Blood-conserving and therapeutic efficacy of intravenous tranexamic acid at different time points after primary total knee arthroplasty with tourniquet application: a randomised controlled trial

BACKGROUND

The use of a tourniquet in combination with tranexamic acid (TXA) not only ensures clear vision, reduces intraoperative blood loss and shortens operative time but also improves cement-bone inter-digitation in total knee arthroplasty (TKA). However, there is no proof whether the blood flow blocking effect of tourniquet affects the antifibrinolytic effect of TXA, and the optimal timing of TXA administration is still unclear. Therefore, this study aims to investigate the effect of the first dose of TXA administered intravenously before tourniquet compression and release in TKA on perioperative blood loss and therapeutic efficacy in patients.

METHODS

In this double-blind trial, 90 patients undergoing primary TKA were randomised into 2 groups: Group A, patients received intravenous TXA 10 min before tourniquet compression (20 mg/kg) and 3, 6 and 24 h later (10 mg/kg), and Group B, patients were treated the same as those in Group A but received intravenous TXA before tourniquet release. The primary outcomes were changes in blood loss, haemoglobin and haematocrit. Secondary outcomes included operation and tourniquet times, blood transfusion rate, subcutaneous petechiae and circumferential changes in the operated limb, visual analogue scale (VAS) score, hospital for special surgery (HSS) score, length of stay (LOS) postoperatively, complications and patient satisfaction.

RESULTS

No statistically significant difference was found between the 2 groups with regard to age, sex, weight, body mass index (BMI), Kellgren-Lawrence class, preoperative blood volume, preoperative laboratory values, operation and tourniquet times, transfusion rate, knee circumference, preoperative HSS, or VAS score (P:n.s.). There was no significant difference in intraoperative blood loss (IBL) (52.7 ml vs. 63.4 ml, P = 0.07), hidden blood loss (HBL) (91.4 ml vs. 119.9, P = 0.4) or total blood loss (TBL) (144.1 ml vs. 183.3 ml, P = 0.72) between Groups A and B. Haemoglobin, haematocrit and red blood cell count (RBC) dropped to a low point on postoperative day 3 and then rebounded, returning to normal levels on day 21, and the trend of change between the 2 groups was not statistically significant (P:n.s.). There was no significant difference in subcutaneous ecchymosis incidence, knee swelling rate, HSS score, VAS score, LOS postoperatively, complication rate or patient satisfaction (P:n.s.).

CONCLUSION

TXA was administered intravenously prior to tourniquet compression could effectively reduce blood loss in patients who had undergone total knee arthroplasty. However, there was no significant difference in knee swelling rate, subcutaneous bruising and petechiae incidence, knee function, complication rate or satisfaction between patients who TXA was given intravenously before tourniquet compression and release in primary TKA.

Response to medical and a novel dietary treatment in newborn screen identified patients with ethylmalonic encephalopathy

Ethylmalonic encephalopathy (EE) is a devastating neurodegenerative disease caused by mutations in the ETHE1 gene critical for hydrogen sulfide (H₂S) detoxification. Patients present in infancy with hypotonia, developmental delay, diarrhea, orthostatic acrocyanosis and petechiae. Biochemical findings include elevated C4, C5 acylcarnitines and lactic and ethylmalonic acid (EMA) in body fluids. Current treatment modalities include metronidazole and N-acetylcysteine (NAC) to lower the production and promote detoxification of toxic H₂S. Patients are typically identified after the onset of clinical symptoms and there is limited information about long term response to treatment. We report the findings of two unrelated patients with EE, identified through newborn screening, who were managed with conventional treatment (NAC, metronidazole alternated with neomycin) and in patient 2, a novel dietary treatment restricting sulfur containing amino acids. Pathogenic mutations were confirmed in the ETHE1 gene (homozygous splice site mutation in patient 1, c.505 + 1G > A; compound heterozygous mutations in patient 2, c.131_132delAG + c.566delG). Both patients were started on metronidazole and NAC by 10 weeks of age and treated for 23 months. Patient 1 did not accept the metabolic formula due to palatability and parental refusal for gastrostomy tube placement. She demonstrated improved biomarkers (EMA, lactic acid and thiosulfate) and an attenuated clinical course. Patient 2 was started on a low methionine and cysteine diet at 8 months of age utilizing SOD Anamix® Early Years, (Nutricia). Baseline EMA levels were (642 mg/g Cr; n = 2) and decreased with medical treatment by 38% to a mean of 399 (n = 4, SD = 71, p 0.0013). With dietary treatment EMA levels were further reduced by 42% to a mean of 233 (n = 8, SD = 52, p 0.0030). Lactic acid, thiosulfates and clinical outcomes were also improved. Our long-term follow-up confirms previous reports of clinical improvement with NAC and metronidazole treatment. Additionally, our studies suggest that a diet restricted in sulfur-containing amino acids results in further improvement in clinical outcomes and biochemical markers.

Primary Sjögren syndrome that initially presented with repeated hypergammaglobulinemic purpura after prolonged sitting: A case report

RATIONALE

Purpura is a common dermatologic manifestation in Sjögren syndrome (SS). When a patient presents with sicca symptoms, the diagnosis of SS is not difficult.

PATIENT CONCERNS

Here, we reported a case of a 52-year-old Chinese woman who initially presented with nonpalpable purpura on both lower extremities, and these lesions had developed soon after prolonged sitting. In the past 2 years, she had repeated cutaneous nonpalpable purpura 4 times. She had no sicca symptoms, dry eyes, or dry mouth.

DIAGNOSES

Combining the laboratory findings, Schirmer test, and labial gland biopsy, primary SS was confirmed.

INTERVENTIONS

The patient was placed on a trial of hydroxychloroquine (200 mg once daily).

OUTCOMES

The purpura on both lower extremities had faded at the sixth day after onset and at the third day after hydroxychloroquine treatment.

LESSONS

These case was not easy to diagnosis primary SS because she had no sicca symptoms. A patient with primary SS who initially presented with recurrent purpura associated with prolonged sitting. Prolonged sitting had been a possible aggravating factor for the cutaneous purpura of this patient with primary SS.

Successful treatment of a patient with ethylmalonic encephalopathy by intravenous N-acetylcysteine

Ethylmalonic encephalopathy (EE) is an autosomal recessive devastating metabolic disorder affecting the brain, gastrointestinal tract, peripheral vessels and rarely the other vascular organs. We report a 10-month-old girl who presented as a meningococcemia clinic but later diagnosed ethylmalonic encephalopathy. Molecular analyses revealed a homozygous c.554 T > G; p. L185R mutation in ETHE1 gene. She was only partially benefited from riboflavine, coenzyme Q10, metronidazole, N-acetylcysteine and symptomatic treatment and discharged from hospital with the sequela of oxygene dependance and developmental delay. We observed N-acetylcysteine 100 mg/kg/day intravenous infusion theraphy may be the most important drug especially in comatous EE patients.

Perifollicular petechiae and easy bruising

This patient was a liver transplant recipient and had a history of malnutrition. One tell-tale sign on the physical exam, however, left no doubt as to the diagnosis.

[Unexpected cutaneous purpura in an infant]

A two-month-old boy visited the hospital due to unexpected cutaneous purpura and thrombocytopenia for 2 days. The physical examination revealed a purple mass on the back. The soft tissue color Doppler ultrasound showed rich blood signals in the tissue, and the results of bone marrow puncture indicated an increased number of megakaryocytes. After the treatment with hormone and gamma globulin, the platelet count rapidly increased and maintained at a normal level. Meanwhile, the boy was given oral administration of propranolol. He was followed up for 4 months and the volume of the mass on the back was reduced significantly. He had a definite diagnosis of hemangioma and immune thrombocytopenia. As for the patients with hemangioma complicated by thrombocytopenia, knowledge of Kasabach-Merritt syndrome should be enhanced and there should be a clarification of the association between thrombocytopenia and hemangioma. There should also be an alertness for thrombocytopenia of other causes.

Prednisone and vardenafil hydrochloride for refractory levamisole-induced vasculitis

Levamisole is an immunomodulatory drug that was previously used to treat various medical conditions, including parasitic infections, nephrotic syndrome, and colorectal cancer. Over the last few years, increasing amounts of levamisole have been used as an adulterant in cocaine. Levamisole-cut cocaine has become a concern because it is known to cause a necrotizing purpuric rash, autoantibody production, and life-threatening leukopenia. Mixed histologic findings of vasculitis and thrombosis are characteristic of levamisole-induced purpura. The recommended management of levamisole-induced vasculitis currently involves withdrawal of the culprit along with supportive treatment. We describe a patient with levamisole-induced vasculitis who continued to develop skin lesions despite self-reported cocaine cessation. Complete resolution of cutaneous disease occurred with the addition of oral prednisone and vardenafil hydrochloride, suggesting the possibility of a new treatment option in patients with refractory disease. In addition, we review the clinical presentation, disease course, diagnostic approach, laboratory findings, histology, and management of levamisole-induced vasculitis. The harmful effects of levamisole-cut cocaine are serious enough that public alerts have been issued to increase awareness. Clinicians should consider the possibility of levamisole exposure in cocaine users presenting with any combination of fever, neutropenia, and necrotic skin lesions, especially in acral areas including the ears.

Topical Human Epidermal Growth Factor in the Treatment of Senile Purpura and the Prevention of Dermatoporosis

BACKGROUND

Senile purpura presents itself as a largely unexplored challenge as it has been long thought of as a benign condition without long-term health sequelae. It is becoming increasingly accepted that skin aging not only results in cosmetic disturbances, but as a functional ones. With modern increases in lifespan, skin atrophy associated with solar damage is presenting as a clinically significant inability to mechanically protect patients. This chronic cutaneous insufficiency/fragility syndrome was recently termed dermatoporosis and senile purpura appears to be a visible marker of early stage dysfunction.

OBJECTIVE

To examine the effects of topically human epidermal growth factor on the clinical presence of senile purpura and its effect on skin thickness as measured via cutaneous ultrasound.

METHODS

Six subjects applied human epidermal growth factor morning and night for six weeks. Clinical outcomes were evaluated by comparing initial clinical photos to 6-week photos and performing a blinded investigator's global assessment (IGA). Skin thickness was evaluated via cutaneous ultrasound measurement.

RESULTS

Ultrasound measurements indicated a mean skin thickening of 195.2 ± 35.7 um (SEM) over 6 weeks. The average number of purpuric lesions decreased from 15 ± 4.6 (SEM) to 2.3 ± 0.7 (SEM) over that same period.

CONCLUSION

Senile purpura presents itself as a cosmetic disturbance posing significant psychological distress and serves as a marker of the severity of skin thinning. In this study, we demonstrate that topical h-EGF diminishes the appearance of senile purpura by thickening skin and may help prevent the development of late stage dermatoporosis.

Calcium Dobesilate (Cd) in Pigmented Purpuric Dermatosis (PPD): A Pilot Evaluation

Pigmented purpuric dermatosis (PPD) is a chronic disorder of unknown etiology. It is quite common, and no therapy is significantly effective. Calcium dobesilate (Cd) has been tried successfully in many vascular disorders. The aim of this study was to evaluate the usefulness and efficacy of Cd in PPD. Nine male patients (7 with Schamberg's and 1 each with lichenoid dermatosis of Gougerot and Blum and lichen aureus) were given Cd 500 mg twice daily for two initial weeks and then 500 mg once daily for a total period of three months. All the patients were followed up for one year after cessation of therapy. The improvement was moderate in 11.11% and mild in 66.67% of cases; 22.22% did not show any improvement. New lesions stopped appearing in two weeks in all patients, and itching also improved in symptomatic cases without any significant side effects. Based upon the results of this pilot study we recommend Cd as the first line therapy for PPD.

Shiitake mushroom-induced flagellate erythema: A striking case and review of the literature

Ingestion of raw or undercooked shiitake mushrooms is associated with a distinctive flagellate erythema. We describe a 61-year-old Caucasian man who presented with a pruritic, erythematous eruption of multiple linear streaks on the trunk and extremities starting 1 day after eating raw shiitake mushrooms. His symptoms and skin lesions resolved with minimal hyperpigmentation within approximately 1 week after treating with topical steroids and oral antihistamines. Skin biopsy showed non-specific findings, including a sparse perivascular and interstitial dermatitis as well as focal vacuolar interface changes. Our case illustrates that this condition is a visibly striking dermatitis with a self-limited course. The pathomechanism of the skin eruption remains unclear.

Clinicopathological features of Churg-Strauss syndrome with severe nerve degeneration: a case report

Churg-Strauss syndrome (CSS) is a rare autoimmune vasculitis of unknown etiology that involves small- and medium-sized blood vessels. Its onset is thought to be associated with adult-onset asthma, and vasculitis typically involves vessels in the lungs. However, due to increased blood and tissue eosinophilia, vasculitis may result in the involvement multiple systems of (neurological, skin, etc.). We report a case of CSS with manifestations that included skin purpura and severe peripheral nerve degeneration in a 56-year-old woman with a recent history of asthma. After the treatment with methylprednisolone and standard immunosuppressive therapy, her rashes resolved, there were no acute asthma attacks, and the numbness in her lower limbs improved.

A randomized, placebo-controlled, double-blind study to evaluate the efficacy of a citrus bioflavanoid blend in the treatment of senile purpura

BACKGROUND

Senile purpura is a common, chronic skin condition affecting more than 10 percent of individuals over the age of 50. Despite being a benign condition, the continual development of purpura lesions in afflicted patients is frequently a source of significant visual and social concern. To date, there are no known effective treatments for this condition.

OBJECTIVES

To evaluate the efficacy of a novel nutraceutical citrus bioflavonoid blend in improving the skin's appearance in patients with senile purpura.

METHODS

A six-week, randomized, multicenter, placebo-controlled, double-blind study was conducted to determine whether a uniquely formulated, oral citrus bioflavonoid supplement could treat active lesions of senile purpura while preventing new lesions from arising. Seventy patients with senile purpura were enrolled and 67 completed the study. Subjects were randomized into two groups receiving either a citrus bioflavonoid blend or placebo medication, which was taken orally twice daily for six weeks. Clinical evaluations were performed by blinded investigators at two locations.

RESULTS

A statistically significant reduction in the number of new purpura lesions in the skin area undergoing clinical study was documented. At the end of six weeks, the citrus bioflavonoid blend treated group showed a 50 percent reduction in purpura lesions from baseline. Patient self-assessment of the effectiveness of the medication echoed the results of an investigator global assessment with a statistically significant improvement in the skin's appearance noted by the patients receiving the active medication. No adverse effects were noted by either the patients or investigators.

CONCLUSION

This new treatment appears to both safely and effectively diminish skin bruising in patients with senile purpura.

[Psychogenic purpura with hematuria and sexual pain disorder: a case report]

Psychogenic purpura (Gardner-Diamond syndrome) is the occurrence and spontaneous recurrence of painful ecchymosis following emotional stress and minor trauma. Although the exact mechanism of this syndrome remains unknown, apart from skin lesions, different types of hemorrhaging have been reported, such as epistaxis, gastrointestinal bleeding, and bleeding from the ear canals and eyes. We report a psychogenic purpura case that presented with hematuria in addition to skin lesions. Based on the psychiatric evaluation she was diagnosed with major depressive disorder, generalized anxiety disorder, and obsessive-compulsive disorder. Additionally, sexual pain disorder accompanied these disorders. With the help of antidepressant and supportive psychotherapy, the patient's ecchymosis and bleeding disappeared. During 8 months of follow-up the symptoms did not return. Vaginismus has not been reported in patients with psychogenic purpura. The presence of vaginismus, which is seen more frequently in eastern cultures and is thought to be related to sociocultural determinants, suggests that some cultural factors may be common to both psychogenic purpura and vaginismus. The aim of this case report was to call attention to a syndrome that is rarely seen and diagnosed, and to discuss its relationship to psychosocial factors. This syndrome should be considered in the differential diagnosis of not only ecchymotic lesions, but also various types of bleeding, including hematuria. Despite the fact that its etiology and treatment are not clearly understood, it should be noted that psychological factors play a role in this disease and therefore, psychopharmacological and psychotherapeutic approaches can be effective.

The role of topical vitamin K oxide gel in the resolution of postprocedural purpura

BACKGROUND AND OBJECTIVE

Facial purpura is a frequent barrier to patient acceptance and satisfaction with the results of various cosmetic procedures. Methods to shorten the duration of purpura after such procedures are often sought by patients. This study evaluated the efficacy and safety of a topical gel containing vitamin K oxide in the resolution of laser induced purpura.

METHODS

In this randomized, double-blinded, placebo-controlled split-face study, 20 subjects with bilateral facial telangiectasia were treated with a pulsed dye laser (PDL) device at purpuric settings. The test articles, a gel containing vitamin K oxide and placebo (vehicle), were each randomly assigned to one side of the subject's face. Subjects applied the test articles twice a day for the following 9 +/- 1 days. Improvement in both focal and general field purpura on each side of the face was assessed by the investigator using photographs. A scale of -100% (worsening) to 100% (improving) was used to rate photos against a baseline photograph obtained 15-30 minutes after treatment with the PDL device.

RESULTS

Resolution of the field of purpura was consistently greater with the vitamin K oxide gel after the second day of treatment. The greatest difference between the vitamin K oxide gel and placebo scores occurred on the fourth day after treatment. Although differences in active versus placebo scores did not reach statistical significance during the nine-day study period, a trend toward faster resolution of purpura with the active product was seen. Treatment-related adverse effects were not observed in any subject.

CONCLUSION

Vitamin K oxide gel appears to hasten the resolution of pulsed dye laser-induced purpura in subjects being treated for bilateral facial telangiectasia, and may well be useful in accelerating resolution of facial bruising from other cosmetic procedures such as fillers used for soft-tissue augmentation as well as other types of cutaneous surgical procedures.

A neonate with petechiae and pancytopenia at birth as uncommon presentation of congenital HIV infection

The authors describe a Thai newborn boy who was presented with petechiae, hepatosplenomegaly and pancytopenia at birth caused by congenital HIV infection. His clinical presentations were appeared on the early onset after birth. The bone marrow finding has shown hypocellularity which was also rare in HIV-infected children.

Prolonged urticaria with purpura: the spectrum of clinical and histopathologic features in a prospective series of 22 patients exhibiting the clinical features of urticarial vasculitis

BACKGROUND

Biopsy specimens of lesions with clinical features of urticarial vasculitis often show a predominantly lymphocytic infiltrate with eosinophils and red blood cell extravasation. Only occasionally is a leukocytoclastic vasculitis encountered, confirming a diagnosis of urticarial vasculitis.

OBJECTIVE

The aim of this study was to assess the clinical presentation and histologic features of patients who meet the clinical criteria for urticarial vasculitis.

METHODS

Patients were recruited who had persistent urticarial lesions individually lasting longer than 24 hours, associated with at least 2 of 3 of the following: pain or tenderness; purpura or dusky changes; and resolution with hyperpigmentation. Patients were interviewed based on a standard questionnaire with regard to their symptoms. Blood tests and chest radiographs were performed to exclude systemic involvement and hypocomplementemia. Skin biopsy specimens were sent for histology and direct immunofluorescence.

RESULTS

Of 22 patients recruited, 19 (86.4%) showed a predominantly lymphocytic infiltrate on histology. Three cases (13.6%) had a neutrophil-predominant infiltrate associated with a leukocytoclastic vasculitis. Twenty (90.9%) had a superficial perivascular infiltrate, and two (9.1%) had a superficial and deep perivascular infiltrate. In all, 21 biopsy specimens (95.5%) showed inflammatory cells within dermal blood vessel walls, obscuring the vessel outline in some. Endothelial cell swelling was seen in 20 biopsy specimens (90.9%), erythrocyte extravasation in 17 (77.3%), nuclear dust in 5 (22.7%), and fibrin extravasation in 2 (9.1%). Multivariate analysis revealed the following features to be independently associated with neutrophil predominance: fulfillment of all 3 minor criteria for urticarial vasculitis-like lesions (P = .007); presence of fibrin on histology (P < .001); presence of nuclear dust on histology (P = .001); hypocomplementemia (P = .001); and anemia (P = .015). There was a trend toward lesions not clearing as readily in the neutrophil-predominant group (P = .071), even with two-modality treatment (P = .089).

LIMITATIONS

Serum immunoelectrophoresis was not done to exclude Schnitzler's syndrome. Electronmicroscopy and cytokine profiling were not performed.

CONCLUSION

Biopsy specimens of lesions with clinical features of urticarial vasculitis reveal that only a minority of patients has leukocytoclastic vasculitis. The majority has a lymphocyte-predominant histology, associated with varying numbers of eosinophils. We favor a lymphocytic vasculitis as a causative explanation in the lymphocyte-predominant group.

Unilateral linear capillaritis: two unusual Chinese cases

Unilateral linear capillaritis (ULC) is a rare special variation of pigmented purpuric dermatosis (PPD), which is characterized clinically by linear or segmental distribution of pigmented purpuric macules located predominantly on the lower extremities and showing a favorable prognosis. In this case report, we describe two unusual cases of ULC, in one male and one female patient, with unilateral lesions involving the upper extremities that loosely follow the dermatome lines. Biopsy results revealed a common histopathology feature to PPD without heavy band-like infiltration in the upper dermis. On review 20 months after the onset, the eruptions of Patient 1 had spontaneously faded from parts of the affected area. Meanwhile, after a period of 18 months post onset, the eruptions of Patient 2 had became less visible after treatment with PUVA for 2 months, leaving a faded pigmentation.

Purpura and serum mixed cryoglobulinemia in psoriatic arthritis

We here firstly describe the case of a psoriatic arthritis associated with cutaneous purpura and lower limbs weakness. The presence of type III mixed cryoglobulinemia in serum was the only possible detected cause. Discrepancies with the hepatitis C virus-related mixed cryoglobulinemia picture are discussed.

Natural history and therapy of 66 patients with mixed cryoglobulinemia

Cryoglobulinemia, a relatively uncommon disorder, is classified into types I, II, and III, with type II consisting of a monoclonal immunoglobulin possessing activity toward a polyclonal component. Many disease associations and therapies have been described but clinical trials are few, and the natural history, causes, therapy, and pathways of cryoglobulinemia require further investigation. Here, we describe the symptoms, comorbidities, treatments, and response of 66 patients with type II cryoglobulinemia by examining the records of all patients evaluated at Mayo Clinic, Rochester, Minnesota, between 3/2/1994 and 11/27/2000, using our prospective dysproteinemia database. Symptoms varied greatly among patients and during the disease course. Most common were purpura (55% of patients), renal disease (26%), edema (24%), neuropathy (18%), and arthralgia (21%). Renal disease required the most aggressive intervention. Laboratory findings did not correlate with disease manifestations or severity. Only age was a significant predictor of mortality. Ten patients had cryoglobulinemia without an identified comorbidity. Thirty-three patients had viral hepatitis alone, 6 had a lymphoproliferative disorder alone, and 5 had a rheumatologic disease alone. Ten patients had a combination of disorders, such that hepatitis C was identified in a total of 40 patients, lymphoproliferative disorders in 16, and rheumatologic disease in 8. Twenty-two different treatments were administered. Corticosteroids were the most common treatment, followed by interferon with or without ribavirin. Type II cryoglobulinemia is a nonfatal disease most frequently associated with hepatitis C. Treatment is generally directed at the underlying condition. Not all patients require treatment, and many can be followed and treated symptomatically.

The treatment of progressive pigmented purpura with ascorbic acid and a bioflavonoid rutoside

Progressive pigmented purpura (PPP) is a group of dermatoses that are benign and usually self-limited. However, they may persist for months or years with frequent recurrences. Numerous treatments have been tried, but no effective therapy has yet proven to be successful. This report documents the treatment of a patient with one subtype of PPP using ascorbic acid and a bioflavonoid rutoside given orally. A 42-year-old male with biopsy-proven Eczematoid-like Purpura of Doucas and Kapetanakis was treated with ascorbic acid 500 mg twice a day and a bioflavonoid rutoside 50 mg twice a day. Treatment was successful, with quick defervescence of the rash and no recurrence to date.

Identification and treatment of scurvy: A case report

Scurvy is a nondiscriminatory disease process resulting from a nutritional deficiency of ascorbic acid (vitamin C). The severe vitamin deficiency produces a breakdown in the cellular structure of the body. This case report describes a middle-age woman with a history of edema, bruising of the lower extremities, anemia, and severe periodontal disease. Her presentation and medical history are classic for the signs of scurvy. Scurvy is now only uncommonly seen in developed countries, but there are still vulnerable populations whose nutritional status can lead to scurvy. The aim of this report is to help the clinician identify and treat scurvy, a disease that was once feared for its high mortality but is now easily treatable, even in cases that have progressed to multiple organ dysfunction and failure.

Post-transfusion purpura

Post-transfusion purpura (PTP) is a rare bleeding disorder caused by alloantibodies specific to platelet antigens. The antibody against the human platelet alloantigen (HPA)-1a is responsible for most of the cases. The majority of affected patients are multiparous women who presumably have been previously sensitized during pregnancy. Blood transfusions rarely have been implicated as the primary cause for alloimmunization in PTP. Thrombocytopenia is usually severe and resolves spontaneously within several weeks. However, patients may develop severe if not fatal bleeding during the course of this disease. The diagnosis is confirmed by demonstrating that the patient's serum contains antibodies to platelet-specific antigens. Treatments for PTP include intravenous immunoglobulin, corticosteroids, and plasmapheresis.

Purpuric generalized lichen nitidus: an unusual eruption simulating pigmented purpuric dermatosis

BACKGROUND

Generalized haemorrhagic lichen nitidus is rare. To our knowledge, this form of presentation has only been reported once.

OBJECTIVE

To describe a new case of generalized haemorrhagic lichen nitidus simulating a pigmented purpuric dermatosis.

METHODS AND RESULTS

We document a 24-year-old man who presented with an 8-month history of a progressive non-pruritic, red-brown papular eruption on the dorsa of the feet, ankles and distal third of the legs. A diagnosis of Schamberg's progressive pigmentary dermatosis was made, and no treatment was prescribed. Two months later, the lesions had extended to the abdomen, groins, forearms, elbows and wrists. Biopsy of the skin of the right foot revealed lesions typical of lichen nitidus with subepidermal extravasation of red cells and capillary wall hyalinization. Macrophages and T lymphocytes were abundant in the infiltrate.

CONCLUSION

Purpuric generalized lichen nitidus should be included in the differential diagnosis of pigmented purpuric dermatoses.

Cutaneous vasculitis - a case for laparotomy?

The diagnosis of gut vasculitis infers a poor prognosis necessitating aggressive therapy. We describe a case with predominant features of a skin-limited vasculitis but atypical debilitating abdominal symptoms. Although endoscopic biopsies were unremarkable, full thickness biopsy taken at laparotomy revealed a necrotizing vasculitis. After treatment with cyclophosphamide, the previously resistant abdominal symptoms resolved. This case illustrates the need to tailor treatment to disease severity, rather than determine it by the type of vasculitis with which the patient has been labelled. In view of the importance of gastrointestinal involvement to therapy decisions, laparotomy may be necessary to establish the presence of vasculitis.

Purpura with cold urticaria in a patient with hepatitis C virus infection-associated mixed cryoglobulinemia type III: successful treatment with interferon-beta

We describe a 54-year-old man with hepatitis C virus (HCV) infection-associated cryoglobulinemia type III. The patient had suffered from cold-induced urticaria that left purpuric eruptions up to 1 cm in diameter, intermittent migratory joint pain for seven years and mild liver dysfunction for nine years. Hemophilia A was diagnosed when the patient was 26 years old, and he was then given infusions of factor VIII for a short time. In both skin biopsy samples from urticarial and purpuric eruptions, mild inflammatory infiltration by polymorphonuclear leukocytes with nuclear dust, extravasation of erythrocytes and deposition of IgM and C3 in the superficial blood vessels were observed. After antiviral treatment with interferon-beta, the clinical symptoms and the cryoglobulin and HCV-RNA in the serum disappeared. There has been no recurrence in the subsequent nine years.

Clinical efficacy and safety of a novel intravenous immunoglobulin preparation in adult chronic ITP

Use of intravenous immunoglobulins (IVIGs) is a well-established therapy in patients with acute or chronic autoimmune thrombocytopenic purpura (ITP). The aim of the present open, prospective study was to investigate efficacy and safety of the novel IVIG preparation BT681 (Biotest Pharma GmbH, Dreieich, Germany) in adult patients with chronic ITP (cITP). In order to fulfil high standards of purity and viral safety, an additional HPLC step has been introduced and validated virus removal and inactivating procedures are included in the manufacturing process of BT681. A total of 24 patients with platelet counts between 3/nl and 27/nl received a total dose of 2 g/kg body weight BT681 in standard dosage regimens: 1.0 g/kg/day for 2 days in 15 patients and 0.4 g/kg/day for five consecutive days in nine patients. Platelet response (platelet count > or =50/nl) and regression of haemorrhages were documented during the 28 days study period and safety parameters including adverse events, laboratory investigations and vital signs were regularly monitored. The overall response rate was 91.7%, that is 22/24 patients responded to BT681 treatment. The median time to platelet response was 3.0 days, the duration of response 25.5 days; the median max. platelet count 222/nl and the time to max. platelet count 7.5 days. During the entire observation period, platelet counts below baseline were only observed in five responders; in half of the patients, platelet counts were even above 50/nl at the end of follow-up. Corresponding to the good platelet response, the clinical symptoms improved markedly in the majority of patients within the first week after start of BT681 infusions with 88.9% overall regression of haemorrhages in comparison with baseline. The evaluation of platelet parameters showed a slight tendency in favour of the 5 days group, evaluation of haemorrhage severity slight advantages for the 2 days group. The adverse event data indicate that the therapy with BT681 was safe and well tolerated in both treatment groups even if minor effects were more frequent in patients treated with the 2 days regimen. The large majority of adverse events were known intolerabilities during the treatment phase described as mild and transient. The results demonstrate that the new immunoglobulin preparation BT681 is effective and safe in the treatment of adult patients with cITP.

Monoclonal rearrangement of the T cell receptor gamma-chain in lichenoid pigmented purpuric dermatitis of gougerot-blum responding to topical corticosteroid therapy

Lichenoid pigmented purpuric dermatitis of Gougerot-Blum belongs to a group of closely related disorders which are termed pigmented purpuric dermatoses. It clinically manifests itself with grouped lichenoid papules in association with purpuric lesions. We report a case of lichenoid pigmented purpuric dermatitis of Gougerot-Blum with a heavy band-like CD4-positive lymphocytic infiltrate and clonal rearrangements of the gamma-chain of the T cell receptors as detected by polymerase chain reaction/denaturing gradient gel electrophoresis. Monoclonal expansion of T cells in combination with certain histological features of mycosis fungoides (MF) might support a biological relationship between lichenoid pigmented purpuric dermatitis of Gougerot-Blum and MF. However, prompt clinical response to topical steroid therapy supports the benign clinical nature of our case.

Noninfectious serious hazards of transfusion

Serious, noninfectious transfusion complications include transfusion-related acute lung injury (TRALI), transfusion-associated graft-versus-host disease, anaphylaxis, hemolysis, and post-transfusion purpura. Prompt recognition and treatment are crucial, but prevention is preferable. Many transfusion reactions are not recognized as such, perhaps because signs and symptoms mimic other clinical conditions. However, any unexpected symptoms in a transfusion recipient should at least be considered as a possible transfusion reaction and be evaluated. Appropriate diagnosis is the key to treatment and may prevent additional reactions, not only in the patient, but possibly, as in the case of TRALI, in other patients.

Recombinant human interferon alpha-2a therapy in children with chronic immune thrombocytopenic purpura

BACKGROUND

In a prospective study, 11 children with chronic immune thrombocytopenic purpura between ages 3 and 18 years were treated with recombinant human interferon alpha 2a (rhIFN alpha-2a).

PATIENTS AND METHODS

A dose of 3 x 10(6) U/m2 three times weekly for 4 to 5 weeks (one cycle) was administered. Patients were treated with one to four cycles of rhIFN alpha-2a, and the outcomes were measured initially and 18 to 30 months after the last cycle.

RESULTS

Good therapeutic responses (defined as platelet count >100 x 10(9)/L) lasting for 18 to 30 months from the last interferon cycle were achieved in 6 of the 11 (55%) patients, including one with a probable spontaneous remission. Fair responses (platelet count 31-60 x 10(9)/L) for 18 months were achieved in 3 of the 11 (27%) patients. Only two patients, each treated only with one interferon cycle, exhibited no response. Side effects of treatment included fever and a flu-like syndrome, which were usually present during the first 14 days of therapy only.

CONCLUSIONS

Interferon-alpha appears to be an effective therapeutic approach to children with chronic immune thrombocytopenic purpura, with the potential of sustained long-term remission. A randomized, placebo-controlled study is needed to confirm its role in this population.

Infantile acute hemorrhagic edema of the skin

Infantile acute hemorrhagic edema (AHE) of the skin is an uncommon form of cutaneous leukocytoclastic vasculitis that occurs in children younger than 3 years. We describe a 10-month-old boy with AHE, in whom the disease appeared after antibiotic treatment for an acute respiratory illness. AHE presented with fever, acral edema, and rosette-shaped purpuric plaques on the face and limbs. The causes of AHE are unclear, as is its nosologic position. Some authors consider the disease as a purely cutaneous form of Henoch-Schönlein purpura, and others believe that AHE should be regarded as a distinct clinicobiologic entity within the spectrum of leukocytoclastic vasculitis.

PUVA therapy in lichen aureus

Lichen aureus is one of the subtypes of a rare group of diseases, pigmented purpuric dermatoses. The natural course of the disease is slow evolution and slow resolution. Treatment is generally limited. We report a case of lichen aureus that responded dramatically to photochemotherapy (PUVA).

Trends in rheumatic disease: update on new diagnostic and treatment strategies

Advances in our understanding of the pathophysiology of rheumatic and immunologic diseases have led to improved therapies, such as tumor necrosis factor inhibitors and bisphosphonates. These drugs can not only alleviate symptoms but also alter the course of the disease. However, they also have significant potential side effects, which mandate, more than ever, correct diagnosis and vigilant monitoring for toxicity.

[Dyshidrosis and acral purpura during polymorphic dermatitis in pregnancy: 2 cases]

BACKGROUND

We describe two severe cases of polymorphic eruption of pregnancy associated with dyshidrosis and purpuric lesions.

CASE-REPORT

Two patients, primigravida at 35 and 34 weeks of amenorrhea, were admitted in our department for a severe and itchy eruption. In the first case, some papular lesions were particularly concentrated on the abdominal striae, associated with vesicles on the limbs. There were plantar dyshidrosis and purpuric macules on the toes. In the second case, there were a maculopapular eruption on the abdomen and limbs, some vesicles and bullae of palms and soles, and a purpura of heels. In both cases, the skin biopsy showed dermic inflammatory, direct immunofluorescence and Pemphigoide Gestationis Factor research were negatives. The two patients were treated with betamethasone dipropionate (Diprosone(R)), and hydroxyzine (Atarax(R)). They gave birth to healthy babies.

DISCUSSION

Dyshidrosis is not exceptional in polymorphic eruption of pregnancy. Indeed, in the several series of polymorphic eruption of pregnancy we checked, a pompholyx distribution was observed in 5 p. 100 of the cases. It is not necessary a sign of pemphigoid gestationis, even if this localization is commonly observed. The purpuric lesions are unusual because, according to our knowledge, there is no description of purpura associated with palmoplantar lesions in polymorphic eruption of pregnancy. The purpuric lesions may be secondary to high capillary permeability, increased by severe dermic inflammation of the polymorphic eruption of pregnancy and, possibly, high level of circulating estrogens.