Case report
Purpura Fulminans Associated with Streptococcus pneumoniae Septicemia in an Asplenic Pediatric Patient
Púrpura fulminante en relación con septicemia por Streptococcus pneumoniae en un paciente pediátrico asplénico
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Konda, D. Zell, C. Milikowski, J. Alonso-Llamazares" "autores" => array:4 [ 0 => array:3 [ "nombre" => "S." "apellidos" => "Konda" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "D." "apellidos" => "Zell" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "C." "apellidos" => "Milikowski" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:4 [ "nombre" => "J." "apellidos" => "Alonso-Llamazares" "email" => array:1 [ 0 => "jalonso2@med.miami.edu" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Dermatology, Howard University College of Medicine, Washington, DC, United States" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, United States" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Púrpura fulminante en relación con septicemia por <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> en un paciente pediátrico asplénico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 673 "Ancho" => 900 "Tamanyo" => 258019 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">H&E 400×; thrombosed vessel and red blood cell extravasation.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 5-year-old Hispanic boy with a past medical history of premature birth at 24 weeks gestation and multivisceral organ transplantation (MVTx) at 2 years of age due to a hepatoblastoma with extensive abdominal compromise was admitted at the ICU with a fever of 103.4° F (39.7<span class="elsevierStyleHsp" style=""></span>°C). He complained of pain in his neck and right leg. He denied the onset of dysuria, cough, or ear pain. The MVTx included the stomach, pancreas, liver, and small and large bowels. He was on oral tacrolimus 1.0<span class="elsevierStyleHsp" style=""></span>mg twice daily to prevent rejection, which was held on admission, and ganciclovir prophylaxis to prevent cytomegalovirus infection secondary to immuno-suppression. The transplant did not include a spleen and consequently he received a pneumococcal conjugate vaccine and was on penicillin prophylaxis due to increased risk of infection. He also had a right lower quadrant ileostomy with normal output and denied any gastrointestinal changes.</p><p id="par0010" class="elsevierStylePara elsevierViewall">On initial examination he was in moderate distress, vasodilated, and hypotensive. After a sepsis workup, he was started with broad spectrum of empiric antibiotics including vancomycin, piperacillin, tazobactam, and ceftriaxone. Venous blood gases revealed a severe mixed acidosis and he was started on fluid resuscitation, pressor support, shock doses of hydrocortisone, and subsequently intubated. Lung edema worsened secondary to extracellular fluid leakage and worsening acute respiratory distress syndrome (ARDS) so transplant surgery placed bilateral pleural pigtail drains to improve ventilation. Hypocalcemia was addressed with continuous calcium infusion and renal failure secondary to sepsis was managed with continuous veno venous hemodiafiltration (CVVHDF).</p><p id="par0015" class="elsevierStylePara elsevierViewall">The day after admission, ecchymoses and petechiae with consolidated irregular areas of blue-black hemorrhagic necrosis and a surrounding erythematous border were noted on his chest and distal extremities (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). He had cyanotic nailbeds with delayed perfusion. We did not have baseline quantitative or functional coagulation assays and levels of protein C, protein S, and antithrombin III were not measured. The rash progressed to numerous tense bullae, which were drained without debridement of the epidermis, and topical mupirocin was applied with Telfa dressing. The drained fluid was sent for culture and had no microbial growth. The dermatology service was consulted and a skin biopsy from the right arm revealed intraepidermal vesicles with focal epidermal necrosis, dermal hemorrhage, and multiple thrombosed vessels in the superficial and reticular dermis without evidence of vasculitis (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 3</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Blood cultures came back as predominantly gram positive cocci in chains consistent with <span class="elsevierStyleItalic">Streptococcus pneumoniae</span>. The antimicrobial regimen was adjusted to linezolid, vancomycin, meropenem, abelcet, and gancyclovir for active coverage of <span class="elsevierStyleItalic">S. pneumoniae</span> septicemia and prophylactic coverage of other flora. He remained afebrile with a resolving leukocytosis and negative blood cultures and the affected areas continued to resolve with scattered hemorrhagic vesicles and crusts. Heparin or clotting factors were not administered because the patient was improving clinically with the adjusted antibiotic regimen by the time the skin biopsy results were obtained. He was weaned to lower settings on the ventilator, his heart rate and blood pressure stabilized, and tacrolimus was restarted due to subtherapeutic levels. Both pleural pigtail drains were removed without complications and CVVHDF was discontinued. He continued to have intermittent hemodialysis and was eventually extubated without complications.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">Purpura fulminans, also known as purpura gangrenosa, was first described by Guelliot in 1884 and is a rapidly progressive syndrome of intravascular thrombosis and hemorrhagic infarction of the skin. It often occurs in infants and small children and is accompanied by vascular collapse, fever and DIC. The disease is further classified into three forms: neonatal purpura fulminans, idiopathic purpura fulminans, and acute infectious purpura fulminans.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> We will focus on the third form, acute infectious purpura fulminans, which our pediatric patient was afflicted with.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Acute infectious purpura fulminans (AIPF) is the most common form and usually occurs in the setting of severe sepsis. It is characterized by large purpura, fever, hypotension, and DIC, although all four features may not be present in every patient. The most common infectious culprits are meningococcus and varicella, followed by gram-negative bacilli, staphylococci, <span class="elsevierStyleItalic">Rickettsia</span>, measles and streptococci, as described in our case.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Including our case, from 1938 to 2011, there have been 19 documented pediatric cases of purpura fulminans in the setting of <span class="elsevierStyleItalic">S. pneumoniae</span> septicemia (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Anatomic or functional asplenia was present in 9 out of 19 patients (47%) and for those cases with documented outcomes, 11 out of 18 patients survived (61%). There was no correlation between the absence or presence of a spleen and survival rates – 5 of 9 asplenic patients survived (56%) and 6 of 9 splenic patients survived (67%).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Gram-negative bacteria are the primary offenders in AIPF due to their ability to harbor endotoxins, such as lipopolysaccharide, in the outer membrane of their cell wall. These endotoxins are potent stimulators of the inflammatory cytokines interleukin (IL)-12, interferon-γ, tumor necrosis factor-α (TNF-α), and IL-1, which consume antithrombin III and proteins C and S. This alters the balance of anticoagulant and procoagulant activity, and ultimately results in a clinical picture of septic shock and DIC. The culprit in our case was a gram-positive encapsulated bacterium, <span class="elsevierStyleItalic">S. pneumoniae</span>, which is rare and often occurs in individuals with immuno-suppression or anatomic or functional asplenia – our patient was afflicted with both. Instead of producing endotoxin, <span class="elsevierStyleItalic">S. pneumoniae</span> releases a high-molecular-weight, glycan-teichoic acid fragment released by hydrolysis of the muramic acid-alanine bonds in the bacterial cell wall. This glycan-teichoic acid fragment is pro-inflammatory and propagates the production of TNF-α, IL-1, prostaglandins, and activation of the complement cascade. In return, vascular endothelial cells express increased cell surface leukocyte adhesion molecules, decreased surface co-factors for thrombin activation of protein C, decreased tissue-type plasminogen activator, and increased type 1 plasminogen inhibitor. This cascade ultimately results in DIC and the production of purpura.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Treatment recommendations for prothrombotic disorders underlying purpura fulminans are still evolving. Management includes supportive therapy, replacement of blood products and clotting factors as appropriate, correction of acid–base and electrolyte abnormalities, and early use of oxygen and mechanical ventilation. Heparin is usually administered as a standard initial therapy to inhibit thrombus formation and consumption of coagulation factors. To avoid further thrombosis, some clinicians favor administering heparin prior to replacement of clotting factors. Protein C has both anti-inflammatory and anticoagulant properties and low levels can be repleted with plasma-derived protein C zymogen concentrates or drotecogin alpha (activated). Fresh frozen plasma (FFP) is also a source of protein C and protein S, but frequent administration is required to maintain adequate plasma levels. Antithrombin III replacement has also been shown to normalize levels and reverse DIC. Patients who need long-term anticoagulation are transitioned to warfarin therapy with overlapping protein C substitution to prevent warfarin-induced skin necrosis.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Documentation of treatment was obtained for 9 out of 19 patients (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Treatment modalities included antibiotics, heparin, fresh frozen plasma, cryoprecipitate, and activated protein C. Even though heparin is generally recommended as a standard initial therapy, it was administered to only one patient – in a case from 1970.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Similarly, only one patient received activated protein C, three received FFP, and one received FFP and cryoprecipitate. Interestingly, 5 of 6 patients survived (83%) after receiving heparin or clotting factors with antibiotics and 3 of 3 patients survived (100%) after receiving antibiotics alone, including our patient. Larger sample sizes are warranted to determine the impact of each of these therapies on survival outcomes of pediatric patients with purpura fulminans.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Additional therapies have been shown to slow the progression of the disease including, recombinant tissue plasminogen activator, prostacyclin, topical nitroglycerin, IV dextran, plasmapheresis, and regional anesthesia. Epsilon aminocaproic acid, vitamin K, ketanserin, hyperbaric oxygen, leech saliva (hirudin), and glucocorticoids have also been utilized with limited anecdotal benefit.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Necrotic tissue should be promptly excised with subsequent wound closure. Further surgical procedures such as escharotomies, fasciotomies, or major amputations might be required once the patient has been stabilized. When amputation is necessary, stump wounds may heal by secondary intention from wound debridement, split-thickness skin grafting, tissue and muscle flaps, plantar skin free transfer, skin expansion, artificial skin, hyperbaric oxygen therapy, and in difficult cases, tissue-engineered skin. In our opinion, early diagnosis and aggressive antibiotic treatment were key factors in the successful outcome of our patient.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "xres261542" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec246085" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres261543" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec246086" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interest" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec246085" "palabras" => array:8 [ 0 => "Purpura fulminans" 1 => "Hemorrhagic necrosis" 2 => "<span class="elsevierStyleItalic">Streptococcus pneumoniae</span>" 3 => "Sepsis" 4 => "Asplenia" 5 => "Immunosuppression" 6 => "Disseminated intravascular coagulation" 7 => "Thrombosis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec246086" "palabras" => array:8 [ 0 => "Púrpura fulminante" 1 => "Necrosis hemorrágica" 2 => "<span class="elsevierStyleItalic">Streptococcus pneumoniae</span>" 3 => "Sepsis" 4 => "Asplenia" 5 => "Inmunosupresión" 6 => "Coagulación intravascular diseminada" 7 => "Trombosis" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Purpura fulminans is a rapidly progressive syndrome of small-vessel thrombosis and hemorrhagic necrosis of the skin accompanied by disseminated intravascular coagulation. We describe a case of <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> septicemia in an asplenic 5-year-old boy on oral tacrolimus, with a past medical history of multivisceral organ transplantation and subsequent development of purpura fulminans on his chest and distal extremities. The acute infectious form of purpura fulminans is usually caused by gram-negative bacteria. Cases secondary to gram-positive encapsulated bacteria usually occur when individuals are immuno-suppressed or have anatomic or functional asplenia. Our patient had both, which likely increased his susceptibility, and he responded well to antimicrobial therapy in addition to prophylactic coverage in the setting of his immunosuppression. We review the literature for similar cases due to <span class="elsevierStyleItalic">S. pneumoniae</span> in the pediatric population and discuss the etiology and treatment of purpura fulminans.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La púrpura fulminante es un síndrome rápidamente progresivo de trombosis de pequeños vasos y necrosis hemorrágica de la piel que se acompaña de coagulación intravascular diseminada. Describimos un caso de septicemia por <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> en un niño de 5 años de edad tratado con tacrolimus oral, con una historia médica previa de trasplante de múltiples vísceras y sin bazo, y el desarrollo subsiguiente de púrpura fulminante en su pecho y la parte distal de sus extremidades. La forma aguda infecciosa de púrpura fulminante es debida habitualmente a bacterias gramnegativas. Los casos secundarios a bacterias grampositivas encapsuladas ocurren por lo general cuando los individuos están inmunosuprimidos o presentan asplenia funcional o anatómica. Nuestro paciente presentaba ambas condiciones, lo cual con seguridad aumentó su susceptibilidad, y respondió bien a la terapia antimicrobiana además de a la cobertura profiláctica en el contexto de su inmunosupresión. Revisamos la literatura buscando casos similares debidos a <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> en la población pediátrica y discutimos la etiología y el tratamiento de la púrpura fulminante.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 675 "Ancho" => 900 "Tamanyo" => 116742 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Widespread areas of purpura and necrosis on right lower extremity with lysed bullae and crusting.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 673 "Ancho" => 900 "Tamanyo" => 256138 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">H&E 400×; focally necrotic keratinocytes, spongiotic vesicles, vascular thrombosis and red blood cell extravasation.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 673 "Ancho" => 900 "Tamanyo" => 258019 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">H&E 400×; thrombosed vessel and red blood cell extravasation.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">ARDS, acute respiratory distress syndrome; <span class="elsevierStyleItalic">PRBCs</span>, packed red blood cells; <span class="elsevierStyleItalic">APC</span>, activated protein C; <span class="elsevierStyleItalic">FFP</span>, fresh frozen plasma; MVT, multivisceral transplantation.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Source \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Age \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">History and clinical presentation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Outcome \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Uhr, 1938<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sepsis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sulfanilamide \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Survived \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adner et al., 1970<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Post-splenectomy for ITP; meningitis and sepsis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Heparin, penicillin G \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Survived \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Coonrod and Leach, 1976<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Post-splenectomy for hypersplenism; sepsis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Died before treatment initiated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Died \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lanzkowsky et al., 1976<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Child \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Post-splenectomy for Hodgkin's disease; sepsis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Died \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cohen et al., 1990<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Asplenic; sepsis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Died \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 month/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Asplenic; sepsis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Survived \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ryan et al., 1993<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sepsis with Waterhouse–Friderichsen syndrome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Died \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Centers for Disease Control and Prevention, 1995<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 infants/children (<5 y) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sepsis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Two died \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cnota et al., 1999<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Child \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Meningitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unknown \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Galanakis et al., 1999<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 month/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Multiple organ failure, sepsis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">FFP, aspirin, penicillin, ceftriaxone, dexamethasone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Survived \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pancharoen et al., 2002<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Congenital asplenia; sepsis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ceftriaxone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Survived \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Noguera et al., 2004<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 month/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sepsis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">FFP, cefotaxime, vancomycin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Survived \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lokeshwar et al., 2006<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 month/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sepsis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Penicillin G, APC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Survived \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Meiners et al., 2006<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 month/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Polysplenia; sepsis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Survived \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bertran et al., 2009<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3/F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Congenital asplenia, recurrent pneumonias; sepsis with Waterhouse–Friderichsen syndrome, multiple organ failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PRBCs, FFP, cryoprecipitate, platelets, corticosteroids, cefotaxime \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Died \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intan et al., 2009<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 month/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sepsis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PRBCs, FFP, penicillin, cefotraxime, vancomycin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Survived \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Konda et al., 2011 (current case) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5/M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MVTx without a spleen; ARDS, acute renal failure, sepsis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Linezolid, vancomycin, meropenem \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Survived \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab367677.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Pediatric purpura fulminans cases due to <span class="elsevierStyleItalic">Streptococcus pneumoniae</span>.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pneumococcal sepsis presenting as purpura fulminans in a healthy infant" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "I.H. Intan" 1 => "A.R. Rozita" 2 => "O. Norlijah" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1179/027249309X12467994694139" "Revista" => array:6 [ "tituloSerie" => "Ann Trop Paediatr" "fecha" => "2009" "volumen" => "29" "paginaInicial" => "235" "paginaFinal" => "238" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19689868" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pneumococcal-associated purpura fulminans in a healthy infant" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A. Noguera" 1 => "C. Fortuny" 2 => "M. Pons" 3 => "F. Cambra" 4 => "A. Palomeque" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Pediatr Emerg Care" "fecha" => "2004" "volumen" => "20" "paginaInicial" => "528" "paginaFinal" => "530" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15295249" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Purpura fulminans in a child with pneumococcal septicemia two years after splenectomy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.M. Adner" 1 => "R.E. Kauff" 2 => "J.D. Sherman" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "JAMA" "fecha" => "1970" "volumen" => "213" "paginaInicial" => "1681" "paginaFinal" => "1683" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/5468716" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Gangrene of the toes following pneumococcemia: treatment with sulfanilamide" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.S. Uhr" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Dis Child" "fecha" => "1938" "volumen" => "56" "paginaInicial" => "1317" "paginaFinal" => "1318" "itemHostRev" => array:3 [ "pii" => "S0014256508716606" "estado" => "S300" "issn" => "00142565" ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Antigenemia in fulminant pneumococcemia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.D. Coonrod" 1 => "R.P. Leach" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Intern Med" "fecha" => "1976" "volumen" => "84" "paginaInicial" => "561" "paginaFinal" => "563" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/5936" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Staging laparotomy and splenectomy: treatment and complications of Hodgkin's disease in children" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "P. Lanzkowsky" 1 => "A. Shende" 2 => "G. Karayalcin" 3 => "I. Aral" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Hematol" "fecha" => "1976" "volumen" => "1" "paginaInicial" => "393" "paginaFinal" => "404" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1008054" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The surgical implications of purpura fulminans" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.R. Cohen" 1 => "R. Lackner" 2 => "A. Keller" 3 => "B. Douglas" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/BF02009457" "Revista" => array:6 [ "tituloSerie" => "Ann Vasc Surg" "fecha" => "1990" "volumen" => "4" "paginaInicial" => "276" "paginaFinal" => "279" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2340249" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fatal childhood pneumococcal Waterhouse–Friderichsen syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C.A. Ryan" 1 => "W. Wenman" 2 => "C. Henningsen" 3 => "S. Tse" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Pediatr Infect Dis J" "fecha" => "1993" "volumen" => "12" "paginaInicial" => "250" "paginaFinal" => "251" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8451106" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hemorrhage and shock associated with invasive pneumococcal infection in healthy infants and children – New Mexico, 1993–1994" "autores" => array:1 [ 0 => array:2 [ "colaboracion" => "Centers for Disease Control and Prevention" "etal" => false ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "MMWR Morb Mortal Wkly Rep" "fecha" => "1995" "volumen" => "43" "paginaInicial" => "949" "paginaFinal" => "952" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7865011" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Purpura fulminans associated with <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> infection in a child" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.F. Cnota" 1 => "L.L. Barton" 2 => "K.H. Rhee" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Pediatr Emerg Care" "fecha" => "1999" "volumen" => "15" "paginaInicial" => "187" "paginaFinal" => "188" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10389955" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Purpura fulminans complicating pneumococcal sepsis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "E. Galanakis" 1 => "M. Apokotou" 2 => "S. Alfadaki" 3 => "E. Gesouli" 4 => "P. Lapatsanis" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Eur J Pediatr" "fecha" => "1999" "volumen" => "158" "paginaInicial" => "171" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10048620" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recurrent purpura fulminans associated with drug-resistant <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> infection in an asplenic girl" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C. Pancharoen" 1 => "P. Chatchatee" 2 => "J. Ngamphaiboon" 3 => "U. Thisyakorn" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Pediatr Infect Dis J" "fecha" => "2002" "volumen" => "21" "paginaInicial" => "80" "paginaFinal" => "81" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11791110" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treatment of acute infectious purpura fulminans with activated protein C" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.R. Lokeshwar" 1 => "T. Singhal" 2 => "S.V. Udani" 3 => "F.N. Kapadia" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Indian Pediatr" "fecha" => "2006" "volumen" => "43" "paginaInicial" => "535" "paginaFinal" => "538" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16820663" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pneumococcal septicaemia with Purpura fulminans in an 11-month-old child" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "P.M. Meiners" 1 => "J. Leon-Villapalos" 2 => "P. Dziewulski" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.bjps.2005.12.029" "Revista" => array:6 [ "tituloSerie" => "J Plast Reconstr Aesthet Surg" "fecha" => "2006" "volumen" => "59" "paginaInicial" => "1377" "paginaFinal" => "1380" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17113523" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Congenital asplenia and pneumococcal purpura fulminans in a pediatric patient: case report with pathological findings and review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S.K. Bertran" 1 => "F.A. Donoso" 2 => "R.P. Cruces" 3 => "R.F. Diaz" 4 => "S.D. Arriagada" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "/S0716-10182009000100009" "Revista" => array:6 [ "tituloSerie" => "Rev Chilena Infectol" "fecha" => "2009" "volumen" => "26" "paginaInicial" => "55" "paginaFinal" => "59" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19350161" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/00017310/0000010400000007/v1_201308270831/S0001731012002797/v1_201308270831/en/main.assets" "Apartado" => array:4 [ "identificador" => "6181" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Caso clínico" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/00017310/0000010400000007/v1_201308270831/S0001731012002797/v1_201308270831/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731012002797?idApp=UINPBA000044" ]
| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 5 | 13 | 18 |
| 2024 Octubre | 70 | 48 | 118 |
| 2024 Septiembre | 79 | 32 | 111 |
| 2024 Agosto | 100 | 63 | 163 |
| 2024 Julio | 79 | 36 | 115 |
| 2024 Junio | 82 | 49 | 131 |
| 2024 Mayo | 58 | 54 | 112 |
| 2024 Abril | 53 | 34 | 87 |
| 2024 Marzo | 76 | 47 | 123 |
| 2024 Febrero | 50 | 24 | 74 |
| 2024 Enero | 56 | 37 | 93 |
| 2023 Diciembre | 51 | 32 | 83 |
| 2023 Noviembre | 89 | 49 | 138 |
| 2023 Octubre | 53 | 35 | 88 |
| 2023 Septiembre | 56 | 48 | 104 |
| 2023 Agosto | 47 | 27 | 74 |
| 2023 Julio | 83 | 54 | 137 |
| 2023 Junio | 68 | 25 | 93 |
| 2023 Mayo | 71 | 42 | 113 |
| 2023 Abril | 73 | 28 | 101 |
| 2023 Marzo | 65 | 38 | 103 |
| 2023 Febrero | 65 | 29 | 94 |
| 2023 Enero | 47 | 50 | 97 |
| 2022 Diciembre | 65 | 50 | 115 |
| 2022 Noviembre | 36 | 52 | 88 |
| 2022 Octubre | 78 | 51 | 129 |
| 2022 Septiembre | 47 | 61 | 108 |
| 2022 Agosto | 59 | 54 | 113 |
| 2022 Julio | 59 | 64 | 123 |
| 2022 Junio | 69 | 57 | 126 |
| 2022 Mayo | 102 | 62 | 164 |
| 2022 Abril | 135 | 55 | 190 |
| 2022 Marzo | 155 | 63 | 218 |
| 2022 Febrero | 151 | 40 | 191 |
| 2022 Enero | 130 | 57 | 187 |
| 2021 Diciembre | 81 | 45 | 126 |
| 2021 Noviembre | 90 | 43 | 133 |
| 2021 Octubre | 88 | 69 | 157 |
| 2021 Septiembre | 67 | 44 | 111 |
| 2021 Agosto | 59 | 47 | 106 |
| 2021 Julio | 62 | 50 | 112 |
| 2021 Junio | 81 | 72 | 153 |
| 2021 Mayo | 77 | 61 | 138 |
| 2021 Abril | 160 | 75 | 235 |
| 2021 Marzo | 102 | 33 | 135 |
| 2021 Febrero | 79 | 41 | 120 |
| 2021 Enero | 105 | 25 | 130 |
| 2020 Diciembre | 68 | 18 | 86 |
| 2020 Noviembre | 72 | 25 | 97 |
| 2020 Octubre | 69 | 24 | 93 |
| 2020 Septiembre | 94 | 32 | 126 |
| 2020 Agosto | 81 | 40 | 121 |
| 2020 Julio | 96 | 25 | 121 |
| 2020 Junio | 93 | 34 | 127 |
| 2020 Mayo | 90 | 32 | 122 |
| 2020 Abril | 83 | 29 | 112 |
| 2020 Marzo | 108 | 31 | 139 |
| 2020 Febrero | 6 | 12 | 18 |
| 2020 Enero | 6 | 4 | 10 |
| 2019 Diciembre | 0 | 5 | 5 |
| 2019 Noviembre | 2 | 3 | 5 |
| 2019 Octubre | 0 | 11 | 11 |
| 2019 Septiembre | 3 | 3 | 6 |
| 2019 Agosto | 3 | 2 | 5 |
| 2019 Julio | 2 | 4 | 6 |
| 2019 Junio | 0 | 2 | 2 |
| 2019 Mayo | 2 | 11 | 13 |
| 2019 Abril | 0 | 15 | 15 |
| 2019 Marzo | 1 | 9 | 10 |
| 2019 Febrero | 3 | 3 | 6 |
| 2019 Enero | 3 | 1 | 4 |
| 2018 Diciembre | 1 | 4 | 5 |
| 2018 Noviembre | 2 | 2 | 4 |
| 2018 Octubre | 2 | 1 | 3 |
| 2018 Septiembre | 5 | 2 | 7 |
| 2018 Agosto | 0 | 8 | 8 |
| 2018 Julio | 0 | 1 | 1 |
| 2018 Junio | 0 | 1 | 1 |
| 2018 Mayo | 1 | 13 | 14 |
| 2018 Abril | 0 | 11 | 11 |
| 2018 Marzo | 2 | 1 | 3 |
| 2018 Febrero | 46 | 10 | 56 |
| 2018 Enero | 50 | 16 | 66 |
| 2017 Diciembre | 63 | 15 | 78 |
| 2017 Noviembre | 47 | 18 | 65 |
| 2017 Octubre | 43 | 20 | 63 |
| 2017 Septiembre | 35 | 31 | 66 |
| 2017 Agosto | 53 | 30 | 83 |
| 2017 Julio | 44 | 17 | 61 |
| 2017 Junio | 64 | 23 | 87 |
| 2017 Mayo | 93 | 33 | 126 |
| 2017 Abril | 47 | 25 | 72 |
| 2017 Marzo | 51 | 30 | 81 |
| 2017 Febrero | 68 | 22 | 90 |
| 2017 Enero | 43 | 28 | 71 |
| 2016 Diciembre | 60 | 25 | 85 |
| 2016 Noviembre | 74 | 30 | 104 |
| 2016 Octubre | 111 | 25 | 136 |
| 2016 Septiembre | 200 | 25 | 225 |
| 2016 Agosto | 79 | 16 | 95 |
| 2016 Julio | 61 | 15 | 76 |
| 2016 Junio | 12 | 13 | 25 |
| 2016 Mayo | 11 | 17 | 28 |
| 2016 Abril | 12 | 5 | 17 |
| 2016 Marzo | 19 | 4 | 23 |
| 2016 Febrero | 12 | 19 | 31 |
| 2016 Enero | 12 | 35 | 47 |
| 2015 Diciembre | 22 | 12 | 34 |
| 2015 Noviembre | 14 | 16 | 30 |
| 2015 Octubre | 8 | 7 | 15 |
| 2015 Septiembre | 10 | 10 | 20 |
| 2015 Agosto | 12 | 5 | 17 |
| 2015 Julio | 40 | 3 | 43 |
| 2015 Junio | 48 | 2 | 50 |
| 2015 Mayo | 62 | 2 | 64 |
| 2015 Abril | 49 | 3 | 52 |
| 2015 Marzo | 53 | 2 | 55 |
| 2015 Febrero | 36 | 2 | 38 |
| 2015 Enero | 49 | 0 | 49 |
| 2014 Diciembre | 54 | 0 | 54 |
| 2014 Noviembre | 38 | 0 | 38 |
| 2014 Octubre | 59 | 0 | 59 |
| 2014 Septiembre | 39 | 0 | 39 |
| 2014 Agosto | 41 | 0 | 41 |
| 2014 Julio | 28 | 0 | 28 |
| 2014 Junio | 58 | 0 | 58 |
| 2014 Mayo | 50 | 0 | 50 |
| 2014 Abril | 55 | 0 | 55 |
| 2014 Marzo | 83 | 11 | 94 |
| 2014 Febrero | 59 | 7 | 66 |
| 2014 Enero | 68 | 16 | 84 |
| 2013 Diciembre | 38 | 11 | 49 |
| 2013 Noviembre | 40 | 14 | 54 |
| 2013 Octubre | 18 | 22 | 40 |
| 2013 Septiembre | 26 | 21 | 47 |
| 2013 Agosto | 2 | 3 | 5 |
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