Endgames Case Review

Purpura in a 5 year old girl

BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2530 (Published 15 June 2017) Cite this as: BMJ 2017;357:j2530
  1. Chi-Hone Lien, department director1,
  2. Ming-Dar Lee, paediatrician1,
  3. Chien-Yu Lin, paediatrician
  1. 1Department of paediatrics, Hsinchu Mackay Memorial Hospital, Hsinchu City, Taiwan
  2. 2Division of infection and pathway medicine, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
  1. Correspondence to C-Yu Lin, v1clin3{at}exseed.ed.ac.uk

A 5 year old girl presented with a one day history of fever, coryzal symptoms, and multiple skin lesions. She also reported abdominal pain and had vomited once. Physical examination revealed hypotension and multiple petechial bruises and purpura-like lesions over the four limbs and the face (fig 1). Over 12 hours, the skin lesions evolved into irregular gangrenous purpura with a central dusky necrosis surrounded by fading redness (fig 2). Blood tests revealed anaemia, thrombocytopenia, high C reactive protein, acute renal failure, and coagulopathy.

Fig 1 Multiple petechial and purpuric lesions

Fig 2 Irregular gangrenous purpura with a central dusky necrosis surrounded by fading redness

Questions

  1. What is the most likely diagnosis?

  2. How would you manage the most likely diagnosis?

  3. What are the preventive measures?

Answers

1. What is the most likely diagnosis?

Short answer

Purpura fulminans caused by Neisseria meningitidis.

Discussion

Purpura fulminans refers to a rapidly progressive thrombotic disorder that manifests with disseminated intravascular coagulation, intravascular thrombosis, and haemorrhagic infarction of the skin.1 It can herald multiple organ failure and has a high mortality rate (10%~ >50%).2 The disease course is fulminant, and early recognition of purpura fulminans is crucial for successful treatment.2 The initial skin lesions can …

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