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01.12.2011 | Case report | Ausgabe 1/2011 Open Access

Journal of Medical Case Reports 1/2011

Empiric treatment of protracted idiopathic purpura fulminans in an infant: a case report and review of the literature

Zeitschrift:
Journal of Medical Case Reports > Ausgabe 1/2011
Autoren:
Fima Macheret, Kavitha N Pundi, Eileen M Broomall, Dawn M Davis, Vilmarie Rodriguez, Chad K Brands
Wichtige Hinweise

Electronic supplementary material

The online version of this article (doi:10.​1186/​1752-1947-5-201) contains supplementary material, which is available to authorized users.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

FM, KP, EB and CB admitted the patient to the pediatric hospital service, performed the patient work-up and wrote the case report. FM was a major contributor in writing the manuscript and did the literature review. DD and VR conducted additional dermatologic and hematologic investigations, respectively. All authors read and approved the final manuscript.
Abbreviations
ACE
angiotensin-converting enzyme
ANA
anti-nuclear antibody
aPTT
activated partial thromboplastin time
ASD
atrial septal defect
AST/ALT
alanine/aspartate transaminase
AT III
anti-thrombin III
BUN
blood urea nitrogen
Cr
creatinine
CRP
C-reactive protein
DRVVT
dilute Russell's viper venom test
ECG
electrocardiogram
ESR
erythrocyte sedimentation rate
HSP
Henoch-Schonlein purpura
PDA
patent ductus arteriosus
PO
per os (by mouth)
PT
prothrombin
RBC ALA
red blood cell Δ-aminolevulinic acid
SQ
subcutaneous.

Introduction

Purpura fulminans (PF) is caused by a relative deficiency in protein C-mediated hemostasis and is classified by etiology and history into neonatal PF, acute infectious PF and idiopathic or post-infectious PF. Neonatal PF is caused by homozygous or compound heterozygous deficiencies in protein C or protein S and manifests shortly after birth [1]. In contrast, acute infectious PF occurs at any age and is most likely a consequence of coagulative consumption of protein C, protein S and anti-thrombin III during sepsis [2, 3]. It is considered a dermatologic manifestation of endotoxin-triggered hemostatic abnormalities (specifically, induced protein C and S deficiency) associated with sepsis and disseminated intravascular coagulation (DIC), most frequently in the setting of serogroup C meningococcemia and endotoxemia [4, 5].
Idiopathic PF, an extremely rare disease, is attributed to the development of anti-protein S antibodies, which form antibody-protein S complexes that are excreted, leading to transient protein S deficiency, hypoactivation of the protein C pathway and dermal vessel hypercoagulability. Important evidence suggests a post-infectious etiology. After D'Angelo et al. [6] identified autoantibodies to protein S in a boy with thromboembolic disease antecedent to varicella infection, Levin et al. [7] discovered and quantified protein S autoantibodies in four children with idiopathic PF following varicella infection. Indeed, Regnault et al. [8] confirmed that protein S autoantibodies obtained from a child with idiopathic PF antecedent to varicella infection caused a hypercoagulable state in vitro. All of the patients in the Levin et al. [7] case series had minimal or undetectable protein S and protein S activity. Some of the patients in the Levin et al. series had other laboratory abnormalities, including elevated anti-cardiolipin immunoglobulin M (IgM) and IgG antibodies, IgG-containing immune complexes, decreased C4B binding protein and decreased protein C activity.
Despite the important work by D'Angelo et al. [6] and Levin et al. [7] with regard to post-varicella etiology, there may be other anti-coagulant factors involved in the disease process. The independent contribution of heterozygous prothrombin G20210 mutations to the development of autoimmune protein S deficiency and idiopathic PF is still unclear. This mutation has been reported in two cases of idiopathic PF and autoantibodies to protein S with decreased protein S levels [9, 10]. The presence of anti-phospholipid antibodies has also been reported in conjunction with protein S deficiency and thrombosis in children [11]. These cases underscore that work-up for suspected idiopathic PF should include clotting factor assessment, rheumatologic evaluation and thrombophilic mutation analysis.

Case presentation

A previously healthy six-month-old Caucasian boy was brought to our pediatric hospital service for a second opinion regarding a six-week history of necrotic skin lesions on his upper and lower extremities. The lesions were initially petechial and rapidly evolved into escharotic plaques over a 10-day period. They were accompanied by the onset of a low-grade intermittent fever and night sweats. One month after his initial presentation, the lesions had spread to involve the distal, dorsal surface of his feet and toes. His parents denied any trauma, burns or other inciting injuries.
He had an extended family history of stroke, miscarriages, deep venous thromboses, pulmonary emboli and multiple sclerosis, but his parents denied any coagulopathies, bleeding disorders or rheumatologic diseases. His social history was non-contributory. His vaccinations were up-to-date, and he had received his most recent ones about three weeks before the onset of the lesions, which included vaccinations for diphtheria-tetanus-acellular pertussis, haemophilus influenzae type B, inactivated polio vaccine, hepatitis B virus, heptavalent pneumococcal vaccine and rotavirus vaccine.
Outside investigations included a negative skeletal survey and normal laboratory studies. He received a short, unsuccessful course of methylprednisolone. At the time of presentation, his only other medications were ranitidine (One and a half mg/kg/day) and omeprazole (0.67 mg/kg/day) for gastroesophageal reflux disease and lactulose for a recent history of constipation that began after rice cereal was added to his diet.
Upon admission to our hospital, his physical examination revealed an infant who was alert, active and intermittently fussy. His vital signs were heart rate 128 beats/minute, blood pressure 126/94 mmHg, respiratory rate 42 breaths/minute and body temperature 36.9°C. His skin examination revealed blackened, eschar-like, linear but serpiginous, stellate, spatially non-contiguous lesions with peripheral yellow crusting. There were symmetrical necrotic plaques on his forearms, distal legs, dorsal surface of his feet and his toes, including the first two toes on each foot (Figures 1a and 1b). Otherwise his physical examination was non-contributory.
The results of our initial laboratory investigation are shown in Table 1. Additionally, a peripheral smear revealed Döhle bodies with toxic granulations. Serum protein electrophoresis revealed hypogammaglobulinemia (γ-globulins 0.3 g/dL). Serial blood cultures were negative for bacteria and fungi.
Table 1
Laboratory evaluation at first admission, dismissal and second admissiona
Test or laboratory evaluation
Admission 1 (dismissal 1)b
Admission 2
Reference range
Hemoglobin
13.1 (9.6c)g/dL
11.5 g/dL
10.5 to 13.5 g/dL
Hematocrit
37.5 (27.6c)%
34.0%
33.0% to 44.0%
Leukocytes
16.5c (15.7c) × 109/L
26.3 × 109/Lc
6 to 11 × 109/L
Thrombocytes
738c (651c) × 109/L
951 × 109/Lc
150 to 450 × 109/L
Neutrophils
11.41c (6.47) × 109/L
-
1.5 to 8.5 × 109/L
Lymphocytes
3.91c (7.65) × 109/L
-
4.0 to 10.5 × 109/L
Monocytes
1.09 (1.42c) × 109/L
-
0.05 to 1.1 × 109/L
Eosinophils
0.00c (0.05) × 109/L
-
0.05 to 0.7 × 109/L
PT
9.8 seconds
9.6 seconds
8.3 to 10.8 seconds
aPTT
30 seconds
30 seconds
21 to 33 seconds
Thrombin time
20 seconds
22 seconds
16 to 25 seconds
Protein C, activity
99%
120%
70% to 150%, adults
Protein S, free
116
144
65% to 160%, men
Protein S, activity
123%
123%
65% to 160%, adults
Anti-thrombin activity
119%
136%c
80% to 130%, > 6 months old
D-dimer
 
200 ng/mL
< 250 ng/mL
Fibrinogen
315 mg/dL
351 mg/dL
200 to 375 mg/dL
DRVVT
 
1.0
< 1.2
APC ratio
 
3.1
> 2.3
Factor VIII
 
170%
55% to 205%, adults
Ristocetin co-factor
 
92%
55% to 200%, adults
von Willebrand factor
 
112%
-
ESR
11 mm/hour
25 mm/hour
-
CRP
5.6 mg/L
9.1 mg/Lc
< 8.0 mg/L
ANA antibody
0.1 U
 
< 1.0
Homocysteine
7 μmol/L
5 μmol/L
< 13 μmol/L
Anti-phospholipid/anti-cardiolipin, IgM
< 4.0
 
-
-IgG
< 4.0
 
-
AST
27 U/Lc
24 U/L
8 to 20 U/L
ALT
18 U/L
15 U/L
8 to 20 U/L
ACE
16 U/L
 
8 to 53 U/L
Cryofibrinogen
Neg
 
Neg
Cryoglobulin
Neg
 
Neg
Plasma porphyrins
< 1 U/L
 
< 1 U/L
RBC ALA dehydratase
8.7 nmol/L/second
 
-
Myeloperoxidase
< 0.2 U
< 0.2 U
< 0.4 U
Proteinase 3
< 0.2 U
< 0.2 U
< 0.4 U
Total protein
5.3 g/dLc
 
6.0 to 7.8 mg/dL
Albumin
3.0 g/dLc
 
3.5 to 5.5 mg/dL
Sodium ion
 
138 mmol/L
135 to 145 mmol/L
Potassium ion
 
5.2 mmol/Lc
3.5 to 5.0 mmol/L
Bicarbonate ion
 
19 mmol/L
18 to 23 mmol/L
Chloride
 
105 mmol/L
95 to 105 mmol/L
BUN
 
9 mg/dLc
3 to 7 mmol/L
Creatinine
 
0.2 mg/dLc
0.7 to 1.0 mg/dL
GGT
 
19 U/L
5 to 40 U/L
Anion gap
 
14 mEq/Lc
8 to 12 mEq/L
Glucose
 
107 mg/dLc
70 to 99 mg/dL
Bilirubin (total/direct)
 
0.2/0.1 mg/dL
0.1 to 1.0/0.0 to 0.3 mg/dL
IgM
80 mg/dL
67 mg/dL
24 to 267 mg/dL
IgG
272 mg/dL
289 mg/dL
164 to 588 mg/dL
IgA
 
130 mg/dLc
16 to 50 mg/dL
IgE
 
7.5 kU/L
< 30 kU/L
Complement C3
 
128 mg/dL
75 to 175 mg/dL
-C4
 
134 mg/dLc
14 to 40 mg/dL
Fc C7
 
59 U/mL
36 to 60 U/mL
-C8
 
60 U/mLc
33 to 58 U/mL
-C9
 
61 U/mL
37 to 61 U/mL
β2 microglobulin
 
5.6 μg/mL
0.70 to 1.80 μg/mL
Zinc
 
0.67 μg/mL
0.6 to 1.20 μg/mL
α1-anti-trypsin
 
144 mg/dL
89 to 230 mg/dL
Cold agglutinin
(Negative)
  
Mycoplasma IgM
0.10
 
< 0.90
-IgG
0.5
 
-
aPT, prothrombin time; aPTT, activated partial thromboplastin time; DRVVT, dilute Russell's viper venom test; APC, activated protein C; ESR, erythrocyte sedimentation rate; CRP, C-reactive protein; ANA, anti-nuclear; IgM, immunoglobulin M; AST, aspartate aminotransferase; ALT, alanine aminotransferase; ACE, angiotensin-converting enzyme; RBC ALA, red blood cell Δ-aminolevulinic acid; BUN, blood urea nitrogen; GGT, γ-glutamyl transferase; Fc, functional component; bvalues in parentheses are those which occurred at first discharge, which was approximately one week after first admission. The second admission occurred 1 week after the first discharge. coutside normal limits.
Punch biopsies from all four limbs revealed a pauci-inflammatory occlusive vasculopathy. Direct immunofluorescence showed strong IgM staining in the superficial and mid-dermal vessels, weak C3 staining in a few superficial vessels and some fibrinogen deposition in the superficial and mid-dermal vessels. Staining for IgG and IgA was negative. Excisional biopsy tissue was cultured and revealed anaerobic Gram-positive cocci (3+), enterococci (3+), Neisseria animaloris (2+) and a few white blood cells, and stains of the biopsy were negative for acid-fast organisms, mycobacterium, and fungi. Immunofluorescence staining was negative for IgG, C3 and fibrinogen, while IgA stained weakly positive in rare dermal blood vessels and IgM stained positive in a few scattered blood vessels in the dermis.
The patient was discharged on wet-to-dry dressing changes, and his laboratory abnormalities at dismissal are shown in Table 1. Prednisolone therapy was tapered over two weeks.
The patient was re-admitted one week later because of progression of his skin disease. Flexion contractures were noted at the elbows and knees. Laboratory values at readmission are shown in Table 1. Genetic analysis revealed that he was a heterozygous carrier of the prothrombin 20210A mutation. Further imaging included computed tomography of the chest and abdomen, which were unrevealing. Additional viral and retroviral studies were all negative, including varicella. His oxidative burst test was also normal. CD11a was not indicative of leukocyte adhesion deficiency. Tests for arsenic, lead, mercury and cadmium were all negative.

Discussion

After the extensive negative work-up and given the lack of a definitive diagnosis, a peripheral inserted central catheter line was placed for the initiation of high-dose IV prednisone (Four mg/kg/day). He was started empirically on IV ampicillin/sulbactam (200 mg/kg/day, seven-day course). Corticosteroids were tapered over the next seven days.
One week later he showed no clinical improvement. Following interdisciplinary conference and consultation with pediatric coagulation experts, we decided to treat him empirically for idiopathic purpura fulminans with dalteparin (two SQ doses at 250 U/kg/day). This regimen was adjusted to 350 U/kg/day divided into two SQ doses to achieve a therapeutic heparin level. Acetylsalicylic acid was also added. Physical therapists were consulted because of motor skill regression with skin contractures.
At his follow-up examination one week later, his parents reported that no new lesions had developed. The eschars had begun to regress centrifugally from their borders, revealing healing pink scars, especially in his upper extremities. After several weeks, peripheral areas of crusting had shed, revealing healed, scarred skin (Figures 2a and 2b).
Follow-up at two months demonstrated dramatic healing (Figures 3a and 3b). While on heparin therapy, he had transient recurrence of petechiae one day after receiving an H1N1 virus vaccination. Any attempt to reduce the low-molecular-weight heparin from twice to once daily led to symmetric recurrence of lesions on his buttocks and thighs. He was transitioned to chronic anti-coagulation with warfarin 1 mg/day, and the lesions have been well controlled when his international normalized ration is in the therapeutic range of two to three. Subsequent urine amino acid analysis and genomic microarray analyses were unremarkable.
About one year after initial presentation, our patient was experiencing developmental delays that were especially noted in gross motor function. Neurology consultation was sought, and their work-up revealed proximal muscle weakness and areflexia. Further investigation revealed that he is heterozygous for a duplication of a thymine nucleoside in his SMN1 gene at position 91 in codon 31, which causes a frame shift mutation and is consistent with spinal muscular atrophy.
The differential diagnosis for an infant with necrotic skin lesions is listed in Table 2. After interdisciplinary consultation, we arrived at a diagnosis of idiopathic PF, a rare prothrombotic syndrome characterized by thrombosis of dermal vasculature and progressive, widespread purpura with necrosis. Our patient's extensive characteristic lesions and stereotypical features on skin biopsy were consistent with those described in prior reported cases. Indeed, our patient's impressive response to anti-coagulation was strikingly similar to that described in prior cases and argues in favor of this diagnosis.
Table 2
Differential diagnosis of necrotic skin lesions in an infanta
System
Diagnoses
Hematologic
Idiopathic thrombocytopenic purpura
Thrombotic thrombocytopenic purpura
Coagulation factor deficiency
Platelet function disorder
Thromboembolic disease
Lupus/anti-phospholipid antibodies
Cryoglobulinemia
Porphyria
Idiopathic red blood cell agglutination
Idiopathic PF
Neonatal PF or other thrombophilic mutation
Infectious
Cellulitis with or without atypical organisms or fungi
Endocarditis (bacterial, fungal or marantic)
Inflammatory
Panniculitis secondary to α1-anti-trypsin deficiency
Pemphigus vulgaris
Pyoderma gangrenosum
Epidermolysis
Vascular
HSP
Leukocytoclastic vasculitis
Hematoma with compartment syndrome
Neoplastic
Leukemia
Lymphoma
Essential thrombocythemia
Cutaneous T-cell lymphoma
Nutritional
Vitamin deficiency (vitamin K)
Mineral deficiency (zinc)
Environmental
Toxic exposure (for example, heavy metals)
Congenital
Combined immune deficiency
Prolidase deficiency
Leukocyte adhesion deficiency
Chronic granulomatous disease
γ-globulinemia
Spinal muscular atrophy
Trauma
 
aPF, purpura fulminans; HSP, Henoch-Schonlein purpura.
The most novel divergence of our patient's idiopathic PF from prior cases was the disparity in laboratory evidence. Fascinatingly, our patient had no absolute or relative deficiencies in protein C and S levels or activities, features present in the prior reported cases. Protein C activity was measured using venom activator and chromogenic peptide substrate; therefore, it is possible that a congenital protein C variant may not have been identified that would require a clot-based assay. Protein S antigen was measured using free protein S assay, and protein S activity was measured using a clot-based end point. This protein S assay can be affected by the presence of lupus anti-coagulant or a specific factor V inhibitor, but we did not identify either of these humoral factors.
Also, the peripheral smear abnormalities, especially the Döhle bodies, can be associated with DIC-linked purpura fulminans, yet we saw no evidence of consumptive coagulopathy characteristic of DIC. The specific role of N. animaloris in the progression of his lesions remains undefined. He may have a novel form of idiopathic PF, possibly preceded by an unidentified infection or caused by a defect in protein S that we were unable to detect using conventional laboratory assays. We are also unable to assess the potential contribution of his series of vaccines to his disease presentation, and although it would be unlikely for a child to develop autoantibodies before 6 months of age, we do not rule out the possibility that he may have developed autoantibodies after immunization.
Another important aberration in the patient's presentation was his age, because he was older than the expected age for neonatal PF and younger than all of the other reported cases of idiopathic PF that we reviewed. While our patient's initial response to anti-coagulation therapy was the aspect of his presentation and outcome, which fit most closely with that of idiopathic PF, his long-term need for anti-coagulation is not consistent with the previously described etiology of this disease.
The photographs associated with this case offer a dramatic example of clinical management for the pediatrician or dermatologist who may see similar lesions in a non-septic infant with an unrevealing laboratory evaluation. The decision to empirically anti-coagulate represented our best scientific response to the overlapping and non-specific findings for idiopathic PF.
In light of his impressive response to treatment as depicted in the final set of images (Figure 3), we wish to highlight an evidence-based approach to empiric treatment of idiopathic PF. Table 3 summarizes the patient age, gender, protein S levels, varicella status, treatments and outcomes of several recent cases reported after the Francis case series [12]. On the basis of the hypothesized etiology of the disease, that is, the development of protein S autoantibodies with thrombogenesis, treatment should include plasmapheresis with intravenous immunoglobulin to eliminate protein S autoantibodies and heparin to improve hemostasis [13]. Fresh frozen plasma should be added to assist the recovery of clotting factors. The dosage of dalteparin was titrated up to 350 U/kg twice daily to reach a target anti-Xa level of 0.5 to 1.0. We also prescribed supplemental 81 mg aspirin once daily. Other emerging modalities have been used to treat acute infectious and neonatal PF and may be applicable in some cases of idiopathic PF, including protein C replacement, anti-thrombin III replacement, prostacyclin and even leech therapy [3, 14]. Long-term management must include physical therapy to assist with weight-bearing if there is any evidence of contracture.
Table 3
Treatment modalities for idiopathic purpura fulminans from recently reported casesa
Case report
Patient and history
PS
Trigger
Treatment (target levels)b
Outcome and treatmentc
Boccara et al. [15]
Two-year-old girl
Varicella three months prior
Low
HHV-6
IVIg 2 g/kg, LMWH, plasmapheresis q12 h, FFP (repeat IVIg if PS < 50%)
Pre-treatment: right leg amputation
Post-treatment: resolution, IVIg 2 ×/day
Özbek et al. [9]
Eight-year-old boy
FVL+/-
G20210A+/-
Low
Not known
Prior treatment: SQ UH, IV ceftriaxone, metronidazole
(One) Bolus 75U UH, 15 days continuous 20 U/kg/hour, twice daily FFP × 5 daysb
(Two) 80 to 100 U/kg SQ heparin for 1 month
(Three) Warfarin (INR Two or Three)
Pre-treatment: necrosis in lower half of body
Post-treatment: resolution
al-Ismail et al. [10]
4.8-year-old boy
G20120A+/-
ANA+
ASO+
Viral titer-
Low
Streptococcus?
(One) Antibiotics, FFP, vitamin K
(Two) IV UH
(aPTT 1.5-2.5 × normal)b
(Three) Enoxaparin 20 mg/q12 hours (anti-Xa level 0.6 U/L)
Pre-treatment: left leg swelling, edema, left femoral vein thrombosis
Post-treatment: resolution
Levin et al.d [7]
6.4-year-old boy
Varicella
One year prior
Low
Fever, vesicular rash
(One) IV penicillin, cefotaxime, 4U FFP, IVIg 1 g/kg, exchange transfusion, methylprednisone, IV heparin 15 U/kg/hour, tPa for PE, prostacyclin
(Two) IV heparin increased to 60 U/kg/hour, FFP 40 mL/kg/day (aPTT 1.5 to 2.5 × normal)b
(Three) Warfarin
Pre-treatment: lesions stopped, right leg amputation, PE1
Post-treatment: then respiratory improvement, resolution
 
5.9-year-old girl
Low
Varicella
(One) IV cefotaxime, acyclovir and heparin bolus 100 U/kg/hour, then 25 U/kg/hour; two volume exchange transfusion, then daily FFP
Pre-treatment: right atrial thrombosis, PEe
Post-treatment: skin grafting
aPS, protein S; INR, international normalized ratio; HHV-6, human herpesvirus 6; IVIg, intravenous immunoglobulin; LMWH, low-molecular-weight heparin; FFP, fresh frozen plasma; PS, protein S; FVL, factor V Leiden; G20210A, prothrombin G20210A mutation; SQ, subcutaneous; UH, unfractionated heparin; IV, intravenous; ANA, anti-nuclear antibody; ASO, anti-streptolysin O antibody; aPTT, activated partial thromboplastin time; tPa, tissue plasminogen activator; PE, pulmonary embolism; +/-, heterozygote; +, antibodies present; bmost effective treatment modality in each case when more than one treatment was applied; cpre- and post-treatment are with respect to most effective treatment in "Treatment (target levels)" column; dLevin et al. [7] case series comprised five cases, but only two had sufficient clinical information both of which are shown here; eboth PEs occurred after initiation of effective treatment but before resolution, which occurred after indicated treatments.
Responses to treatment in the referenced cases were similar to those of our patient. Lesions regressed as early as one day after therapy was initiated. Protein C and protein S levels often took weeks to months to return to normal reference levels. As noted in Table 3 some patients lost extremities to gangrene, emphasizing the need for immediate initiation of anti-coagulation as well as surgical excision of gangrene to prevent subsequent sepsis.

Conclusion

We report the first known case of idiopathic PF without protein C or S deficiency and necessitating chronic anti-coagulation. Pediatric patients presenting with indolent, symmetric, necrotic, eschar-like lesions who have an unrevealing infectious, inflammatory and hematologic work-up should undergo an empiric trial of anti-coagulation to help prevent downstream catastrophic consequences of PF. Starting anti-coagulation decisively may also help to prevent developmental delays in rapidly growing infants with this disease.

Consent

Written informed consent was obtained from the patient's next-of-kin for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Acknowledgements

The authors thank the pediatric hospital service members who helped to conduct our patient's work-up. We thank the Mayo Clinic photography department for the pictures that contribute to the impact of this case report. We also appreciate the input of our medical genetics team, including Dr. Jay Ellison.
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://​creativecommons.​org/​licenses/​by/​2.​0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

FM, KP, EB and CB admitted the patient to the pediatric hospital service, performed the patient work-up and wrote the case report. FM was a major contributor in writing the manuscript and did the literature review. DD and VR conducted additional dermatologic and hematologic investigations, respectively. All authors read and approved the final manuscript.

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