Key words: purpura fulminans, pneumococcus, sepsis Table 1 Laboratory findings on admission Hematology Coagulation RBC 404 x 104 /mm3 PT 14.6 sec Hb15

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1 Key words: purpura fulminans, pneumococcus, sepsis Table 1 Laboratory findings on admission Hematology Coagulation RBC 404 x 104 /mm3 PT 14.6 sec Hb15.8 g/dlfib mg/dl WBC 115 x 102 /mm3 FDP fcg/ml Plt 5.3 x 104 /mm3 ATIII 53 % ESR4 mm/lhr Blood Gas Analysis Biochemistry (room air) GOT85 IU/L PH GPT21 IU/L pco mmhg LDH 1,283 IU/L p mmhg Cr3.0 mg/dl CPK1,221 IU/L HCO mmol/l BUN42 mg/dl BE-8.9 mmol/l BS147 mg/dl CRP >12 mg/di

2 1118 大西て代謝性アシドーシスを認めた(Table 1).胸基喜他部急検査の)測レ線上は異常を認めなかった. 経過:入院時,ショック,腎融解症と診断され,そ疑われた.補液,昇不全,DIC,横紋筋 (ARDS)を院時より時間を逐って四肢に末梢ほど強い紫斑,チ (Fig-1).CPKも日よりadult ンピシリン(ABPC)12 g/日投与等で初期治療を開始したが,入ゼが生じ,翌翌31日著増し15,000以 second Fig. 2 marked cyanosis hospital acral 院翌 syndrome 吸不全が進行し,1993年1月日)より人工呼吸器管理となった. Pneumoniaeが断.多 of left hand 分離され,同菌による敗血症と診臓器不全の管理と抗生剤の大量投与を続行 and lower extremity on the day. gangrene of right hand distress 入院時の血液培養及び尿培養よりStreptococcus 上と(緊 and purpura respiratory 発症,呼 1日(第3病アノー日には広範に四肢が暗紫色となった Fig. 1 血症に伴う骨格筋膚の変化や四肢の壊死が進行する一方で,入の基盤として敗血症が最も圧,ア定上限を越え,敗の壊死性病変の進行によるものと診断された.皮 on the 27th hospital and both day immediately before amputation legs. 感染症学雑誌第68巻第9号

3 Table 2 Serial change of protein C antigen and protein S

4 1) Mourice, A. M.: Streptococcus Pneumoniae. In Principles and Practice of Infectious Diseases 3rd ed. (Mandell, G.L., Douglas, R. G. & Bennett, J. E. ed.), p , Churchill Living- stone, New York, ) Chu, D. Z. J. & Blaisdell, F. W.: Purpura fulminans. Am. J. Surg., 143: , ) Johansen, K. & Hansen, S. T.: Symmetrical peripheral gangrene (Purpura fulminans) complicating pneumococcal sepsis. Amer. J. Surg., 165: , 1993.

5 8) Kato, N. & Morioka, T.: Purpura fulminans secondary to Xanthomonas maltiphilia sepsis in an adult with aplastic anemia. J. Dermatol., 18: , ) Bisno, A. L. & Freeman, J. C.: The syndrome of asplenia, pneumococcal sepsis and disseminated intravascular coagulation. Ann. Intern. Med., 72: , ) Johansen, K., Murphy, T., Pavlin, E. & Ledbetter, D.: Digital ischemia complicating pneumococcal sepsis. Reversal with sympathetic blockade. Crit Care Med., 19: , ) Denning, D. W., Gilliland, L., Hewlett, A., Hughes, L. O. & Reid, C. D. L.: Peripheral symmetrical gangrene successfully treated with epoprostenol and tissue plasminogen activator. Lancet, 2: , ) Hautekeete, M. L., Berneman, Z. N., Bridts, C., Buyssens, N. & Peetermans, M. E.: Purpura fulminans in pneumococcal sepsis. Arch. Intern. Med., 146: , ) Marlar, R. A., Endres-Brooks, J. & Miller, C.: Serial studies of protein C and its plasma inhibitor in patients with disseminated intravascular coagulation. Blood, 66: 59-63, ) Winkler, M. J. & Trunkey, D.: Dopamine gangrene: association with disseminated intravascular coagulation. Am. J. Surg., 142: , Purpura Fulminans Complicating Pneumococcal Sepsis: A Case Report Motoki OHNISHI1), Yoshikata SHIMIZU2), Kaori IWATA1), Yasumi OOKOCHI4) & Kenji OOE3) Department of Medicine1), Anaesthesia2) and Pathology3), Asahi General Hospital First Department of Internal Medicine, Tokyo Medical and Dental University, School of Medicine4) An unusual case of a 67-year-old man is reported with fulminant pneumococcal sepsis. He had been healthy before, and the identified predisposing factors were only that he was a chronic alcohol drinker and was a HCV carrier. He presented signs of acute renal failure, liver dysfunction, adult respiratory distress syndrome and disseminated intravascular coagulation. Subsequently purpura fulminans (symmetrical peripheral gangrene) with major extremity involvement developed. He finally survived with amputation of both legs, right forearm and two fingers of left hand. Purpura fulminans is a rare catastophic disease, with initial hemorrhagic skin lesions that progress to gangrene. It usually follows an infectious illness, and although it most commonly occurs in children, it can occur in adults with predisposing factors such as alcoholic, asplenia, AIDS and so on. In adults, pneumococcus and meningococcus are microorganisms that have been reported most frequently as caused agents in Europe and America. But in Japan the previously reported adult case was the only one complicating Xanthomonas maltophilia sepsis, and none accompanying pneumococcal sepsis. Congenital protein C deficiency is recognized to be able to cause purpura fulminans especially in patients with risk factors. In our case, protein C antigen was decreased in the acute stage but gradually increased later toward normal, so this decrease was thought to be concomitant with the initial disseminated intravascular coagulation rather than compatible with protein C deficiency.

BUN, CRP K mg/ cm, 49.6 kg, BMI /72 mmhg, 92/ Hb 6.7 g/dl PT-INR CT 1 MRI 2a, b T1 T2 T1 MRI

BUN, CRP K mg/ cm, 49.6 kg, BMI /72 mmhg, 92/ Hb 6.7 g/dl PT-INR CT 1 MRI 2a, b T1 T2 T1 MRI 20 2 2015 1 2 3 85 K CT Abstract A case of renal subcapsular hematoma resulting from trigger point injection under excessive effect of anticoagulant YAMANE Tateki, UMEDA Akira and SHIMAO Hitoshi An 85-year-old