[Management of purpura fulminans apropos of 21 cases: diagnostic delay and therapeutic problems]

To evaluate the diagnostic delay and therapeutic insufficiencies delay before the transfer in ICU of the children admitted in the ICU of the children's hospital of Tunis with a purpura fulminans (PF).

A retrospective, descriptive study, of children with PF referred between January 2000 and January 2006 to a the paediatric intensive care unit (PICU) of the children's hospital of Tunis. The PF diagnosis was retained in any child presenting a feverish purpura and circulatory insufficiency signs. The optimal diagnostic and therapeutic charge taking was defined in three levels: parental, the first line doctors, and the hospital doctors. The symptoms' duration and the various treatments which were lavished to the patients were taken from the medical observations of the patients transferred in our PICU.

Twenty one observations were collected. Twelve patients (57.1%) were addressed by a doctor exerting in a dispensary or by a free practicing doctor, 5 patients (23.8%) were transferred from a regional hospital and 4 children (19.1%) directly consulted the children hospital of Tunis urgencies delayed parental recognition occured in 11 children. The PF diagnosis was not evoked by the first line doctor in 62%. Eleven (52.4%) of the children with meningococcal disease were seen but not admitted by a doctor in the 48 hours before admission. Apart from 2 patients (9.5%) who were hospitalized in reanimation directly of the urgencies, all the other patients forwarded by a general pediatry service. In general pediatry, the PF diagnosis was not evoked in 3 cases (15.8%), 31.6% of patients had unnecessary a lumbar punctures and shock was not recognised or treated in 26.3%. Twelve patients (52.2%) died. The duration of hospitalization in general pediatry is significantly higher among deceased patients (5.5 +/- 6.6 hours) than among the surviving patients (2.6 +/- 1.5 hours); p < 0.05.

Suboptimal treatement in PF is due to failure of parents, general practioners and hospital doctors to recognise specific features of the illness. Improvement in outcome could be achieved by public education and better training of clinicians in recognition, resuscitation, and stabilisation of seriously ill children.