Use of recombinant tissue plasminogen activator in children with meningococcal purpura fulminans: a retrospective study.
OBJECTIVE
Meningococcal disease causes septic shock with associated disseminated intravascular coagulation and hemorrhagic skin necrosis. In severe cases, widespread vascular thrombosis leads to gangrene of limbs and digits and contributes to morbidity and mortality. Uncontrolled case reports have suggested that thrombolytic therapy may prevent some complications, and the use of tissue plasminogen activator (t-PA) has been widespread. Our aim was to summarize the clinical outcome and adverse effects where systemic t-PA has been used to treat children with fulminant meningococcemia.


METHODS
International, multiple-center, retrospective, observational case note study between January 1992 and June 2000.


METHODS
Twenty-four different hospitals in seven European countries and Australia.


METHODS
A total of 62 consecutive infants and children with severe meningococcal sepsis in whom t-PA was used for the treatment of predicted amputations and/or refractory shock (40 to treat severe ischemia, 12 to treat shock, and ten to treat both).


METHODS
t-PA was administered with a median dose of 0.3 mg.kg(-1).hr(-1) (range, 0.008-1.13) and a median duration of 9 hrs (range, 1.2-83).


RESULTS
Twenty-nine of 62 patients died (47%; 95% confidence interval, 28-65). Seventeen of 33 survivors had amputations (11 below knee/elbow or greater loss; six less severe). In 12 of 50 patients to whom t-PA was given for imminent amputation, no amputations were observed. Five developed intracerebral hemorrhages (five of 62, 8%; 95% confidence interval, 0.5-16). Of these five, three died, one developed a persistent hemiparesis, and one recovered completely.


CONCLUSIONS
The high incidence of intracerebral hemorrhage in our study raises concerns about the safety of t-PA in children with fulminant meningococcemia. However, due to the absence of a control group in such a severe subset of patients, whether t-PA is beneficial or harmful cannot be answered from the unrestricted use of the drug that is described in this report. Our experience highlights the need to avoid strategies that use experimental drugs in an uncontrolled fashion and to participate in multiple-center trials, which are inevitably required to study rare diseases.
Department of Pediatrics, University of Graz, Austria.
Werner
W
Zenz
Bettina
B
Zoehrer
Michael
M
Levin
Sergio
S
Fanconi
Tassos D
TD
Hatzis
Geoff
G
Knight
Marcus
M
Müllner
Saul N
SN
Faust
D000671:Amputation, Surgical / Q000706:statistics & numerical data; D001315:Australia / Q000453:epidemiology; D002543:Cerebral Hemorrhage / Q000453:epidemiology; D002648:Child; D002675:Child, Preschool; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D005060:Europe / Q000453:epidemiology; D005260:Female; D006801:Humans; D011695:IgA Vasculitis / Q000188:drug therapy* / Q000401:mortality; D007223:Infant; D007231:Infant, Newborn; D007261:Infusions, Intra-Arterial; D007262:Infusions, Intravenous; D008297:Male; D008589:Meningococcal Infections / Q000188:drug therapy* / Q000401:mortality; D012189:Retrospective Studies; D016019:Survival Analysis; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*
D010959:Tissue Plasminogen Activator