Acute Infectious Purpura Fulminans

60M ITP s/p splenectomy.
1d chills/rigors, diarrhea, nausea.

🚨2hrs later, develops a new full-body rash 👇

No sick contacts, travel. Recent tick bite. 🐱at home. No raw seafood

Admitted to ICU in multipressor shock. Ddx?


Ddx is very broad! A key here is what can lead to the rash (purpura fulminans) and critical illness. Here are a few leading thoughts on the list:

  • Strep pneumo, N.meningitidis
  • Vibrio, aeromonas
  • Capnocytophaga
  • RMSF

Another pit stop here to think about high risk pathogens in setting of asplenia. Of these, the starred organisms below can lead to purpura fulminans. For more info on asplenia + infection risk, check out this tweetorial:

Your blood cxs identify GNR and pt slowly improving on abxs.

Final dx: Septic shock, multiorgan system failure, purpura fulminans secondary to Capnocytophaga!

Now a closer look at Capnocytophaga thanks to @JeffLarnard

Capnocytophaga infections can be difficult to identify. DIC or shock can occur in 13% of cases. Keep in mind that the patient may not have a preceding bite/scratch – and you should keep on the differential even if there is just a dog/cat at home!

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3373098/

6/
Acute infectious purpura fulminans = syndrome of intravascular thrombosis/occlusion ➡️Rapidly progresses to septic shock, DIC, MOF

https://pubmed.ncbi.nlm.nih.gov/30128591/

https://pubmed.ncbi.nlm.nih.gov/30335142/

Thanks to our guests from Hematology (@justine_ryu, Pavan Bendaputi). Great learning point = pts with PF have a severe deficiency in protein C and may benefit from tx with Prot C concentrate. Here is a prior case from Dr. Bendapudi and @k_stephensonMD

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6234356/

Originally tweeted by BIDMC Infectious Diseases Fellowship (@BIDMC_IDFellows) on 11 August, 2020.

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