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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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2
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Pérez-Acevedo G, Bosch-Alcaraz A, Torra-Bou JE. Efficacy and safety of a hyperoxygenated fatty acid compound in improving the microcirculation of purpura fulminans in paediatric patients with sepsis: a pilot study. ENFERMERIA INTENSIVA 2024; 35:13-22. [PMID: 37527957 DOI: 10.1016/j.enfie.2023.07.003] [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: 02/07/2023] [Revised: 03/13/2023] [Accepted: 04/10/2023] [Indexed: 08/03/2023]
Abstract
INTRODUCTION Purpura fulminans (PF) is a serious complication of sepsis resulting from a set of alterations characterised by the development of ecchymotic haemorrhagic lesions and skin necrosis. AIM To analyse the efficacy and safety of the topical application of HOFA compound, in the cutaneous microcirculation of PF lesions in paediatric patients affected by sepsis. MATERIAL AND METHODS A prospective quasi-experimental pre-test/post-test single-group conducted in a Paediatric Intensive Care Unit of a third level hospital was performed. Paediatric patients aged 0-18 years with sepsis were included. Somatic oximetry values were measured before and after application of HOFAs every 4h over the first three days of the patients' hospitalisation. Patient's socio-demographic and clinical variables and somatic oximetry by placing a sensor for measuring tissue perfusion on the area with PF were determined. RESULTS Four patients were recruited, with a median age of 98 months. The purpuric lesions measured were mainly located on both feet and hands and, in two patients, also on the lateral malleoli and calves of both lower extremities. A total of 225 measurements were obtained, with mean pre-intervention scores of 71.17±15.65% versus 73.68±14.83% post-intervention. Statistical significance (p<0.001) was observed upon comparison of the pre- and post-intervention measurements. CONCLUSIONS Early and continued application of HOFAs in the management of sepsis-induced PF is an effective and safe practice in the cases analysed. In more than half of the episodes analysed, an increase in tissue microcirculation was observed after the application of HOFAs, with no adverse events.
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Affiliation(s)
- G Pérez-Acevedo
- Unidad de Cuidados Intensivos Pediátricos, Sant Joan de Déu Hospital, Esplugues de Llobregat, Barcelona, Spain
| | - A Bosch-Alcaraz
- Departamento de Enfermería de Salud Pública, Salud Mental y Maternoinfantil, Escuela de Enfermería, Facultad de Medicina y Ciencias de la Salud, Universidad de Barcelona, Spain.
| | - J E Torra-Bou
- Facultat Infermeria i Fisioteràpia, Universitat de Lleida, TR2Lab Research Group, Universitat de Vic-Universitat Central de Catalunya, Vic, Barcelona, Spain
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3
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A Rare Cause of a Rare Disorder: E. coli-Induced Purpura Fulminans Secondary to Urinary Tract Infection. Case Rep Crit Care 2022; 2022:9291424. [PMID: 35433054 PMCID: PMC9007638 DOI: 10.1155/2022/9291424] [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: 12/05/2021] [Revised: 02/27/2022] [Accepted: 03/07/2022] [Indexed: 11/17/2022] Open
Abstract
Purpura fulminans is a devastating thrombotic disorder infrequently encountered in medical practice and amongst the medical literature. It is a hematologic emergency in which prompt recognition and initiation of treatment are critical to mitigate its significant morbidity and mortality. Surgical evaluation is commonly required, since the debilitating skin and soft tissue necrosis often degenerate into necrotizing fasciitis, critical limb ischemia, warranting surgical interventions in either a staged or single-step approach. Purpura fulminans can be neonatal, infectious, or idiopathic. Infection-induced purpura fulminans is less common, and only a few microorganisms have been associated with this condition: Meningococcus spp., Pneumococcus spp., or Staphylococcus spp. This report presents a rare case of Escherichia coli-induced purpura fulminans. Apart from the unfortunate partial amputation of all left-hand five digits, our patient made a full recovery following effective infectious source control, supportive care with volume resuscitation, anticoagulation, and wound care.
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4
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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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5
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Bendapudi PK, Whalen MJ, Lahoud-Rahme M, Villalba JA. Case 7-2021: A 19-Year-Old Man with Shock, Multiple Organ Failure, and Rash. N Engl J Med 2021; 384:953-963. [PMID: 33704941 DOI: 10.1056/nejmcpc2027093] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Pavan K Bendapudi
- From the Departments of Medicine (P.K.B.), Pediatrics (M.J.W., M.L.-R.), and Pathology (J.A.V.), Massachusetts General Hospital, and the Departments of Medicine (P.K.B.), Pediatrics (M.J.W., M.L.-R.), and Pathology (J.A.V.), Harvard Medical School - both in Boston
| | - Michael J Whalen
- From the Departments of Medicine (P.K.B.), Pediatrics (M.J.W., M.L.-R.), and Pathology (J.A.V.), Massachusetts General Hospital, and the Departments of Medicine (P.K.B.), Pediatrics (M.J.W., M.L.-R.), and Pathology (J.A.V.), Harvard Medical School - both in Boston
| | - Manuella Lahoud-Rahme
- From the Departments of Medicine (P.K.B.), Pediatrics (M.J.W., M.L.-R.), and Pathology (J.A.V.), Massachusetts General Hospital, and the Departments of Medicine (P.K.B.), Pediatrics (M.J.W., M.L.-R.), and Pathology (J.A.V.), Harvard Medical School - both in Boston
| | - Julian A Villalba
- From the Departments of Medicine (P.K.B.), Pediatrics (M.J.W., M.L.-R.), and Pathology (J.A.V.), Massachusetts General Hospital, and the Departments of Medicine (P.K.B.), Pediatrics (M.J.W., M.L.-R.), and Pathology (J.A.V.), Harvard Medical School - both in Boston
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6
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Eliwan H, Omer M, McKenna E, Kelly LA, Nolan B, Regan I, Molloy EJ. Protein C Pathway in Paediatric and Neonatal Sepsis. Front Pediatr 2021; 9:562495. [PMID: 35186813 PMCID: PMC8849213 DOI: 10.3389/fped.2021.562495] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 12/20/2021] [Indexed: 11/24/2022] Open
Abstract
Protein C plays a major role in the physiological regulation of coagulation pathways through inactivation of factor Va, factor VIIIa, and plasminogen activator inhibitor. Protein C is involved in the control of inflammation during sepsis, by inhibiting release of pro-inflammatory cytokines, thereby controlling neutrophil, and monocyte effects on injured tissue. Recombinant human activated protein C (rhAPC) reduced mortality in adult sepsis in earlier studies but had no significant benefit in more recent trials. Protein C levels are reduced during paediatric and neonatal sepsis, which may play a major role in the development of disseminated intravascular thrombosis, purpura fulminans, and multiorgan dysfunction. The role of protein C in paediatric sepsis requires further clinical and immunological evaluation to define the patient subgroups who may benefit from this therapy. Newer versions of rhAPC are under development with less risk of haemorrhage potentially broadening the scope of this intervention.
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Affiliation(s)
- Hassan Eliwan
- National Children's Research Centre, Dublin, Ireland.,Department of Paediatrics, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
| | - Murwan Omer
- Department of Paediatrics, Children's Health Ireland at Tallaght, Dublin, Ireland
| | - Ellen McKenna
- Department of Paediatrics, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
| | - Lynne A Kelly
- National Children's Research Centre, Dublin, Ireland.,Department of Paediatrics, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland.,Trinity Research in Childhood Centre, Dublin, Ireland
| | - Beatrice Nolan
- Department of Haematology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Irene Regan
- National Children's Research Centre, Dublin, Ireland.,Department of Haematology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Eleanor J Molloy
- National Children's Research Centre, Dublin, Ireland.,Department of Paediatrics, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland.,Department of Paediatrics, Children's Health Ireland at Tallaght, Dublin, Ireland.,Trinity Research in Childhood Centre, Dublin, Ireland.,Department of Neonatology, Children's Health Ireland at Crumlin, Dublin, Ireland.,Department of Paediatrics, Coombe Women's and Infant's University Hospital, Dublin, Ireland
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7
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Persistence of endothelial thrombomodulin in a patient with infectious purpura fulminans treated with protein C concentrate. Blood Adv 2019; 2:2917-2921. [PMID: 30396911 DOI: 10.1182/bloodadvances.2018024430] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 10/11/2018] [Indexed: 12/26/2022] Open
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8
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Hensch LA, Hui SKR, Teruya J. Coagulation and Bleeding Management in Pediatric Extracorporeal Membrane Oxygenation: Clinical Scenarios and Review. Front Med (Lausanne) 2019; 5:361. [PMID: 30693282 PMCID: PMC6340094 DOI: 10.3389/fmed.2018.00361] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 12/17/2018] [Indexed: 12/23/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-saving procedure that requires careful coagulation management. Indications for ECMO continue to expand, leading to more complicated patients treated by ECMO teams. At our pediatric institution, we utilize a Coagulation Team to guide anticoagulation, transfusion and hemostasis management in an effort to avoid the all-to-common complications of bleeding and thrombosis. This team formulates a coagulation plan in conjunction with a multidisciplinary ECMO team after careful review of all available laboratory data as well as the patient's clinical status. Here, we present our general strategies for ECMO management in various clinical scenarios and a review of the literature pertaining to coagulation management in the pediatric ECMO setting.
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Affiliation(s)
- Lisa A Hensch
- Division of Transfusion Medicine & Coagulation, Texas Children's Hospital, Houston, TX, United States.,Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, United States
| | - Shiu-Ki Rocky Hui
- Division of Transfusion Medicine & Coagulation, Texas Children's Hospital, Houston, TX, United States.,Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, United States
| | - Jun Teruya
- Division of Transfusion Medicine & Coagulation, Texas Children's Hospital, Houston, TX, United States.,Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, United States
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9
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Lécuyer H, Virion Z, Barnier JP, Matczak S, Bourdoulous S, Bianchini E, Saller F, Borgel D, Nassif X, Coureuil M. An ADAM-10 dependent EPCR shedding links meningococcal interaction with endothelial cells to purpura fulminans. PLoS Pathog 2018; 14:e1006981. [PMID: 29630665 PMCID: PMC5908201 DOI: 10.1371/journal.ppat.1006981] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 04/19/2018] [Accepted: 03/20/2018] [Indexed: 01/03/2023] Open
Abstract
Purpura fulminans is a deadly complication of Neisseria meningitidis infections due to extensive thrombosis of microvessels. Although a Disseminated Intra-vascular Coagulation syndrome (DIC) is frequently observed during Gram negative sepsis, it is rarely associated with extensive thrombosis like those observed during meningococcemia, suggesting that the meningococcus induces a specific dysregulation of coagulation. Another specific feature of N. meningitidis pathogenesis is its ability to colonize microvessels endothelial cells via type IV pili. Importantly, endothelial cells are key in controlling the coagulation cascade through the activation of the potent anticoagulant Protein C (PC) thanks to two endothelial cell receptors among which the Endothelial Protein C Receptor (EPCR). Considering that congenital or acquired deficiencies of PC are associated with purpura fulminans, we hypothesized that a defect in the activation of PC following meningococcal adhesion to microvessels is responsible for the thrombotic events observed during meningococcemia. Here we showed that the adhesion of N. meningitidis on endothelial cells results in a rapid and intense decrease of EPCR expression by inducing its cleavage in a process know as shedding. Using siRNA experiments and CRISPR/Cas9 genome edition we identified ADAM10 (A Disintegrin And Metalloproteinase-10) as the protease responsible for this shedding. Surprisingly, ADAM17, the only EPCR sheddase described so far, was not involved in this process. Finally, we showed that this ADAM10-mediated shedding of EPCR induced by the meningococcal interaction with endothelial cells was responsible for an impaired activation of Protein C. This work unveils for the first time a direct link between meningococcal adhesion to endothelial cells and a severe dysregulation of coagulation, and potentially identifies new therapeutic targets for meningococcal purpura fulminans. Neisseria meningitidis (meningococcus) is responsible for a severe syndrome called purpura fulminans in which the coagulation system is totally dysregulated, leading to an extensive occlusion of blood microvessels. The pathogenesis of this syndrome is still not understood. Here we show that the meningococcus, when adhering on the apical surface of endothelial cells, induces the activation of membranous protease named ADAM-10, which in turn hydrolyses a cellular receptor called EPCR. The latter is key for the activation of a circulating potent anticoagulant, the Protein C (PC). PC activation is then impaired following meningococcal adhesion on endothelial cells. This work unveils for the first time a specific dysregulation of coagulation induced by the meningococcus and potentially identifies new therapeutic targets for meningococcal purpura fulminans.
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Affiliation(s)
- Hervé Lécuyer
- Institut Necker Enfants Malades, INSERM U1151, CNRS UMR8253, Paris, France
- Université Paris Descartes, Paris, France
- Assistance Publique–Hôpitaux de Paris, Hôpital Universitaire Necker Enfants Malades, Service de Microbiologie Clinique, Paris, France
- * E-mail:
| | - Zoé Virion
- Institut Necker Enfants Malades, INSERM U1151, CNRS UMR8253, Paris, France
- Université Paris Descartes, Paris, France
| | - Jean-Philippe Barnier
- Institut Necker Enfants Malades, INSERM U1151, CNRS UMR8253, Paris, France
- Université Paris Descartes, Paris, France
- Assistance Publique–Hôpitaux de Paris, Hôpital Universitaire Necker Enfants Malades, Service de Microbiologie Clinique, Paris, France
| | - Soraya Matczak
- Institut Necker Enfants Malades, INSERM U1151, CNRS UMR8253, Paris, France
- Université Paris Descartes, Paris, France
| | - Sandrine Bourdoulous
- Université Paris Descartes, Paris, France
- Institut Cochin, INSERM U1016, CNRS UMR8104, Paris, France
| | - Elsa Bianchini
- INSERM UMR-S1176, Université Paris-Sud, Université Paris Saclay, Le Kremlin-Bicêtre, France
| | - François Saller
- INSERM UMR-S1176, Université Paris-Sud, Université Paris Saclay, Le Kremlin-Bicêtre, France
| | - Delphine Borgel
- INSERM UMR-S1176, Université Paris-Sud, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique–Hôpitaux de Paris, Hôpital Universitaire Necker Enfants Malades, Service d’Hématologie Biologique, Paris, France
| | - Xavier Nassif
- Institut Necker Enfants Malades, INSERM U1151, CNRS UMR8253, Paris, France
- Université Paris Descartes, Paris, France
- Assistance Publique–Hôpitaux de Paris, Hôpital Universitaire Necker Enfants Malades, Service de Microbiologie Clinique, Paris, France
| | - Mathieu Coureuil
- Institut Necker Enfants Malades, INSERM U1151, CNRS UMR8253, Paris, France
- Université Paris Descartes, Paris, France
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10
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Hematologic Manifestations of Childhood Illness. Hematology 2018. [DOI: 10.1016/b978-0-323-35762-3.00152-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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11
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Colling ME, Bendapudi PK. Purpura Fulminans: Mechanism and Management of Dysregulated Hemostasis. Transfus Med Rev 2017; 32:69-76. [PMID: 29157918 DOI: 10.1016/j.tmrv.2017.10.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 08/21/2017] [Accepted: 10/13/2017] [Indexed: 01/30/2023]
Abstract
Purpura fulminans (PF) is a highly thrombotic subtype of disseminated intravascular coagulation that can accompany severe bacterial, and more rarely, viral infections. PF is associated with an extremely high mortality rate, and patients often die of overwhelming multisystemic thrombosis rather than septic shock. Survivors typically experience amputation of involved extremities and significant scarring in affected areas. Despite the devastating clinical course associated with this hemostatic complication of infection, the mechanism of PF remains poorly understood. Severe acquired deficiency of protein C and dysfunction of the protein C-thrombomodulin pathway as well as other systems that exert a negative regulatory effect on coagulation have been implicated. Management of PF involves treatment of the underlying infection, aggressive anticoagulation, and robust transfusion support aimed at correcting acquired deficiencies in natural anticoagulant proteins. In this review, we address the diagnosis and management of PF with a focus on a rational approach to this condition informed by the available data. Proposed mechanisms underlying the dysregulation of coagulation seen in PF are also covered, and implications for therapy are discussed.
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Affiliation(s)
- Meaghan E Colling
- Department of Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Pavan K Bendapudi
- Harvard Medical School, Boston, MA; Division of Hematology, Massachusetts General Hospital, Boston, MA; Blood Transfusion Service, Massachusetts General Hospital, Boston, MA.
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12
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Rudloff I, Cho SX, Bui CB, McLean C, Veldman A, Berger PJ, Nold MF, Nold‐Petry CA. Refining anti-inflammatory therapy strategies for bronchopulmonary dysplasia. J Cell Mol Med 2017; 21:1128-1138. [PMID: 27957795 PMCID: PMC5431131 DOI: 10.1111/jcmm.13044] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 10/24/2016] [Indexed: 12/20/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD) is a severe lung disease of preterm infants, which is characterized by fewer, enlarged alveoli and increased inflammation. BPD has grave consequences for affected infants, but no effective and safe therapy exists. We previously showed that prophylactic treatment with interleukin-1 receptor antagonist (IL-1Ra) prevents murine BPD induced by perinatal inflammation and hyperoxia. Here, we used the same BPD model to assess whether an alternative anti-inflammatory agent, protein C (PC), is as effective as IL-1Ra against BPD. We also tested whether delayed administration or a higher dose of IL-1Ra affects its ability to ameliorate BPD and investigated aspects of drug safety. Pups were reared in room air (21% O2 ) or hyperoxia (65% or 85% O2 ) and received daily injections with vehicle, 1200 IU/kg PC, 10 mg/kg IL-1Ra (early or late onset) or 100 mg/kg IL-1Ra. After 3 or 28 days, lung and brain histology were assessed and pulmonary cytokines were analysed using ELISA and cytokine arrays. We found that PC only moderately reduced the severe impact of BPD on lung structure (e.g. 18% increased alveolar number by PC versus 34% by IL-1Ra); however, PC significantly reduced IL-1β, IL-1Ra, IL-6 and macrophage inflammatory protein (MIP)-2 by up to 89%. IL-1Ra at 10 mg/kg prevented BPD more effectively than 100 mg/kg IL-1Ra, but only if treatment commenced at day 1 of life. We conclude that prophylactic low-dose IL-1Ra and PC ameliorate BPD and have potential as the first remedy for one of the most devastating diseases preterm babies face.
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Affiliation(s)
- Ina Rudloff
- Ritchie CentreHudson Institute of Medical ResearchMelbourneVictoriaAustralia
- Department of PaediatricsMonash UniversityMelbourneVictoriaAustralia
| | - Steven X. Cho
- Ritchie CentreHudson Institute of Medical ResearchMelbourneVictoriaAustralia
- Department of PaediatricsMonash UniversityMelbourneVictoriaAustralia
| | - Christine B. Bui
- Ritchie CentreHudson Institute of Medical ResearchMelbourneVictoriaAustralia
- Department of PaediatricsMonash UniversityMelbourneVictoriaAustralia
| | - Catriona McLean
- Department of Anatomical PathologyAlfred HospitalMelbourneVictoriaAustralia
- Central Clinical SchoolMonash UniversityMelbourneVictoriaAustralia
| | - Alex Veldman
- Ritchie CentreHudson Institute of Medical ResearchMelbourneVictoriaAustralia
| | - Philip J. Berger
- Ritchie CentreHudson Institute of Medical ResearchMelbourneVictoriaAustralia
- Department of PaediatricsMonash UniversityMelbourneVictoriaAustralia
| | - Marcel F. Nold
- Ritchie CentreHudson Institute of Medical ResearchMelbourneVictoriaAustralia
- Department of PaediatricsMonash UniversityMelbourneVictoriaAustralia
| | - Claudia A. Nold‐Petry
- Ritchie CentreHudson Institute of Medical ResearchMelbourneVictoriaAustralia
- Department of PaediatricsMonash UniversityMelbourneVictoriaAustralia
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13
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New HV, Berryman J, Bolton-Maggs PHB, Cantwell C, Chalmers EA, Davies T, Gottstein R, Kelleher A, Kumar S, Morley SL, Stanworth SJ. Guidelines on transfusion for fetuses, neonates and older children. Br J Haematol 2016; 175:784-828. [DOI: 10.1111/bjh.14233] [Citation(s) in RCA: 173] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Helen V. New
- NHS Blood and Transplant; London UK
- Imperial College Healthcare NHS Trust; London UK
| | | | | | | | | | | | - Ruth Gottstein
- St. Mary's Hospital; Manchester/University of Manchester; Manchester UK
| | | | - Sailesh Kumar
- Mater Research Institute; University of Queensland; Brisbane Australia
| | - Sarah L. Morley
- Addenbrookes Hospital/NHS Blood and Transplant; Cambridge UK
| | - Simon J. Stanworth
- Oxford University Hospitals NHS Trust/NHS Blood and Transplant; Oxford UK
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14
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Fruchtman Y, Strauss T, Rubinstein M, Ben Harush M, Revel-Vilk S, Kapelushmik J, Paret G, Kenet G. Skin Necrosis and Purpura Fulminans in Children With and Without Thrombophilia--A Tertiary Center's Experience. Pediatr Hematol Oncol 2016; 32:505-10. [PMID: 26436558 DOI: 10.3109/08880018.2015.1068896] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Purpura fulminans (PF) is a very rare clinicopathologic skin disorder comprising dermal microvascular thrombosis associated with perivascular hemorrhage of multiple origins. It may occur as the presenting symptom of severe congenital deficiency of protein C (PC) or protein S (PS) during the newborn period, or later in life following oral anticoagulant therapy with vitamin K antagonists, or of sepsis that may be associated with disseminated intravascular coagulation. Treatment consists of anticoagulants and PC concentrates during acute episodes. We report our experience in the diagnosis and management of pediatric PF. The medical records of the 6 children aged 2-16 years (median: 5 years) who presented with PF to our tertiary care center between 1996 and 2013 were studied. The thrombophilia workup revealed either the presence of congenital homozygous PC deficiency, prothrombotic polymorphisms (factor V Leiden and FIIG20210A heterozygosity), acquired PC/PS deficiency, or no discernible thrombophilia. The skin necrosis resolved following conservative fresh-frozen plasma/anticoagulant therapy in 2 cases, whereas 3 children required interventional plastic surgery. The sixth case, a 10-year-old child with severe PC deficiency, heterozygous factor V Leiden, and FIIG20210A, received recombinant activated PC. PF in childhood is rare and has multiple etiologies. Understanding of the variable pathogenesis and risk factors will facilitate diagnosis and appropriate clinical management.
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Affiliation(s)
- Yariv Fruchtman
- a Department of Pediatric Emergency Care and Pediatric Hematology Unit , Soroka Medical Center , Beer-Sheba , Israel , affiliated to the Ben Gurion University of the Negev , Beer Sheva , Israel.,b Thrombosis Unit, National Hemophilia Center , Safra Children's Hospital, Sheba Medical Center , Tel Hashomer, Israel
| | - Tzipora Strauss
- b Thrombosis Unit, National Hemophilia Center , Safra Children's Hospital, Sheba Medical Center , Tel Hashomer, Israel.,c Department of Neonatology , Safra Children's Hospital, Sheba Medical Center , Tel Hashomer, Israel
| | - Marina Rubinstein
- d Department of Critical Care, Safra Children's Hospital , Sheba Medical Center , Tel Hashomer , Israel , affiliated to the Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Miriam Ben Harush
- a Department of Pediatric Emergency Care and Pediatric Hematology Unit , Soroka Medical Center , Beer-Sheba , Israel , affiliated to the Ben Gurion University of the Negev , Beer Sheva , Israel
| | - Shoshana Revel-Vilk
- e Department of Pediatric Hematology/Oncology , Hadassah Hebrew University Medical Center , Jerusalem , Jerusalem , Israel
| | - Joseph Kapelushmik
- a Department of Pediatric Emergency Care and Pediatric Hematology Unit , Soroka Medical Center , Beer-Sheba , Israel , affiliated to the Ben Gurion University of the Negev , Beer Sheva , Israel
| | - Gideon Paret
- d Department of Critical Care, Safra Children's Hospital , Sheba Medical Center , Tel Hashomer , Israel , affiliated to the Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Gili Kenet
- b Thrombosis Unit, National Hemophilia Center , Safra Children's Hospital, Sheba Medical Center , Tel Hashomer, Israel
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15
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Abstract
BACKGROUND Previously, we found that plasma protein C (PC) activity ≤10% significantly increased the probability of the occurrence of death during neonatal sepsis. Accordingly, if the activity of plasma PC declined during the course of sepsis to ≤10%, we administered a nonactivated PC zymogen to increase a PC activity. The aim of that retrospective analysis was to explore treatment effects of PC zymogen supplementation in septic infants, with plasma PC activity ≤10%. METHODS A database was used to locate 85 newborns treated with PC from among 458 analyzed infants with confirmed sepsis. RESULTS The median birth weight and gestational age of treated infants were, respectively, 1010.0 g and 29 weeks. In 47 infants, early-onset sepsis developed, whereas in 38 neonates, late-onset sepsis was recognized. PC was given as a single dose of 200 IU/kg. Among 458 septic patients, death occurred in 19 newborns (4.2%), exclusively in infants with plasma PC activity ≤10%. In 15 infants, death occurred in the course of early-onset sepsis and 4 newborns died of late-onset sepsis (early-onset sepsis vs. late-onset sepsis; P = 0.036; χ with the Yates correction). CONCLUSIONS An increased risk of death in septic neonates with plasma PC activity ≤10% suggests the necessity for its evaluation and possibility of supplementation of PC zymogen.
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16
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Fatal purpura fulminans and Waterhouse-Friderichsen syndrome from fulminant Streptococcus pneumoniae sepsis in an asplenic young adult. IDCases 2016; 6:1-4. [PMID: 27583208 PMCID: PMC4995527 DOI: 10.1016/j.idcr.2016.08.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 08/10/2016] [Accepted: 08/10/2016] [Indexed: 11/23/2022] Open
Abstract
Asplenic patients are at increased risk for sepsis and fulminant infection. Sepsis in these patients is typically secondary to encapsulated bacteria, with Streptococcus pneumoniae being the most frequent pathogen. Rare complications of severe sepsis include purpura fulminans and bilateral adrenal hemorrhage (Waterhouse-Friderichsen syndrome). We present the case of a 36-year-old woman, healthy except for splenectomy years prior for idiopathic thrombocytopenic purpura treatment, who presented with fever. Upon presentation to our hospital, three hours after symptoms onset, she had purpura fulminans and shock. Despite timely antimicrobials and maximal resuscitative efforts, her disease progressed and she expired 12 hours after symptoms onset. Autopsy revealed bilateral adrenal hemorrhage; acute adrenal crisis likely contributed to her refractory shock. Prior to her presentation, she had not received guideline-based post-splenectomy care. Sepsis in asplenic patients can be fulminant and rapidly fatal. Streptococcus pneumoniae remains the most frequent cause, despite decreasing rates in recent years related to widespread pneumococcal vaccination. Guideline-based vaccinations and "pill-in-pocket" therapy can be life-saving for asplenic patients. Purpura fulminans represents an extreme manifestation of disseminated intravascular coagulation, is more common in asplenic patients, and portends a poor prognosis. Waterhouse-Friderichsen syndrome can be seen concurrently with purpura fulminans and further portends a poor prognosis; pre-mortem diagnosis requires a high index of suspicion.
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17
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Perillo T, Muggeo P, Arcamone G, Leonardis FD, Santoro N. Non Activated Protein C Supplementation in Septic Pediatric Hematological Patients. Pediatr Rep 2016; 8:6488. [PMID: 27433305 PMCID: PMC4933811 DOI: 10.4081/pr.2016.6488] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Revised: 04/17/2016] [Accepted: 05/23/2016] [Indexed: 12/29/2022] Open
Abstract
The purpose of the study was to examine safety and efficacy of non-activated Protein C (PC) supplementation in our cohort of septic pediatric hematological patients. We conducted a retrospective study of 22 septic patients receiving human plasma-derived PC concentrate from 2008 to 2015 at our Pediatric Oncology Center (Bari, Italy). The Surviving sepsis campaign definitions for sepsis, severe sepsis and septic shock were used to define the patients' septic status. For each patient, we calculated Lansky performance status scale (LPSS) and a risk score defined the Hematologic risk score (HRS) that we created in 2007. Patients were defined as High risk for severe sepsis/septic shock in case of HRS>3. HRS<3 identified low risk patients. Baseline serum PC levels, PC administration dosage and duration and days until a 20% improvement in LPSS. Observed baseline serum PC levels (bPC) blood concentrations ranged from 31 to 80%. Patients received PC supplementation in case of low age-related bPC levels or >10% PC concentration decrease within 12 hours from the first evaluation. All patients received 80 U/kg/day PC, intravenously, every twenty-four hours. No drug-related adverse event was observed. The observed sepsis-related mortality rate in our cohort was 9%. PC supplementation in our cohort appeared to be safe, and, probably due to prompt PC administration, we observed an overall mortality that was much lower than expected mortality in cancer severe septic patients.
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Affiliation(s)
- Teresa Perillo
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, University of Bari , Italy
| | - Paola Muggeo
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, University of Bari , Italy
| | - Giampaolo Arcamone
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, University of Bari , Italy
| | - Francesco De Leonardis
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, University of Bari , Italy
| | - Nicola Santoro
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, University of Bari , Italy
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18
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Kurnik K, Bidlingmaier C, Hütker S, Olivieri M. [Haemostatic disorders in children]. Hamostaseologie 2016; 36:109-25. [PMID: 26988657 DOI: 10.5482/hamo-15-04-0016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 03/04/2016] [Indexed: 12/28/2022] Open
Abstract
Haemorrhagic and thrombotic events occur in both children and adults. The underlying causes are congenital or acquired disorders. In contrast to haemorrhagic disorders, inherited thrombotic disorders nearly exclusively in association with additional external risk factors lead to thrombotic events predominantly during the newborn period and adolescence. It is necessary to be aware of age-specific properties of coagulation in order to correctly interpret clinical and laboratory findings and to provide optimal care for children with haemorrhagic and thrombotic complications.
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Affiliation(s)
- Karin Kurnik
- Priv.-Doz. Dr. med. Karin Kurnik, Kinderklinik im Dr. von Haunerschen Kinderspital Klinikum der Universität München, Lindwurmstr. 4, 80337 München,
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19
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Pallua N, Heimann K, Almarzouqi F, Bohr S. Early-onset compartment syndrome of the limbs, a rare complication of meningococcal septicemia in infants? JPRAS Open 2015. [DOI: 10.1016/j.jpra.2015.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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20
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Brunkhorst FM, Patchev V. [Sepsis-associated Purpura Fulminans International Registry--Europe (SAPFIRE)]. Med Klin Intensivmed Notfmed 2014; 109:591-5. [PMID: 25348051 DOI: 10.1007/s00063-014-0402-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 09/16/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Purpura fulminans is a rare life-threatening condition which is characterized by disseminated thrombosis in dermal and systemic microcirculation, cutaneous hemorrhages with progressing necrosis and multiple organ failure. The underlying pathogenesis is based on the disruption of the intrinsic anticoagulation cascade, with protein C deficiency being considered the leading factor in this process. In the majority of cases, the condition emerges as consumptive coagulopathy associated with severe sepsis. OBJECTIVES Epidemiological data on sepsis-associated purpura fulminans (SAPF) are scarce and evidence-based treatment guidelines have not been established yet. While restoration of the balance in the coagulation cascade is a declared therapeutic goal, evaluations of the efficacy of different therapeutic approaches in randomized clinical trials are still lacking. The causal role of individual microbial pathogens also requires comprehensive evaluation. METHODS A prospective multicenter Sepsis-Associated Purpura Fulminans International Registry-Europe (SAPFIRE) will be established in the first quarter of 2015. For the first time, participating centers will systematically collect information on etiology, clinical course, biomarkers, treatment, morbidity, and mortality of SAPF. RESULTS The SAPFIRE data will be periodically evaluated and disseminated. Retrospective analysis of each center's data and regular access to aggregated information collected by other centers will enable the participants to monitor and update care quality standards.
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Affiliation(s)
- F M Brunkhorst
- Center of Sepsis Control and Care (CSCC), Klinik für Anaesthesiologie und Intensivtherapie, Universitätsklinikum Jena, Salvador-Allende-Platz 29, 07747, Jena, Deutschland,
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21
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Martinelli I, Bucciarelli P, Artoni A, Fossali EF, Passamonti SM, Tripodi A, Peyvandi F. Anticoagulant treatment with rivaroxaban in severe protein S deficiency. Pediatrics 2013; 132:e1435-9. [PMID: 24144709 DOI: 10.1542/peds.2013-1156] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
We report a case of a 6-year-old girl with severe protein S deficiency due to a homozygous mutation and recurrent episodes of skin necrosis. She developed purpura fulminans at birth and a catheter-related venous thrombosis complicated by massive pulmonary embolism at the sixth day of life. Long-term oral anticoagulant therapy with a vitamin K-antagonist was started with a therapeutic range of the international normalized ratio of prothrombin time between 2.0 and 3.0. Unfortunately, this common range was not sufficient because recurrent episodes of warfarin-induced skin necrosis developed if the international normalized ratio was <4.0. Vitamin K antagonists decrease plasma level of vitamin K-dependent coagulation proteins, including the natural anticoagulant protein C. In our patient, the hypercoagulable state due to warfarin-induced reduction of protein C, other than severe protein S deficiency, outweighed the anticoagulant efficacy of the inhibition of procoagulant factors II, VII, IX, and X. The switch of anticoagulant therapy from warfarin to rivaroxaban, a direct inhibitor of activated factor X that does not inhibit other vitamin K-dependent proteins, resulted in the disappearance of skin necrosis at 1 year of follow-up. Rivaroxaban may be considered as a valid anticoagulant alternative in patients with severe inherited protein S deficiency and warfarin-induced skin necrosis.
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Affiliation(s)
- Ida Martinelli
- Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via Pace, 9, 20122 Milan, Italy.
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22
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Christiaans SC, Wagener BM, Esmon CT, Pittet JF. Protein C and acute inflammation: a clinical and biological perspective. Am J Physiol Lung Cell Mol Physiol 2013; 305:L455-66. [PMID: 23911436 DOI: 10.1152/ajplung.00093.2013] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
The protein C system plays an active role in modulating severe systemic inflammatory processes such as sepsis, trauma, and acute respiratory distress syndrome (ARDS) via its anticoagulant and anti-inflammatory properties. Plasma levels of activated protein C (aPC) are lower than normal in acute inflammation in humans, except early after severe trauma when high plasma levels of aPC may play a mechanistic role in the development of posttraumatic coagulopathy. Thus, following positive results of preclinical studies, a clinical trial (PROWESS) with high continuous doses of recombinant human aPC given for 4 days demonstrated a survival benefit in patients with severe sepsis. This result was not confirmed by subsequent clinical trials, including the recently published PROWESS-SHOCK trial in patients with septic shock and a phase II trial with patients with nonseptic ARDS. A possible explanation for the major difference in outcome between PROWESS and PROWESS-SHOCK trials is that lung-protective ventilation was used for the patients included in the recent PROWESS-SHOCK, but not in the original PROWESS trial. Since up to 75% of sepsis originates from the lung, aPC treatment may not have added enough to the beneficial effect of lung-protective ventilation to show lower mortality. Thus whether aPC will continue to be used to modulate the acute inflammatory response in humans remains uncertain. Because recombinant human aPC has been withdrawn from the market, a better understanding of the complex interactions between coagulation and inflammation is needed before considering the development of new drugs that modulate both coagulation and acute inflammation in humans.
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Affiliation(s)
- Sarah C Christiaans
- Dept. of Anesthesiology, Univ. of Alabama at Birmingham, 619 S. 19th St., JT926, Birmingham, AL 35249.
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Craciun EM, Altfelder F, Kuss N, Poeschl J, Ruef P. Anti-inflammatory effects of selected drugs on activated neonatal and adult neutrophils. Scandinavian Journal of Clinical and Laboratory Investigation 2013; 73:407-13. [PMID: 23713554 DOI: 10.3109/00365513.2013.796591] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
AIM In view of the central role of granulocytic neutrophils in the context of inflammatory reactions, the present study focuses on anti-inflammatory effects of drugs on activated neutrophils in neonates and adults. METHODS Sixteen blood samples of neonates and adults were investigated in a prospective study. Loss of deformability, morphological changes, and increases in neutrophil elastase were determined as measures of neutrophil activation due to incubation with the pro-inflammatory cytokine interleukin-8. For inhibition experiments, the blood samples were also incubated with the phosphodiesterase inhibitors milrinone and piclamilast, the protease inhibitor urinastatin, ketamine, protein C concentrate, and the nitric oxide donor FK 409. Changes in deformability were investigated with a cell transit analyzer, morphological changes by microscopic observation, and the extent of neutrophil elastase release with an enzyme immunoassay. RESULTS The drugs milrinone, piclamilast, urinastatin, ketamine, protein C concentrate and FK 409 showed deactivating effects on activated neutrophils in recommended clinical doses. They improved deformability as well as reduced pseudopod formation and the release of neutrophil elastase. The effects on neutrophils did not differ between neonates and adults despite their functional differences. CONCLUSION We conclude that these drugs may reduce the inflammatory response and improve microcirculation in neonates and adults during inflammation.
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Affiliation(s)
- Eugenia M Craciun
- Clinic of Neonatology, Department of Pediatrics, University of Heidelberg, Heidelberg, Germany
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Purpura Fulminans following Thermal Injury. Case Rep Emerg Med 2013; 2013:782386. [PMID: 23762660 PMCID: PMC3665217 DOI: 10.1155/2013/782386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 04/19/2013] [Indexed: 11/24/2022] Open
Abstract
Purpura fulminans is a rare syndrome of intravascular thrombosis and hemorrhagic infarction of the skin, which is an unusual cutaneous manifestation of disseminated intravascular coagulation. It often occurs in small children and babies due to infection and/or sepsis, rarely in adults in clinic. We report the first case of deadly purpura fulminans following thermal injury in a 64-year-old Chinese woman. The purpura developed sharply and aggravated multiple organ dysfunction. The patient died of purpura fulminans, disseminated intravascular coagulation, and multiple organ dysfunction syndrome.
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25
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[Purpura fulminans, venous thrombosis and constitutional thrombophilia in an infant]. Arch Pediatr 2013; 20:499-502. [PMID: 23566584 DOI: 10.1016/j.arcped.2013.02.077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2012] [Revised: 11/09/2012] [Accepted: 02/28/2013] [Indexed: 11/22/2022]
Abstract
The association of idiopathic purpura fulminans (PF) and venous thrombosis (VT) seldom reveals constitutional thrombophilia in an infant. We report a case of PF in an 18-month-old infant. Laboratory tests showed disseminated intravascular coagulation (DIVC) with normal rates of C and S proteins and antithrombin. The echo-Doppler examination conveyed venous thrombosis of the lower limbs, while the genetic study showed heterozygous mutation of Factor II (G 20210A). Precocious and multidisciplinary management included frozen fresh plasma supplementation and necrosectomy with skin grafts. The diagnosis and therapeutic problems posed by PF combined with deep venous thrombosis are discussed.
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26
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Circulating nucleosomes and severity of illness in children suffering from meningococcal sepsis treated with protein C. Crit Care Med 2012; 40:3224-9. [DOI: 10.1097/ccm.0b013e318265695f] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Della Valle P, Pavani G, D'Angelo A. The protein C pathway and sepsis. Thromb Res 2011; 129:296-300. [PMID: 22154246 DOI: 10.1016/j.thromres.2011.11.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2011] [Revised: 11/07/2011] [Accepted: 11/08/2011] [Indexed: 10/14/2022]
Abstract
After the discovery of the key components of the protein C (PC) pathway a beneficial effect on survival of the infusion of activated protein C (APC) in animal models of sepsis was demonstrated, leading to the development of recombinant human activated protein C (rh-APC) as a therapeutic agent. It soon became clear that rather than the anticoagulant and profibrinolytic activities of APC, its anti-inflammatory and cytoprotective properties played a major role in the treatment of patients with severe sepsis. Such properties affect the response to inflammation of endothelial cells and leukocytes and are exerted through binding of APC to at least five receptors with intracellular signaling. The main APC protective mechanism involves binding of the Gla-domain to the endothelial protein C receptor (EPCR) and cleavage of protease activated receptor 1 (PAR-1), eliciting suppression of proinflammatory cytokines synthesis and of intracellular proapoptotic pathways and activation of endothelial barrier properties. However, thrombin cleaves PAR-1 with much higher catalytic efficiency, followed by pro-inflammatory, pro-apoptotic and barrier disruptive intracellular signaling, and it is unclear how APC can exert a protective activity through the cleavage of PAR-1 when thrombin is also present in the same environment. Interestingly, in endothelial cell cultures, PAR-1 cleavage by thrombin results in anti-inflammatory and barrier protective signaling provided occupation of EPCR by the PC gla-domain, raising the possibility that the beneficial effects of rh-APC might be recapitulated in vivo by administration of h-PC zymogen to patients with severe sepsis. Recent reports of h-PC infusion in animal models of sepsis support this hypothesis.
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Affiliation(s)
- Patrizia Della Valle
- Coagulation Service & Thrombosis Research Unit, Scientific Institute San Raffaele, Milano, Italy
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29
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Abstract
Neonatal purpura fulminans is a rare, life-threatening condition, caused by congenital or acquired deficiencies of protein C or S. The condition is often fatal unless there is early recognition of the clinical symptoms, prompt diagnosis, and judicious replacement therapy is initiated. The clinical presentation is that of acute disseminated intravascular coagulation and hemorrhagic skin necrosis. The management includes an acute phase of replacement therapy with fresh frozen plasma or protein C concentrate and a maintenance therapy that includes anticoagulation with warfarin or low molecular weight heparin. This review focuses on the management of severe protein C deficiency.
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