Dextran therapy of purpura fulminans

Massive infectious soft-tissue injury: diagnosis and management of necrotizing fasciitis and purpura fulminans

LEARNING OBJECTIVES

After studying the article, the participant should be able to: 1. Describe the most common bacteriology of necrotizing fasciitis and purpura fulminans. 2. Describe the "finger test" in the diagnosis of necrotizing fasciitis. 3. Discuss the three presentation patterns of necrotizing fasciitis. 4. Discuss the pathophysiology of acute infectious purpura fulminans. 5. Discuss the treatment strategies for necrotizing fasciitis and purpura fulminans, including the use of artificial skin substitutes. Necrotizing fasciitis and purpura fulminans are two destructive processes that involve skin and soft tissues. The plastic and reconstructive surgeon may frequently be called on for assistance in the diagnosis, treatment, and/or reconstruction of patients with these conditions. Understanding the natural history and unique characteristics of these processes is essential for effective surgical management and favorable patient outcome. A comprehensive review of the literature pertaining to these two conditions is presented, outlining the different pathophysiologies, the patterns of presentation, and the treatment strategies necessary for successful management of these massive infectious soft-tissue diseases.

Postinfectious purpura fulminans caused by an autoantibody directed against protein S

OBJECTIVE

To determine the mechanism responsible for idiopathic purpura fulminans, we investigated the procoagulant and anticoagulant pathways in five consecutive patients, four after varicella, and the fifth after a nonspecific infection.

METHODS

Procoagulant and anticoagulant factors, including protein C, protein S, and antithrombin III, were measured by quantitative or functional assays. Anti-protein S autoantibodies were identified by dot blotting and Western blotting, and quantified serially by enzyme-linked immunosorbent assay. Clinical and laboratory data were collated retrospectively.

RESULTS

In each case the disease began 7 to 10 days after the onset of the precipitating infection, with rapidly progressive purpura leading to extensive areas of skin necrosis. The illness was complicated by impaired perfusion of limbs or digits (two patients), peripheral gangrene resulting in an above-knee amputation (one patient), and major organ dysfunction caused by thromboembolic phenomena involving the lungs (two patients), the heart (one patient), or the kidneys (one patient). Protein S levels were virtually undetectable at the time of admission and failed to respond to infusions of fresh frozen plasma, despite correction of other procoagulant and anticoagulant factors. All five children had anti-protein S IgM and IgG autoantibodies, which persisted for less than 3 months after admission. Decline in the anti-protein S IgG antibody concentration was associated with normalization of the plasma protein S levels.

CONCLUSIONS

Autoimmune protein S deficiency may be a common mechanism causing postinfectious idiopathic purpura fulminans. Recognition of the pathophysiologic mechanism may provide a rational basis for treatment. Immediate heparinization, infusions of fresh frozen plasma, and, in cases complicated by major vessel thrombosis, the use of tissue-type plasminogen activator may limit thromboembolic complications.

Purpura fulminans with haemolytic anaemia

A 10-month-old female infant with purpura fulminans is reported. The patient had clotting abnormality compatible with consumption coagulopathy. Histopathological examination revealed the presence of microthrombi. Heparin was effective in correcting the clotting defects. The infant also suffered from microangiopathic haemolytic anaemia. She died 17 days after the onset of the illness from infection in spite of antibiotic therapy.

Purpura necrotica as a complication of ventriculoatrial shunts in hydrocephalus

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