokushimaJapan
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27
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Reda S, Rühl H, Witkowski J, Müller J, Pavlova A, Oldenburg J, Pötzsch B. PC Deficiency Testing: Thrombin-Thrombomodulin as PC Activator and Aptamer-Based Enzyme Capturing Increase Diagnostic Accuracy. Front Cardiovasc Med 2021; 8:755281. [PMID: 34708097 PMCID: PMC8542722 DOI: 10.3389/fcvm.2021.755281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 09/12/2021] [Indexed: 11/30/2022] Open
Abstract
Protein C (PC) activity tests are routinely performed in a thrombophilia workup to screen for PC deficiency. Currently used tests combine conversion of PC to activated PC (APC) by the snake venom Protac with subsequent APC detection through hydrolysis of a chromogenic peptide substrate or prolongation of a clotting time. In this prospective cohort study, we analyzed how different modes of PC activation and subsequent APC determination influence the diagnostic accuracy of PC activity testing in a cohort of 31 patients with genetically confirmed PC deficiency. In addition to chromogenic and clot-based measurement, an oligonucleotide-based enzyme capture assay utilizing a basic exosite-targeting aptamer was used for APC detection. To study the influence of the PC activation step on diagnostic sensitivity, PC activation through Protac and through the thrombin-thrombomodulin (TM) complex were compared. Twenty-six (84%) and 24 (77%) PC deficient patients were identified as true-positive using the chromogenic and the clot-based PC activity assay, respectively. True-positive results increased to 27 (87%) when the basic exosite-targeting aptamer approach was used for APC measurement. Additional replacement of the PC activator Protac by thrombin-TM gave true-positive results in all patients. These data indicate that the mode of PC activation is crucial in determining the accuracy of PC activity testing and that diagnostic sensitivity can be significantly improved by replacing the PC activator Protac with thrombin-TM. APC detection using a basic exosite-targeting aptamer achieves high sensitivity toward mutations outside the active center while being less subject to interfering factors than clot-based PC activity assays.
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Affiliation(s)
- Sara Reda
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Heiko Rühl
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Jana Witkowski
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Jens Müller
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Anna Pavlova
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Bernd Pötzsch
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
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28
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Griss J, Eichinger S, Winkler S, Weninger W, Petzelbauer P. A case of COVID-19 vaccination-associated forme fruste purpura fulminans. Br J Dermatol 2021; 186:e1. [PMID: 34585371 PMCID: PMC8652590 DOI: 10.1111/bjd.20744] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 11/29/2022]
Abstract
We report the case of a female, 77 year old patient with multi-localized skin infarctions following vaccination with mRNA-1273 (Moderna). This phenomenon is to our knowledge otherwise only seen in infection-associated purpura fulminans - which was thoroughly ruled out in our patient. This report demonstrates that we need to be vigilant of a wider array of vascular phenomena related to Covid vaccinations.
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Affiliation(s)
- J Griss
- Department of Dermatology, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, 1090, Austria
| | - S Eichinger
- Division of Hematology and Hemostaseology, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, 1090, Austria
| | - S Winkler
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine 1, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, 1090, Austria
| | - W Weninger
- Department of Dermatology, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, 1090, Austria
| | - P Petzelbauer
- Department of Dermatology, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, 1090, Austria
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29
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Maebayashi A, Hayashi N, Kamata S, Sugita A, Tang X, Kawana K. Thrombus formation and ischemic necrosis of the uterus and adnexa due to purpura fulminans: A case report. J Obstet Gynaecol Res 2021; 47:4478-4483. [PMID: 34525489 DOI: 10.1111/jog.15027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/28/2021] [Accepted: 09/01/2021] [Indexed: 11/28/2022]
Abstract
Purpura fulminans (PF) is a syndrome characterized by the sudden onset of progressive skin hemorrhage, necrosis of the extremities, and thrombotic occlusion. Although the cause is believed to be protein C deficiency, many aspects of this syndrome have yet to be clarified. A 45-year-old Japanese woman, G2P2 (vaginal delivery), developed fever and lower abdominal pain. It was her 5th day of menstruation, and a tampon had been in the vagina for a few days. Septic shock and disseminated intravascular coagulation were diagnosed, and multidisciplinary treatment was started. Also, toxic shock syndrome due to tampon use was suspected. The purpura on the limbs turned into blisters and then blackish-purple spots, leading to hemorrhagic necrosis within a few days. Moreover, imaging showed that the uterus and both adnexa had enlarged significantly, and raised suspicion of abscess formation. Total hysterectomy and bilateral adnexectomy were performed, and the histopathological diagnosis was hemorrhagic necrosis due to extensive thrombus formation. In men, PF affects the scrotum and penis, leading to autoamputation of the male genitalia, while there are no reports of PF involving the female genitalia. Regarding the PF, in this case, we considered the possibility of pathologic conditions progressing to the female genitalia.
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Affiliation(s)
- Aki Maebayashi
- Department of Obstetrics and Gynecology, Nihon University Hospital, Tokyo, Japan
| | - Nobuki Hayashi
- Department of Obstetrics and Gynecology, Nihon University Hospital, Tokyo, Japan.,Department of Obstetrics and Gynecology, Nihon University School of Medicine, Tokyo, Japan
| | - Saki Kamata
- Department of Obstetrics and Gynecology, Nihon University Hospital, Tokyo, Japan.,Department of Obstetrics and Gynecology, Nihon University School of Medicine, Tokyo, Japan
| | - Atsunori Sugita
- Department of Emergency and Critical Care Center, Nihon University Hospital, Tokyo, Japan
| | - Xiaoyan Tang
- Department of Pathology and Microbiology, Nihon University Hospital, Tokyo, Japan
| | - Kei Kawana
- Department of Obstetrics and Gynecology, Nihon University School of Medicine, Tokyo, Japan
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30
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Abstract
ABSTRACT Purpura fulminans can result in significant full-thickness wounds, posing a challenge in the pediatric population, given the paucity of donor sites for reconstruction. The authors present the case of an 11-month-old patient for whom a split-thickness skin allograft (TheraSkin) was successfully implemented as a temporizing measure for a large leg wound.
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31
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Rana K, Gupta A, Sood A, Gupta M. Factors leading to neonatal mortality due to neonatal purpura fulminans through the lens of a child death review. BMJ Case Rep 2021; 14:e237281. [PMID: 34167969 PMCID: PMC8230994 DOI: 10.1136/bcr-2020-237281] [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] [Accepted: 06/01/2021] [Indexed: 11/04/2022] Open
Abstract
A case of neonatal death due to neonatal purpura fulminans (NPF) was brought to community physicians' notice by the auxiliary nurse midwife in her catchment area as part of the routine demographic health surveillance. The community physician then conducted the child death review in the community. The neonate was born out of consanguineous marriage (mother married to her first-degree maternal cousin) with spontaneous conception. This neonate was fourth in the birth order. The second-order and third-order births had also suffered from NPF and died. The baby was delivered in a tertiary care setting, and the paediatric surgeon planned debridement of the affected part on the third day of the birth, as per the mother. However, due to inadequate counselling regarding the procedure, mother left the hospital without seeking care against medical advice, and the child died at home.
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Affiliation(s)
- Kirtan Rana
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Atul Gupta
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aditya Sood
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Madhu Gupta
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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32
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Nusbaum KB, Korman AM, Tyler KH, Kaffenberger JA, Trinidad JC, Dean S, Cataland S, Kaffenberger BH. In vitro diagnostics for the medical dermatologist. Part II: Hypercoagulability tests. J Am Acad Dermatol 2021; 85:301-310. [PMID: 33852929 DOI: 10.1016/j.jaad.2021.03.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 10/21/2022]
Abstract
The skin often provides initial clues of hypercoagulability with features such as livedo reticularis, livedo racemosa, retiform purpura, necrosis, and ulcerations. Because these cutaneous manifestations are nonspecific, laboratory testing is often needed to evaluate for underlying causes of hypercoagulability. Importantly, these disorders are reported to be the most common mimicker, resulting in an erroneous diagnosis of pyoderma gangrenosum. Understanding inherent properties of, and indications for, available tests is necessary for appropriate ordering and interpretation of results. Additionally, ordering of these tests in an indiscriminate manner may lead to inaccurate results, complicating the interpretation and approach to management. This second article in this continuing medical education series summarizes information on methodology, test characteristics, and limitations of several in vitro laboratory tests used for the work up of hypercoagulability and vasculopathic disease as it pertains to dermatologic disease.
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Affiliation(s)
| | - Abraham M Korman
- Division of Dermatology, Department of Internal Medicine, The Ohio State University, Columbus, Ohio
| | - Kelly H Tyler
- Division of Dermatology, Department of Internal Medicine, The Ohio State University, Columbus, Ohio
| | - Jessica A Kaffenberger
- Division of Dermatology, Department of Internal Medicine, The Ohio State University, Columbus, Ohio
| | - John C Trinidad
- Division of Dermatology, Department of Internal Medicine, The Ohio State University, Columbus, Ohio
| | - Steven Dean
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University, Columbus, Ohio
| | - Spero Cataland
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, Ohio
| | - Benjamin H Kaffenberger
- Division of Dermatology, Department of Internal Medicine, The Ohio State University, Columbus, Ohio.
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33
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Morales Hernandez MDM, Carranza M, Patel B, Calvert J, Masri G. Purpura Fulminans in a Patient With Septic Shock due to Escherichia coli Bacteremia With Emphysematous Pyelitis. Cureus 2021; 13:e13249. [PMID: 33717756 PMCID: PMC7952243 DOI: 10.7759/cureus.13249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Purpura fulminans (PF) is a rapidly fatal disorder predominantly encountered in patients with an acquired deficiency of physiologic anticoagulants due to severe sepsis and septic shock with disseminated intravascular coagulation (DIC). This consumptive process eventually leads to widespread thrombosis, hemorrhagic necrosis, and gangrene. Rapid identification followed by aggressive management of the underlying etiology with a multidisciplinary team is critical to prevent long-term organ dysfunction, disability from amputation, and death. While bleeding is a common finding in DIC, anticoagulation must be considered if PF is present. We report a case of Escherichia coli--associated emphysematous pyelitis leading to bacteremia, septic shock, and PF with small- and medium-sized vessel thrombosis and acral ischemia.
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Affiliation(s)
| | - Michael Carranza
- Internal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Bijal Patel
- Internal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Joshua Calvert
- Internal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Ghania Masri
- Internal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
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34
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Beato Merino M, Diago A, Fernandez-Flores A, Fraga J, García Herrera A, Garrido M, Idoate Gastearena M, Llamas-Velasco M, Monteagudo C, Onrubia J, Pérez-González Y, Pérez Muñoz N, Ríos-Martín J, Ríos-Viñuela E, Rodríguez Peralto J, Rozas Muñoz E, Sanmartín O, Santonja C, Santos-Briz A, Saus C, Suárez Peñaranda J, Velasco Benito V. Clinical and Histopathologic Characteristics of the Main Causes of Vascular Occusion — Part II: Coagulation Disorders, Emboli, and Other. ACTAS DERMO-SIFILIOGRAFICAS 2021. [DOI: 10.1016/j.adengl.2020.12.024] [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] Open
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35
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Seidel H, Haracska B, Naumann J, Westhofen P, Hass MS, Kruppenbacher JP. Laboratory Limitations of Excluding Hereditary Protein C Deficiency by Chromogenic Assay: Discrepancies of Phenotype and Genotype. Clin Appl Thromb Hemost 2021; 26:1076029620912028. [PMID: 32309994 PMCID: PMC7288809 DOI: 10.1177/1076029620912028] [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] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Protein C (PC) deficiency is associated with an increased risk for venous thromboembolism (VTE). In daily practice, exclusion of a hereditary PC deficiency is often based on a single determination of PC activity, by either clotting time–based or mostly chromogenic assay. However, diagnosis of hereditary PC deficiency is challenging due to several laboratory and clinical limitations. We compared the potential of PC activity values measured by either chromogenic or clotting time–based assay to predict a variation in the PROC gene. One hundred one (35%) of 287 patients carried variations within the PROC gene, including 2 previously not published variations. In 20 (20%) patients with identified variation, PC activity, determined by chromogenic assay, was within the reference range. For prediction of an underlying genetic defect determined by chromogenic and clotting time–based assay, sensitivity was 80% versus 99%, specificity 75% versus 18%, positive predictive value 64% versus 39%, and negative predictive value (NPV) 88% versus 97%. The lower NPV of chromogenic versus clotting time–based PC assay can be mainly explained by the presence of PC deficiency type IIb. Following our proposed diagnostic algorithm, additional measurement of PC activity by clotting time–based assay in case of a positive VTE history improves detection of this subtype of PC deficiency. Considering potential therapeutic consequences for primary and especially for secondary VTE prophylaxis, genetic analysis is required not only for confirmation but also for clarification of PC deficiency.
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Affiliation(s)
- Holger Seidel
- Centrum für Blutgerinnungsstörungen und Transfusionsmedizin, Bonn, Germany
| | - Bianca Haracska
- Centrum für Blutgerinnungsstörungen und Transfusionsmedizin, Bonn, Germany
| | - Jennifer Naumann
- Centrum für Blutgerinnungsstörungen und Transfusionsmedizin, Bonn, Germany
| | - Philipp Westhofen
- Centrum für Blutgerinnungsstörungen und Transfusionsmedizin, Bonn, Germany
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Pöschl J, Behnisch W, Beedgen B, Kuss N. Case Report: Successful Long-Term Management of a Low-Birth Weight Preterm Infant With Compound Heterozygous Protein C Deficiency With Subcutaneous Protein C Concentrate Up to Adolescence. Front Pediatr 2021; 9:591052. [PMID: 34650936 PMCID: PMC8506145 DOI: 10.3389/fped.2021.591052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/25/2021] [Indexed: 12/18/2022] Open
Abstract
Homozygous/compound heterozygous forms of congenital protein C deficiency are often associated with severe antenatal and postnatal thrombotic or hemorrhagic complications. Protein C deficiency frequently leads to severe adverse outcomes like blindness and neurodevelopmental delay in children and may even lead to death. The most widely used long-term postnatal treatment consists of oral anticoagulation with vitamin K antagonists (e.g., warfarin), which is supplemented with protein C concentrate in acute phases. Subcutaneous infusions have been described in infants mostly from 2 months of age after severe postnatal thrombosis, but not in newborns or premature infants without thromboembolism. We report the first case of a compound heterozygous protein C-deficient preterm infant, born at 31+5 weeks of gestation to parents with heterozygous protein C deficiency (protein C activity 0.9% at birth). We focus on both prenatal and perinatal management including antithrombotic treatment during pregnancy, the cesarean section, and continuous postnatal intravenous and consecutive subcutaneous therapy with protein C concentrate followed by a change of therapy to direct oral anticoagulants (DOACs) (apixaban). We report successful home treatment with subcutaneous protein C concentrate substitution overnight (target protein C activity >25%) without complication up to 12.5 years of age. We propose that early planned cesarean section at 32 or preferably 34 weeks of gestation limits potential maternal side effects of anticoagulation with vitamin K antagonists and reduces fetal thromboembolic complications during late pregnancy. Intravenously administered protein C and early switch to subcutaneous infusions (reaching about 3 kg body weight) resulted in sufficient protein C activity and has guaranteed an excellent quality of life without any history of thrombosis for 13 years now. In older children with protein C deficiency, as in our case, DOACs could be a new therapeutic option.
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Affiliation(s)
- Johannes Pöschl
- Department of Neonatology, Heidelberg University Children's Hospital, Heidelberg, Germany
| | - Wolfgang Behnisch
- Department of Pediatric Oncology, Hematology and Immunology, Heidelberg University Children's Hospital, Heidelberg, Germany
| | - Bernd Beedgen
- Department of Neonatology, Heidelberg University Children's Hospital, Heidelberg, Germany
| | - Navina Kuss
- Department of Neonatology, Heidelberg University Children's Hospital, Heidelberg, Germany
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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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The use of negative-pressure wound therapy over a cultured epithelial autograft for full-thickness wounds secondary to purpura fulminans in an infant. Arch Plast Surg 2020; 48:338-343. [PMID: 33207856 PMCID: PMC8143943 DOI: 10.5999/aps.2020.01032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 07/29/2020] [Indexed: 11/08/2022] Open
Abstract
Purpura fulminans is a serious condition that can result in severe morbidity in the pediatric population. Although autologous skin grafts remain the gold standard for the coverage of partial- to full-thickness wounds, they have several limitations in pediatric patients, including the lack of planar donor sites, the risk of hemodynamic instability, and the limited graft thickness. In Singapore, an in-house skin culture laboratory has been available since 2005 for the use of cultured epithelial autografts (CEAs), especially in burn wounds. However, due to the fragility of CEAs, negative-pressure wound therapy (NPWT) dressings have been rarely used with CEAs. With several modifications, we report a successful case of NPWT applied over a CEA in an infant who sustained 30% total body surface area full-thickness wounds over the anterior abdomen, flank, and upper thigh secondary to purpura fulminans. We also describe the advantages of using NPWT dressing over a CEA, particularly in pediatric patients.
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Baker P, Platton S, Gibson C, Gray E, Jennings I, Murphy P, Laffan M. Guidelines on the laboratory aspects of assays used in haemostasis and thrombosis. Br J Haematol 2020; 191:347-362. [PMID: 32537743 DOI: 10.1111/bjh.16776] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Peter Baker
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sean Platton
- Haemophilia Centre, Barts Health NHS Trust, London, UK
| | - Claire Gibson
- Specialist Haemostasis, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Elaine Gray
- Haemostasis Section, Biotherapeutics Group, National Institute for Biological Standards and Controls, Hertfordshire, UK
| | | | - Paul Murphy
- Department of Haematology, the Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Mike Laffan
- Centre for Haematology, Imperial College and Hammersmith Hospital, London, UK
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40
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Beato Merino MJ, Diago A, Fernandez-Flores A, Fraga J, García Herrera A, Garrido M, Idoate Gastearena MA, Llamas-Velasco M, Monteagudo C, Onrubia J, Pérez-González YC, Pérez Muñoz N, Ríos-Martín JJ, Ríos-Viñuela E, Rodríguez Peralto JL, Rozas Muñoz E, Sanmartín O, Santonja C, Santos-Briz A, Saus C, Suárez Peñaranda JM, Velasco Benito V. Clinical and Histopathologic Characteristics of the Main Causes of Vascular Occusion - Part II: Coagulation Disorders, Emboli, and Other. ACTAS DERMO-SIFILIOGRAFICAS 2020; 112:103-117. [PMID: 33075291 DOI: 10.1016/j.ad.2020.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 10/08/2020] [Indexed: 12/15/2022] Open
Abstract
Vascular occlusion has multiple, diverse clinical manifestations, some of which can have grave consequences for patients. It also has a wide variety of causes, including thrombi, which we recently addressed in partI of this review. In this second part, we look at additional causes of vascular occlusion.
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Affiliation(s)
- M J Beato Merino
- Servicio de Anatomía Patológica, Hospital Universitario La Paz, Madrid, España
| | - A Diago
- Servicio de Dermatología, Hospital Universitario Miguel Servet, Zaragoza, España
| | - A Fernandez-Flores
- Servicio de Anatomía Patológica, Hospital Universitario El Bierzo, Ponferrada, León, España.
| | - J Fraga
- Servicio de Anatomía Patológica, Hospital Universitario de La Princesa, Madrid, España
| | - A García Herrera
- Servicio de Anatomía Patológica, Hospital Clínic, Barcelona, España
| | - M Garrido
- Servicio de Anatomía Patológica, Hospital Universitario 12 de Octubre, Madrid, España
| | - M A Idoate Gastearena
- Servicio de Anatomía Patológica, Hospital Universitario Virgen Macarena, Departamento de Citología, Histología y Anatomía Patológica, Facultad de Medicina, Universidad de Sevilla, Sevilla, España
| | - M Llamas-Velasco
- Servicio de Dermatología, Hospital Universitario de La Princesa, Madrid, España
| | - C Monteagudo
- Servicio de Anatomía Patológica, Hospital Clínico Universitario de Valencia, Facultad de Medicina, Universidad de Valencia, Valencia, España
| | - J Onrubia
- Servicio de Anatomía Patológica, Hospital Universitario San Juan de Alicante, Sant Joan d'Alacant, Alicante, España
| | | | - N Pérez Muñoz
- Servicio de Anatomía Patológica, Hospital Universitari General de Catalunya, Quirónsalud, Sant Cugat del Vallès, Barcelona, España
| | - J J Ríos-Martín
- Servicio de Anatomía Patológica, Hospital Universitario Virgen Macarena, Sevilla, España
| | - E Ríos-Viñuela
- Servicio de Dermatología, Fundación Instituto Valenciano de Oncología, Valencia, España
| | - J L Rodríguez Peralto
- Departamento de Anatomía Patológica, Hospital Universitario 12 de Octubre, Universidad Complutense, Instituto de Investigación I+12, Madrid, España
| | - E Rozas Muñoz
- Departamento de Dermatología, Hospital de San Pablo, Coquimbo, Chile
| | - O Sanmartín
- Servicio de Dermatología, Fundación Instituto Valenciano de Oncología, Valencia, España
| | - C Santonja
- Servicio de Anatomía Patológica, Fundación Jiménez Díaz, Madrid, España
| | - A Santos-Briz
- Servicio de Anatomía Patológica, Hospital Universitario de Salamanca, Salamanca, España
| | - C Saus
- Servicio de Anatomía Patológica, Hospital Universitario Son Espases, Palma de Mallorca, España
| | - J M Suárez Peñaranda
- Servicio de Anatomía Patológica, Hospital Clínico Universitario de Santiago, Santiago de Compostela, La Coruña, España
| | - V Velasco Benito
- Servicio de Anatomía Patológica, Hospital Universitario de Cruces, Barakaldo, Vizcaya, España
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Brozyna JR, Sardiña LA, Sharma A, Theil KS, Bergfeld WF. Acute purpura fulminans-a rare cause of skin necrosis: A single-institution clinicopathological experience. J Cutan Pathol 2020; 47:1003-1009. [PMID: 32356378 DOI: 10.1111/cup.13732] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 04/15/2020] [Accepted: 04/21/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Purpura fulminans, an uncommon syndrome of intravascular thrombosis with hemorrhagic infarction of the skin, is often accompanied by disseminated intravascular coagulation (DIC) and multi-organ failure, and may ultimately lead to death. METHODS Herein, we document 13 skin biopsies from 11 adult patients with the clinical diagnosis of sepsis and confirmed histopathologic diagnosis of intravascular thrombosis and/or DIC, compatible with acute infectious purpura fulminans (AIPF). Detailed history and clinical examination were performed, and the lesions were correlated with histopathologic findings. Any underlying medical disease was taken into consideration. RESULTS There were 5 males and 6 females with lower extremity or peri-incisional purpuric skin lesions. The most important comorbidities identified were a history of surgical procedure or neoplasm, although 4 patients had no relevant underlying history. Most skin biopsies revealed focal epidermal ischemia or necrosis and 3 showed full-thickness epidermal necrosis. In the underlying dermis, there were fibrin thrombi in superficial and deep blood vessels with acute inflammation. Changes of an inflammatory destructive vasculitis were identified in 5 cases. No bacteria or fungi were identified on histopathology. CONCLUSIONS AIPF is a rapidly-progressing medical emergency which may be identified by histopathology in culture-negative cases. Biopsies may show neutrophilic infiltrate without infective organisms.
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Affiliation(s)
- Jeremy R Brozyna
- Department of Dermatology, Cleveland Clinic, Cleveland, Ohio, USA.,Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Luis A Sardiña
- Department of Dermatology, Cleveland Clinic, Cleveland, Ohio, USA.,Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anurag Sharma
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Karl S Theil
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Wilma F Bergfeld
- Department of Dermatology, Cleveland Clinic, Cleveland, Ohio, USA.,Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Abstract
The severe bacterial diseases discussed herein are those that present dermatological lesions as their initial manifestations, for which the dermatologist is often called upon to give an opinion or is even the first to examine the patient. This review focuses on those that evolve with skin necrosis during their natural history, that is, necrotizing fasciitis, Fournier gangrene, and ecthyma gangrenosum. Notice that the more descriptive terminology was adopted; each disease was individualized, rather than being referred by the generic term "necrotizing soft tissue infections". Due to their relevance and increasing frequency, infections by methicillin-resistant Staphylococcus aureus (MRSA) were also included, more specifically abscesses, furuncle, and carbuncle, and their potential etiologies by MRSA. This article focuses on the epidemiology, clinical dermatological manifestations, methods of diagnosis, and treatment of each of the diseases mentioned.
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Djurdjevic N, Taweesedt PT, Paulson M, LaNou A, Radovanovic M, Patel JN, Veselinovic M, McDermott WR, Dumic I. Septic Shock and Purpura Fulminans Due to Streptococcus pneumoniae Bacteremia in an Unvaccinated Immunocompetent Adult: Case Report and Review. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e923266. [PMID: 32513908 PMCID: PMC7304654 DOI: 10.12659/ajcr.923266] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Despite proven efficacy of vaccinations against Streptococcus pneumoniae in preventing infection, only 70% of eligible individuals receive the vaccine in the United States. Pneumococcal bacteremia represents a form of invasive pneumococcal disease and is associated with high mortality, especially in immunocompromised patients and the elderly. Purpura fulminans is a rare complication and manifestation of disseminated intravascular coagulation and sepsis. It is exceedingly rare in the setting of pneumococcal bacteremia, particularly in immunocompetent individuals. CASE REPORT We report a generally healthy 67-year-old male with schizophrenia who refused pneumococcal vaccination. He had an intact and functional spleen with a functional immune system. The patient presented with fever and diarrhea. He subsequently progressed to develop purpura fulminans and septic shock due to S. pneumoniae bacteremia. Despite an extensive search for the primary source of infection, none could not be identified. Due to timely initiation of appropriate antibiotic therapy and aggressive supportive care in an intensive care unit, he recovered despite multi-organ failure that developed throughout his hospitalization. CONCLUSIONS We present a rare manifestation of a potentially preventable disease and emphasize the importance of pneumococcal vaccination in order to decrease the risk of developing invasive pneumococcal disease. Furthermore, we discuss etiology, diagnosis, differential diagnosis, and evidence-based management of purpura fulminans and invasive pneumococcal disease with a literature review. Purpura fulminans due to S. pneumoniae is exceedingly rare in immunocompetent patients and an unusual clinical manifestation of pneumococcal bacteremia.
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Affiliation(s)
| | | | | | - Abigail LaNou
- Mayo Clinic, Alix School of Medicine, Rochester, MN, USA
| | | | - Janki N Patel
- Mayo Clinic, Alix School of Medicine, Rochester, MN, USA
| | | | | | - Igor Dumic
- Mayo Clinic, Alix School of Medicine, Rochester, MN, USA
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Retiform purpura: A diagnostic approach. J Am Acad Dermatol 2020; 82:783-796. [DOI: 10.1016/j.jaad.2019.07.112] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/15/2019] [Accepted: 07/28/2019] [Indexed: 12/28/2022]
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Cooper PC, Pavlova A, Moore GW, Hickey KP, Marlar RA. Recommendations for clinical laboratory testing for protein C deficiency, for the subcommittee on plasma coagulation inhibitors of the ISTH. J Thromb Haemost 2020; 18:271-277. [PMID: 31999059 DOI: 10.1111/jth.14667] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 09/30/2019] [Accepted: 10/17/2019] [Indexed: 11/28/2022]
Abstract
Inherited protein C (PC) deficiency increases risk of venous thromboembolism (VTE) by 5 to 10-fold in thrombosis-prone families; however, heterozygous PC deficiency alone does not determine that a subject has thrombophilia. Protein C deficient subjects, who lack additional inherited risk factors such as factor V Leiden or have no major acquired risk factors, may not suffer from VTE. In addition, PC deficiency may be acquired, often due to vitamin K antagonist treatment or liver disease. In contrast, homozygous or compound heterozygous PC deficiencies are rare and serious disorders, and affected infants are often in families with no history of PC deficiency or thrombosis. Laboratories commonly use the chromogenic PC assay to diagnose deficiency. Chromogenic assay is recommended due to its good specificity, but this assay fails to detect the rare type 2b deficiency where the defect is due to poor interaction with calcium ions, phospholipid, protein S, and factor Va and factor VIIIa. The clotting-based assay of PC is capable of detecting type 2b deficiency but it has reduced specificity. Importantly, PC level varies with age, adult reference ranges cannot be applied to babies or children and levels may not reach those of adults even in adolescence. Pre-analytical variables in the specimen affect measurement of PC, and can be assay-dependent; for example, a partially clotted sample will have falsely raised PC level by chromogenic assay but reduced level by clotting-based assay. Direct oral anticoagulants falsely raise PC level in the clotting-based assay but the standard chromogenic assay is unaffected.
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Affiliation(s)
- Peter C Cooper
- Coagulation Laboratory, Royal Hallamshire Hospital, Sheffield, UK
| | - Anna Pavlova
- Institut für Experimentelle Hämatologie und Transfusionsmedizin Universitätsklinikum Bonn, Bonn, Germany
| | - Gary W Moore
- Diagnostic Haemostasis & Thrombosis, Viapath Analytics, Guy's & St. Thomas' Hospitals, London, UK
| | - Kieron P Hickey
- Coagulation Laboratory, Royal Hallamshire Hospital, Sheffield, UK
| | - Richard A Marlar
- Department of Pathology, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
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Nasrullah A, Javed A, Tariq U, Young M, Moeen Z, Balaan M. Purpura Fulminans: a Rare but Fierce Presentation of Pneumococcal Sepsis. Eur J Case Rep Intern Med 2019; 7:001373. [PMID: 32015972 PMCID: PMC6993916 DOI: 10.12890/2019_001373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 11/29/2019] [Indexed: 11/30/2022] Open
Abstract
Infectious purpura fulminans (PF) is a rare presentation of disseminated intravascular coagulopathy (DIC) due to diffuse intravascular thrombosis and haemorrhagic infarction of the skin. PF can present in infancy/childhood or adulthood and usually presents as ecchymotic skin lesions, fever and hypotension. It is most commonly a consequence of sepsis related to Neisseria meningitidis, Streptococcus pneumoniae or Haemophilus influenzae. Despite aggressive management of sepsis with intravenous fluids, antibiotics, and conventional and nonconventional therapies, the condition still carries a mortality rate of 43%[1]. Streptococcus pneumoniae mostly presents with community-acquired pneumonia. We present a case of PF secondary to DIC related to Pneumococcal sepsis in an otherwise healthy and immunocompetent patient.
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Affiliation(s)
- Adeel Nasrullah
- Department of Internal Medicine, Allegheny Health Network; Pittsburgh, USA
| | - Anam Javed
- Department of Internal Medicine, University College of Medicine and Dentistry, Lahore, Pakistan
| | - Usman Tariq
- Department of Internal Medicine, Allegheny Health Network; Pittsburgh, USA
| | - Meilin Young
- Departement of Pulmonology and Critical care, Allegheny Health Network, Pittsburgh, USA
| | - Zunera Moeen
- Department of Internal Medicine, Texas Tech Permian Basin, Odessa, USA
| | - Marvin Balaan
- Departement of Pulmonology and Critical care, Allegheny Health Network, Pittsburgh, USA
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47
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Holland JR, Ciener DA. A Baby With Bruises. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2019. [DOI: 10.1016/j.cpem.2019.100729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Aungraheeta R, FitzGibbon L, Reilly-Stitt C, Mumford AD. Differential effects of direct factor IIa and factor Xa inhibitors in protein C-deficient plasma detected using thrombin generation and viscoelastometry assays. Int J Lab Hematol 2019; 42:126-133. [PMID: 31756037 DOI: 10.1111/ijlh.13126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 10/27/2019] [Accepted: 10/28/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Protein C (PC) deficiency results in dysregulated thrombin generation and increases thrombosis risk. METHODS In order to investigate the potential effects of anticoagulant drugs in PC deficiency, we evaluated the pharmacodynamic effect of selective direct factor (F) IIa inhibitors (dabigatran and argatroban), selective direct FXa inhibitors (rivaroxaban and apixaban) and an indirect FXa/FIIa inhibitor (enoxaparin) in commercial PC-deficient plasma using thrombin generation and viscoelastometry assays modified to reflect PC anticoagulant activity. RESULTS Endogenous thrombin potential (ETP) and peak thrombin concentration (PTC) were increased in PC-deficient plasma but this corrected completely with PC concentrate. Inhibition of FIIa and FXa with the selective inhibitors also corrected the increased ETP and PTC but required high drug concentrations. There was sustained low-level thrombin generation in PC-deficient plasma with FXa inhibitors but not with FIIa inhibitors. Adding PC concentrate to PC-deficient plasma anticoagulated with dabigatran had little additional effect on ETP or PTC. In contrast, addition of even small quantities of PC concentrate to PC-deficient plasma anticoagulated with rivaroxaban further diminished ETP, primarily by abolishing sustained thrombin generation. In the viscoelastometry assay, the coagulation time was shortened and α-angle increased in PC-deficient plasma. These abnormalities reversed with both dabigatran and rivaroxaban. CONCLUSION The selective direct FXa and FIIa inhibitors at high concentrations both counteracted the abnormal thrombin generation and clot formation observed in PC-deficient plasma, but with qualitative differences in their effects.
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Affiliation(s)
- Riyaad Aungraheeta
- School of Cellular and Molecular Medicine, Faculty of Life Sciences, University of Bristol, Bristol, UK
| | - Lucy FitzGibbon
- Department of Haematology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | - Andrew D Mumford
- School of Cellular and Molecular Medicine, Faculty of Life Sciences, University of Bristol, Bristol, UK.,Department of Haematology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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The authors reply. Crit Care Med 2019; 47:e1040. [PMID: 31738266 DOI: 10.1097/ccm.0000000000004063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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50
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Abstract
Hemorrhagic rashes are observed in a wide variety of conditions, ranging from harmless to life-threatening. This review offers a stepwise approach, which helps limit the possible differential diagnoses based on the clinical manifestations and the clinical picture. The most common and most important conditions, including infectious, coagulation and embolic disorders, vasculitides, and vasculopathies, are briefly reviewed focusing on morphology. Dermatologists often need to distinguish among infectious, reactive, or autoimmune etiologies of the rash and determine if the condition is dangerous or even life-threatening in order to make the right decision. Dermatologic expertise provides vital input in the diagnosis and care of complex interdisciplinary patients, such as those with sepsis, purpura fulminans, and thrombotic thrombocytopenic purpura.
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