The Patient with Purpura in the ICU or in the Emergency Room
A serious life-threatening infection, especially meningococcemia or endocarditis, should always be considered in acutely ill patients with purpura. A haematological work-up including platelet count, fibrinogen, plasma D-dimer levels, thrombin time and fib
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The Patient with Purpura in the ICU or in the Emergency Room Dan Lipsker
Not to be missed ACUTE PURPURA HIGH FEVER & SEPSIS
PETECHIAL PURPURA -Endocarditis -Septicemia
STELLAR AND/OR RETIFORM PURPURA, Necrotic livedoid ecchymotic rapidly extensive
PURPURA FULMINANS Emergency treatment
-meningococceal sepsis -varicella gangraenosa -Haemophilus influenzae -Streptococcus pneumoniae - gram negative bacterial infections - Plasmodium falciparum - other infections
Purpura may be a feature of drug & viral eruptions
LOW OR NO FEVER ; NO SEPSIS PURPURA + BLEEDING DISORDER ecchymoses, mucosal bleeding
STELLAR AND/OR RETIFORM PURPURA, necrosis; Cyanosis ulceration,
cholesterol THROMBOTIC MICROANGIOPATHY # Infection (to be excluded) # Embolism :cholesterol, myxoma
# Thrombosis & hyperviscocity:
-Antiphospholipid antibody syndrome -Thrombotic thrombocytopenic purpura -Warfarin induced skin necrosis -Disseminated IV coagulation -Monoclonal gammapathies, cryo -Sickle cell disease -Myeloproliferative disorders
#Non vasculitic vessel wall pathology:
-Calciphylaxis -Hyperoxaluria -Amyloidosis -Radiation arteriopathy
# vasospasm:
-Thrombopenia: Peripheral: idiopathic thrombopenic purpura, Central -.thrombopathies -haemophilia, -excess of anticoagulant treatment Disseminated intravascular INFILTRATED PETECHIAL PURPURA - Septic vasculitis - Systemic vasculitis with cutaneous involvement, including micro-PAN, Wegener granulomatosis, PAN, … - Cutaneous leucocytoclastic vasculitis and cutaneous PAN
D. Lipsker Clinique Dermatologique 1, Place de l’hôpital, 67091 Strasbourg Cedex, France
J. Revuz et al. (eds.), Life-Threatening Dermatoses and Emergencies in Dermatology, DOI: 10.1007/978-3-540-79339-7_32, © Springer-Verlag Berlin Heidelberg 2009
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Core Messages
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A serious life-threatening infection, especially meningococcemia or endocarditis, should always be considered in acutely ill patients with purpura. A haematological work-up including platelet count, fibrinogen, plasma D-dimer levels, thrombin time and fibrin degradation products should be performed in patients presenting with purpura in the emergency room. Stellate and retiform (net-like arrangement) purpura must always raise concern, because they are indicative of an acute thrombotic purpura, of which purpura fulminans is one possible cause.
The goal in the acutely ill patient with purpura is not to miss a serious but curable infection or a haematological disorder. A cutaneous haemorrhage is called purpura. It is a red spot that does not blanch with pressure. Depending on origin of purpura, the same process that provokes cutaneous bleeding might be responsible of bleeding in other organs. Purpura can result from different mechanisms and four disease categories, with overlapping mechanisms, should be considered in patients with acute onset purpura: – Serious infectious diseases, especially meningococcemia and endocarditis – Haematological disorders, either involving primary haemostasis, as for example thrombopenia (< 20,000 m
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