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Clinical spectrum and short-term outcome of adult patients with purpura fulminans: a French multicenter retrospective cohort study

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Abstract

Purpose

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.

Methods

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).

Results

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.

Conclusion

Purpura fulminans carries a high mortality and morbidity. Pneumococcal PF leads to a higher risk of amputation.

Trials registration

NCT03216577.

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Acknowledgements

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).

Author information

Authors and Affiliations

  1. Service de Réanimation Médicale, Groupe de Recherche CARMAS, Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Universitaire Henri Mondor, 51, Avenue du Maréchal de Lattre de Tassigny, 94010, Créteil, France

    Damien Contou, Christian Brun-Buisson, Armand Mekontso Dessap & Nicolas de Prost

  2. Service de Réanimation Polyvalente, Centre Hospitalier Victor Dupouy, 69 Rue du Lieutenant-Colonel Prudhon, 95100, Argenteuil, France

    Damien Contou

  3. Service de Réanimation Médicale, Hôpital Bichat Claude Bernard, Assistance Publique-Hôpitaux de Paris, 46 Rue Henri Huchard, 75018, Paris, France

    Romain Sonneville

  4. Service de Santé Publique, Hôpital Henri-Mondor, Assistance Publique-Hôpitaux de Paris, 51,Avenue du Maréchal de Lattre de Tassigny, 94010, Créteil, France

    Florence Canoui-Poitrine & Richard Layese

  5. Clinical Epidemiology and Ageing Unit, Université Paris-Est, UPEC, DHU A-TVB, IMRB-EA7376 CEpiA, Créteil, France

    Florence Canoui-Poitrine

  6. Service de Réanimation Médico-chirurgicale, Centre Hospitalier Départemental de Vendée, Boulevard Stéphane Moreau, 85925, La Roche-sur-Yon, France

    Gwenhaël Colin

  7. Service de Réanimation Médicale, Centre Hospitalier Universitaire de Poitiers, 2 Rue de la Milétrie, 86021, Poitiers, France

    Rémi Coudroy

  8. INSERM CIC1402, ALIVE Group, Université de Poitiers, Poitiers, France

    Rémi Coudroy

  9. Service de Réanimation Médicale, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 27 Rue du Faubourg Saint-Jacques, 75014, Paris, France

    Frédéric Pène

  10. Service de Réanimation Médicale, Centre Hospitalier Universitaire de Rennes, 2 Rue Henri le Guilloux, 35033, Rennes, France

    Jean-Marc Tadié

  11. Réanimation Médicale, Hospices Civils de Lyon, Groupement Hospitalier Edouard Herriot, 3 Quai des Célestins, 69002, Lyon, France

    Martin Cour

  12. Service de Réanimation Médicale, Centre Hospitalier Universitaire de Rouen, 1 Rue de Germont, 76000, Rouen, France

    Gaëtan Béduneau

  13. Service de Réanimation Polyvalente, Centre Hospitalier de Melun, 98 Rue Freteau de Peny, 77000, Melun, France

    Antoine Marchalot

  14. CHRU de Tours, Médecin Intensive Réanimation, CIC 1415, CRICS-TriggerSEP, Centre d’étude des Pathologies Respiratoires, INSERM U1100, Université de Tours, Tours, France

    Laurent Guérin

  15. Service de Réanimation Polyvalente, Centre Hospitalier de Melun, 98 Avenue du Général Patton, 77000, Melun, France

    Sébastien Jochmans

  16. Service de Réanimation Médicale, Centre Hospitalier Régional Universitaire, 2 Boulevard Tonnellé, 37000, Tours, France

    Stephan Ehrmann

  17. Service de Réanimation Médicale, Centre Hospitalier Universitaire Grenoble Alpes, Avenue Maquis du Grésivaudan, 38700, La Tronche, France

    Nicolas Terzi

  18. Service de Réanimation Médicale, Centre Hospitalier Régional Universitaire de Lille, 2 Avenue Oscar Lambret, 59000, Lille, France

    Sébastien Préau

  19. Service de Réanimation Médicale, Centre Hospitalier Régional d’Orléans, 1 Rue Porte Madeleine, 45000, Orléans, France

    François Barbier

  20. Service de Réanimation Médico-Chirurgicale, GH Le Havre, 76600, Le Havre, France

    Guillaume Schnell

  21. Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris, 178 Rue des Renouillers, 92700, Colombes, France

    Damien Roux

  22. Service de Réanimation Médico-Chirurgicale, Centre Hospitalier de Tourcoing, 55 Rue du Président Coty, 59200, Tourcoing, France

    Olivier Leroy

  23. Service de Réanimation Médico-Chirurgicale, Centre Hospitalier Intercommunal Poissy/Saint-Germain-en-Laye, 10 Rue du Champ Gaillard, 78300, Poissy, France

    Claire Pichereau

  24. Service de Réanimation Médico-Chirurgicale, Hôpital Maison Blanche, Centre Hospitalier Universitaire de Reims, 51092, Reims, France

    Elodie Gélisse

  25. Service de Réanimation Médicale, Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Universitaire Saint-Louis, 1 Avenue Claude Vellefaux, 75010, Paris, France

    Lara Zafrani

Authors
  1. Damien Contou
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  2. Romain Sonneville
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  3. Florence Canoui-Poitrine
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  4. Gwenhaël Colin
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  5. Rémi Coudroy
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  6. Frédéric Pène
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  7. Jean-Marc Tadié
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  8. Martin Cour
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  9. Gaëtan Béduneau
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  10. Antoine Marchalot
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  11. Laurent Guérin
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  12. Sébastien Jochmans
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  13. Stephan Ehrmann
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  14. Nicolas Terzi
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  15. Sébastien Préau
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  16. François Barbier
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  17. Guillaume Schnell
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  18. Damien Roux
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  19. Olivier Leroy
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  20. Claire Pichereau
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  21. Elodie Gélisse
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  22. Lara Zafrani
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  23. Richard Layese
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  24. Christian Brun-Buisson
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  25. Armand Mekontso Dessap
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  26. Nicolas de Prost
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Consortia

For the Hopeful Study Group

  • Laurent Argaud
  • , François Barbier
  • , Amélie Bazire
  • , Gaëtan Béduneau
  • , Frédéric Bellec
  • , Pascal Beuret
  • , Pascal Blanc
  • , Cédric Bruel
  • , Christian Brun-Buisson
  • , Gwenhaël Colin
  • , Delphine Colling
  • , Alexandre Conia
  • , Rémi Coudroy
  • , Martin Cour
  • , Damien Contou
  • , Fabrice Daviaud
  • , Vincent Das
  • , Jean Dellamonica
  • , Nadège Demars
  • , Stephan Ehrmann
  • , Arnaud Galbois
  • , Elodie Gelisse
  • , Julien Grouille
  • , Laurent Guérin
  • , Emmanuel Guérot
  • , Samir Jaber
  • , Caroline Jannière-Nartey
  • , Sébastien Jochmans
  • , Mathieu Jozwiak
  • , Pierre Kalfon
  • , Antoine Kimmoun
  • , Alexandre Lautrette
  • , Jérémie Lemarié
  • , Charlène Le Moal
  • , Christophe Lenclud
  • , Nicolas Lerolle
  • , Olivier Leroy
  • , Antoine Marchalot
  • , Bruno Mégarbane
  • , Armand Mekontso Dessap
  • , Etienne de Montmollin
  • , Frédéric Pène
  • , Claire Pichereau
  • , Gaëtan Plantefève
  • , Sébastien Préau
  • , Gabriel Preda
  • , Nicolas de Prost
  • , Jean-Pierre Quenot
  • , Sylvie Ricome
  • , Damien Roux
  • , Bertrand Sauneuf
  • , Matthieu Schmidt
  • , Guillaume Schnell
  • , Romain Sonneville
  • , Jean-Marc Tadié
  • , Yacine Tandjaoui
  • , Martial Tchir
  • , Nicolas Terzi
  • , Xavier Valette
  • , Lara Zafrani
  •  & Benjamin Zuber

Corresponding author

Correspondence to Damien Contou.

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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.

Additional information

The members of the Hopeful Study Group are listed in “Acknowledgements” section.

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Contou, D., Sonneville, R., Canoui-Poitrine, F. et al. Clinical spectrum and short-term outcome of adult patients with purpura fulminans: a French multicenter retrospective cohort study. Intensive Care Med 44, 1502–1511 (2018). https://doi.org/10.1007/s00134-018-5341-3

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