Treatment of meningococcal purpura fulminans

In France, the incidence of meningococcal infections is increasing. The mos t severe presentation, called purpura fulminans, has a death rate of 20-25% ; 5 to 20% of the survivors need skin grafts and/or amputations. Diagnosis of invasive meningococcal infection is very difficult when purpura and "tox ic" appearance are absent. one should take into account parents' impression of their ill child. This diagnosis must be evoked in any child presenting with febrile purpura (like in the United Kingdom, parents should be encoura ged to use the "tumbler test" to identify a vasculitic rash); a fulminant f orm is to be suspected in the presence of only one ecchymosis and signs of infection, remembering that recognition of shock is difficult in children. Recently, the Health Authority has recommended to administer a third genera tion cephalosporin promptly (before biological investigations) for any chil d with signs of infection and a necrotic or ecchymotic purpura (> 3 mm of d iameter), and then to refer the patient to the hospital. By grouping the pa tients from 7 studies, it can be observed that preadmission antibiotic admi nistration has a protective effect on mortality (odds ratio: 0.36; 95% conf idence interval. 0.23-0.56); a negative effect was observed in only one of these series. Children with purpura fulminans should be referred to a paedi atric intensive care unit. Management includes antibiotics, steroids, fluid resuscitation and catecholamines (be aware of hypoglycaemia, particularly in infants, and hypocalcaemia). Treatment of cutaneous necrosis and distal ischemia is difficult and still controversial: antithrombin, protein C, tis sue plasminogen activator and vasodilator infusion have no proven efficacy. Cases must be rapidly notified to the Public Health Service who will insti tute chemoprophylaxis for close contacts. Given the predominance of serogro up B in France, we hope that an efficient vaccine will soon become availabl e. (C) 2001 Editions scientitiques et medicales Elsevier SAS.