A 15-month-old pediatric patient diagnosed with purpura fulminans secondary to severe meningococcal infection in lower extremities complicated with multiple organ failure, septic shock, acute pulmonary edema complicated by nosocomial necrosis requiring ventilatory supportD
Four days after admission to the pediatric intensive care unit (ICU), the patient was referred to our department for evaluation of skin lesions.
We observed flictenes and signs of skin suffering in the right upper limb (RLJ) and mainly in the lower limbs (LLL), accompanied by purpuric lesions and irreversible necrosis of both feet.
Given the torpid evolution and extension of the lesions, surgical intervention was decided 17 days later.
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We performed superficial debridement to place the deep necrosis zone and Biobrane® (Biobrane, Smith & Nephew B.V., Barcelona, Spain).
The intervened areas were cured before and after surgery.
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Because of the poor evolution of the wounds, we contacted the Traumatology Service for reassessment.
Two bone scans were performed within 15 days to assess the status of both lower limbs and both reported the existence of bone tissue without uptake from approximately the proximal third of the tibia.
Due to the established posterior mobility of the nerve, with evident irreversible necrosis and bad odor, pediatric traumatologists decide, according to the family, to perform bilateral infra-rotulian amputation to preserve the maximum.
Pathological examination revealed multiple vascular thrombosis and necrosis requiring bleaching of the skin and tissues.
During the postoperative period, necrosis of blade tissues was further limited in the coverage area of both amputation stumps, resulting in exposure of the tibial and peroneal segments of both extremities.
Due to the short length of the stumps, a new amputation of the segments and coverage with proximal tissue could not be performed, as it would not guarantee the possible future placement of the prostheses.
Therefore, we chose to start negative pressure therapy with VAC® system to promote tissue growth and removal of exudate from wounds.
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First, the limbs were washed with 0.4% jabonosal chlorhexidine solution and saline solution.
Then, VAC-Granufoam® dressings were placed according to VAC® therapy clinical guidelines.
At first, we used the median dressings according to the Pitta-VAC® model (10.11), a soft dressing, as two halves, so that each of them is partially separated to be placed over the area to treat.
This technique is described as fast in its design and execution.
However, in areas where necrosis is patched, we have noted that this system makes the skin healthy if it comes into direct contact with the reticulated polyurethane dressing, making it necessary to place it under hydrocolloid dressings.
We decided, therefore, to return to the classic placement of dressings: small fragments fixed on the loss of substance connected to each other by intimate contact in one of its parts.
The pressure used was -125 mmHg and continuously.
Granulation in bed and improvement were evident.
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After 40 days of therapy, we were able to recover exposed bone segments and after placement of regenerative plates Integra® (left thigh bone plates, 1 month thick mesh), definitive coverage of the mesh San Priest, France.
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The evolution was satisfactory, with complete epithelialization of the amputation stumps, and the patient was discharged after exactly 4 months of hospitalization.
We continued outpatient follow-up for 3 more weeks.
Two years after the event, the patient is undergoing rehabilitation of her neurological sequelae, trunk control and adaptation to infracondylar prosthesis.
