Clinical spectrum and short-term outcome of adult patients with purpura fulminans: a French multicenter retrospective cohort study
- 728 Downloads
Data on purpura fulminans (PF) in adult patients are scarce and mainly limited to meningococcal infections. Our aim has been to report the clinical features and outcomes of adult patients admitted in the intensive care unit (ICU) for an infectious PF, as well as the predictive factors for limb amputation and mortality.
A 17-year national multicenter retrospective cohort study in 55 ICUs in France from 2000 to 2016, including adult patients admitted for an infectious PF defined by a sudden and extensive purpura, together with the need for vasopressor support. Primary outcome variables included hospital mortality and amputation during the follow-up period (time between ICU admission and amputation, death or end of follow-up).
Among the 306 included patients, 126 (41.2%; 95% CI 35.6–46.9) died and 180 (58.8%; 95% CI 53.3–64.3) survived during the follow-up period [13 (3–24) days], including 51/180 patients (28.3%, 95% CI 21.9–35.5) who eventually required limb amputations, with a median number of 3 (1–4) limbs amputated. The two predominantly identified microorganisms were Neisseria meningitidis (63.7%) and Streptococcus pneumoniae (21.9%). By multivariable Cox model, SAPS II [hazard-ratio (HR) = 1.03 (1.02–1.04); p < 0.001], lower leucocytes [HR 0.83 (0.69–0.99); p = 0.034] and platelet counts [HR 0.77 (0.60–0.91); p = 0.007], and arterial blood lactate levels [HR 2.71 (1.68–4.38); p < 0.001] were independently associated with hospital death, while a neck stiffness [HR 0.51 (0.28–0.92); p = 0.026] was a protective factor. Infection with Streptococcus pneumoniae [sub-hazard ratio 1.89 (1.06–3.38); p = 0.032], together with arterial lactate levels and ICU admission temperature, was independently associated with amputation by a competing risks analysis.
Purpura fulminans carries a high mortality and morbidity. Pneumococcal PF leads to a higher risk of amputation.
KeywordsPurpura fulminans Sepsis Septic shock Limb amputation Streptococcus pneumoniae Neisseria meningitidis
List of the members of the Hopeful Study Group: Laurent Argaud (Lyon), François Barbier (Orléans), Amélie Bazire (Brest), Gaëtan Béduneau (Rouen), Frédéric Bellec (Montauban), Pascal Beuret (Roanne), Pascal Blanc (Pontoise), Cédric Bruel (Saint-Joseph), Christian Brun-Buisson (Mondor, AP-HP), Gwenhaël Colin (La Roche-sur-Yon), Delphine Colling (Roubaix), Alexandre Conia (Chartres), Rémi Coudroy (Poitiers), Martin Cour (Lyon), Damien Contou (Henri Mondor—AP-HP and Argenteuil), Fabrice Daviaud (Corbeil-Essonnes), Vincent Das (Montreuil), Jean Dellamonica (Nice), Nadège Demars (Antoine Beclère, AP-HP), Stephan Ehrmann (Tours), Arnaud Galbois (Quincy sous Sénart), Elodie Gelisse (Reims), Julien Grouille (Blois), Laurent Guérin (Ambroise Paré—AP-HP), Emmanuel Guérot (HEGP, AP-HP), Samir Jaber (Montpellier), Caroline Jannière-Nartey (Créteil), Sébastien Jochmans (Melun), Mathieu Jozwiak (Kremlin Bicêtre, AP-HP), Pierre Kalfon (Chartres), Antoine Kimmoun (Nancy), Alexandre Lautrette (Clermont Ferrand), Jérémie Lemarié (Nancy), Charlène Le Moal (Le Mans), Christophe Lenclud (Mantes La Jolie), Nicolas Lerolle (Angers), Olivier Leroy (Tourcoing), Antoine Marchalot (Dieppe), Bruno Mégarbane (Lariboisière, AP-HP), Armand Mekontso Dessap (Mondor, AP-HP), Etienne de Montmollin (Saint-Denis), Frédéric Pène (Cochin, AP-HP), Claire Pichereau (Poissy), Gaëtan Plantefève (Argenteuil), Sébastien Préau (Lille), Gabriel Preda (Saint-Antoine, AP-HP), Nicolas de Prost (Henri Mondor, AP-HP), Jean-Pierre Quenot (Dijon), Sylvie Ricome (Aulnay-sous-Bois), Damien Roux (Louis Mourier, AP-HP), Bertrand Sauneuf (Cherbourg), Matthieu Schmidt (Pitié Salpétrière, AP-HP), Guillaume Schnell (Le Havre), Romain Sonneville (Bichat, AP-HP), Jean-Marc Tadié (Rennes), Yacine Tandjaoui (Avicenne, AP-HP), Martial Tchir (Villeneuve Saint Georges), Nicolas Terzi (Grenoble), Xavier Valette (Caen), Lara Zafrani (Saint-Louis, AP-HP), Benjamin Zuber (Versailles).
Compliance with ethical standards
Conflicts of interest
This study received a financial support of the Fondation de France (#0069110). The authors have not disclosed any potential conflicts of interest.
- 1.Vincent JL, Nadel S, Kutsogiannis DJ, Gibney RT, Yan SB, Wyss VL, Bailey JE, Mitchell CL, Sarwat S, Shinall SM, Janes JM (2005) Drotrecogin alfa (activated) in patients with severe sepsis presenting with purpura fulminans, meningitis, or meningococcal disease: a retrospective analysis of patients enrolled in recent clinical studies. Crit Care 9:R331–R343CrossRefPubMedPubMedCentralGoogle Scholar
- 2.Lerolle N, Carlotti A, Melican K, Aubey F, Pierrot M, Diehl JL, Caille V, Hekimian G, Gandrille S, Mandet C, Bruneval P, Dumenil G, Borgel D (2013) Assessment of the interplay between blood and skin vascular abnormalities in adult purpura fulminans. Am J Respir Crit Care Med 188:684–692CrossRefPubMedGoogle Scholar
- 3.Fitzgerald CJ, Pranikoff TV, Ross GA, Mou S, Givner LB, Shetty AK (2011) Purpura fulminans caused by community-associated methicillin-resistant Staphylococcus aureus. Am J Emerg Med 30(1013):e1011–e1014Google Scholar
- 12.Levin M, Quint PA, Goldstein B, Barton P, Bradley JS, Shemie SD, Yeh T, Kim SS, Cafaro DP, Scannon PJ, Giroir BP (2000) Recombinant bactericidal/permeability-increasing protein (rBPI21) as adjunctive treatment for children with severe meningococcal sepsis: a randomised trial. rBPI21 Meningococcal Sepsis Study Group. Lancet 356:961–967CrossRefPubMedGoogle Scholar
- 15.Vincent JL, Moreno R, Takala J, Willatts S, De Mendonca A, Bruining H, Reinhart CK, Suter PM, Thijs LG (1996) The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med 22:707–710CrossRefPubMedGoogle Scholar
- 21.Barquet N, Domingo P, Cayla JA, Gonzalez J, Rodrigo C, Fernandez-Viladrich P, Moraga-Llop FA, Marco F, Vazquez J, Saez-Nieto JA, Casal J, Canela J, Foz M (1999) Meningococcal disease in a large urban population (Barcelona, 1987–1992): predictors of dismal prognosis. Barcelona Meningococcal Disease Surveillance Group. Arch Intern Med 159:2329–2340CrossRefPubMedGoogle Scholar