Use of protein-C concentrate, heparin, and haemodiafiltration in meningococcus-induced purpura fulminans.

Abstract

BACKGROUND:

Inflammatory and coagulation processes are both affected in meningococcaemia. Severe acquired protein-C deficiency in meningococcaemia is usually associated with substantial mortality: in survivors, skin grafts, amputation, and end-organ failure are not uncommon. Protein C is a natural anticoagulant and also has important anti-inflammatory activity. We assessed the effects of early replacement therapy with protein-C concentrate together with continuous veno-venous haemodiafiltration and conventional treatment in meningococcaemia.

METHODS:

12 patients aged between 3 months and 27 years with meningococcaemia and severe acquired protein-C deficiency (mean 0.20 IU/mL) were studied. All patients had septic shock, widespread purpura, skin necrosis, and disseminated intravascular coagulopathy. After a test dose of protein-C concentrate, patients received a continuous infusion with the dose adjusted daily to keep the plasma concentration between 0.8 and 1.2 IU/mL. 11 patients were given unfractionated intravenous heparin (10-15 IU kg-1 h-1). Nine patients had haemodiafiltration and one had peritoneal dialysis. The Glasgow meningococcal septicaemia prognostic score and the paediatric risk of mortality score predicted a minimum mortality of 80% and 57%, respectively.

FINDINGS:

No patient died. No adverse reactions to the treatment were seen. Two patients had lower-limb amputations, one of whom had a thrombotic cerebrovascular accident; both patients had received the protein-C concentrate and heparin later than the rest of the group (60 h [16.97] vs 12 h [3.13]). One patient developed chronic renal failure despite receiving protein-C infusion 15 h after admission.

INTERPRETATION:

The acquired severe deficiency of protein C in meningococcaemia contributes to the pathogenesis of the thrombotic necrotic lesions in the skin and other organs and probably has an important role in the inflammatory response. Protein-C therapy is merely one approach to improve the host response in this syndrome. We suggest that a double-blind, randomised, controlled multicentre trial is needed to confirm our results.

• Authors: O P Smith, B White, D Vaughan, M Rafferty, L Claffey, B Lyons, W Casey
• Journal: Lancet (London, England) (Lancet) Vol. 350 Issue 9091 Pg. 1590-3 (Nov 29 1997) ISSN: 0140-6736 [Print] England
• PMID: 9393338 (Publication Type: Clinical Trial, Journal Article)

Chemical References

• Anticoagulants
• Protein C
• Heparin

Topics

• Adolescent
• Adult
• Anticoagulants (therapeutic use)
• Child
• Child, Preschool
• Female
• Hemodiafiltration
• Heparin (therapeutic use)
• Humans
• IgA Vasculitis (etiology, therapy)
• Male
• Meningitis, Meningococcal (complications, therapy)
• Prognosis
• Protein C (therapeutic use)
• Treatment Outcome