Standard treatment includes the immediate, meaning in the emergency room, administration of 2 different antibiotics to cover both Staph and Neisseria. It will most frequently involve PICU admission, often intubation and ventilation, and an aggressive fluid resuscitation similar to that seen with burns. Different from burns, though, these patients will often require pressors and inotropes to support their circulation. Treatment will also require replacement of blood products, including packed red blood cells, fresh frozen plasma and platelets and, often, additional clotting factors as well. Topical wound care, which is something that is familiar to me, is often the point at which the surgeon becomes involved.
I am going to present a case of a 5-month-old female with a 3-4 day history of upper respiratory congestion and fever progressing to lethargy and a rash, prompting her visit to the hospital. She was admitted to the PICU, given 2 antibiotics, pressors, ventilatory support, hydrocortisone and blood products. Her condition worsened and she was transferred to Children's Hospital where an antifungal agent was added, her blood pressure was supported with milrinone and further blood products, including antithrombin III, were given.
She developed, over time, severe purpura which progressed to symmetric peripheral gangrene. She subsequently had five operations, including excision of the necrotic tissue, allografting of those defects and subsequently amputation and autografting. Unfortunately, her outcome included, in the end analysis, 4-extremity amputations, altered mental status and death.
The accompanying pictures show the progression of her disease over time. It is all a typical pattern for purpura fulminans.