J Reconstr Microsurg 2002; 18(1): 017-022
DOI: 10.1055/s-2002-19704
Copyright © 2002 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

Sequential Microsurgical Flap Reconstruction Following Purpura Fulminans during Infancy and Childhood

A. Jester1 2 , K.-L. Waag1 2 , G. Germann1 2 , B. Bickert1
  • 1Department of Hand, Plastic and Reconstructive Surgery-Burn Centre-BG-Trauma Center Ludwigshafen, Ludwigshafen, Germany
  • 2Department of Plastic and Hand Surgery, The University of Heidelberg, Germany
Further Information

Publication History

Publication Date:
24 January 2002 (online)

ABSTRACT

Purpura fulminans is a potentially lethal complication of meningococcal septicemia, characterized by progressive hemorrhagic skin lesions, which can result in extensive necrosis and mummification of all the extremities. With improving survival rates in infancy and childhood, plastic surgeons are challenged more often to provide sufficient and stable soft-tissue coverage. Usually, conservative methods, such as skin grafting or amputation, are favored by many pediatric surgeons, since further specialized departments and training are not required. Often secondary reconstructive procedures to improve soft-tissue coverage have to be performed to achieve proper prosthetic fitting. Microsurgical techniques are used only in selected cases, after failure of other procedures for defect coverage.

In two cases of post-acute purpura fulminans, two free flaps and three microsurgically dissected flaps were used as primary measures for defect coverage and preservation of stump length. Despite the presence of vasculitis, all flaps survived. In a third case, secondary reconstructive measures had to be performed 1 year after purpura fulminans due to insufficient soft-tissue coverage after lower leg amputation. This patient also had contractures on both hands and no grip function after complete finger loss. Several microsurgical procedures were performed to improve grip function and soft-tissue coverage.

The primary use of microsurgical techniques prevents lengthy secondary reconstructive measures.

REFERENCES

  • 1 Bhullar I S, Hansbrough J. Etiology and optimal treatment of severe cases of meningococcal purpural fulminans.  Contemporary Surg . 1997;  51 352-56
  • 2 Toews W H, Bass J W. Skin manifestation of meningococcal infection: an immediate indicator of prognosis.  Am J Dis Child . 1974;  127 173-78
  • 3 Cremer B, Leclerc F, Jude R. Are there specific hemostatic abnormalities in children surviving septic shock with purpura and having skin necrosis or limb ischemia that need skin grafts or limb amputation?.  Eur J Pediatr . 1999;  138 127-132
  • 4 Powars D R, Larsen R, Johnson J. Epidemic meningococcemia and purpura fulminans with induced protein C deficiency.  Clin Infect Dis . 1993;  17 254-60
  • 5 Herrera R, Hobar P C, Ginsburg C M. Surgical intervention for the complications of meningococcal-induced purpura fulminans.  Pediatr Infect Dis J . 1994;  13 734-7
  • 6 Whitney T M, Buncke H J, Lineaweaver W C, Alpert B S. Multiple microvascular transplants: a preliminary report of simultaneous versus sequential reconstruction.  Ann Plast Surg . 1989;  22 392-404
  • 7 Huang D B, Price M, Pokorny J. Reconstructive surgery in children after meningococcal purpura fulminans.  J Pediatr Surg . 1999;  34.3 595-601
  • 8 Redett R, Bury T F, McClinton M A. The use of simultaneous free latissimus dorsi tissue transfers for reconstruction of bilateral upper extremities in a case of purpura fulminans.  J Hand Surg . 2000;  25A 559-564
  • 9 Gurevitch P S, Barsukov V S, Popov N P. Vascular changes in hyperacute meningococcal sepsis as a manifestation of pathogenic action of immune complexes.  Cor Vasa . 1983;  25.6 443-449
  • 10 Braendtzaeg P, Halstensen A, Kierulf P. Molecular mechanisms in the compartmentalized inflammatory response presenting as meningococcal meningitis or septic shock.  Microbiol Pathogenesis . 1992;  13 423-431
  • 11 Mele J A, Lindner S, Capozzi A. Treatment of thromboembolic complications of fulminant mengococcal septic shock.  Ann Plast Surg . 1997;  38.3 283-290
  • 12 Ikeda C, Capozzi A. Management of skin loss in meningococcal infection.  Ann Plast Surg . 1987;  19.4 375-77
  • 13 Paris J J, Newman V. Ethical issues in quadruple amputation in a child with meningococcal septic shock.  J Perinatol . 1993;  13 56-8
  • 14 Jacobs R F, Hsi S, Wilson C B. Apparent meningococcemia: clinical features of disease due to Haemophilus influenzae and Neisseria meningitis Pediatrics .  1983;  72.4 469-72
  • 15 Yuen J C. Free-muscle-flap coverage of exposed knee joints following fulminant meningococcemia (Comments).  Plast Reconstr Surg . 1997;  99.3 880-4
  • 16 Venkat Ramakishnan V, Krishna A, Damilakos P. Limb salvage using free tissue transfer following meningococcal septicemia (Letter, Comment).  Plast Reconstr Surg . 1998;  101.2 548-0