Purpura fulminans due to MSSA Toxic Shock Syndrome

Introduction: Purpurafulminansis a rare and serious complication of anacute infectious process, characterized by large purpuricskin lesions, fever, hypotension, and DIC. The mostcommon infectious cause of purpurafulminansismeningococcal disease, though few case reports in theliterature describe Staph aureusas a causative organism. Case Report: •A 53 year-old woman with a history of heart blocks/ppacemaker placement in 2002 presented to the ED withnausea, vomiting, fevers, chills, diffuse muscle pain and asyncopalepisode. •She was found to have multi-organ dysfunction on labs,including AKI and thrombocytopenia.On hospital day 2, shedeveloped acrocyanosis. She became febrile & hypotensive requiring transfer tothe ICU for vasopressor support. Blood cultures were obtained. She wasstarted on broad-spectrum antibiotictherapy . •Because of the patient’s thrombocytopenia and overall critical illness,the differential diagnosis included TTP, DIC, HUS, drug-induced hemolytic anemia, or a rare disorder calledcatastrophic antiphospholipidantibody syndrome (CAPS). •She was treated empirically for CAPS with plasma exchange,heparin, andsteroids. •Blood cultures were positive for methicillin-sensitive Staphaureus, and antibodies for CAPS were negative. •Antibiotictherapy was narrowed toCefazolin, and her infected pacemaker was extracted. •She required bilateral below-the-knee amputations as well as multiple finger amputations duetonecrosis. •Most likely diagnosis is purpurafulminansfrom MSSA toxicshock syndrome. Discussion: • In acutely ill patients with skin findings described in this case as well as multi-organ dysfunction, there are several life-threatening diagnoses which must be recognized and treated promptly . •Given the 50% risk of mortality even with prompt initiation of therapy for CAPS, we did not delay in starting this patient on plasma exchange . •In purpurafulminans, the clotting cascade is disrupted by bacterial endotoxins and inflammatory cytokines, leading to a procoagulantand anticoagulant state, which in turn leads to intravascular thrombosis and hemorrhagic infarction of the skin . • A report of 5 cases of purpurafulminanscaused by MSSA TSS was published in the journal Clinical Infectious Diseases in 2005, and the isolated strains of MSSA were noted to produce higher-than-expected levels of endotoxins normally associated with TSS. •Treatment of purpurafulminansfrom MSSA TSS is antibiotic therapy. •It remains a rare and serious complication of acute infection which providers should keep on their differential of life-threatening illnesses associated with thrombocytopenia and purpuricskin lesions.https://digitalcommons.providence.org/psv_internal/1005/thumbnail.jp