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Staphylococcal Purpura Fulminans: Report of a Case
Hedieh Honarpisheh1, Robert Camp, Rossitza Lazova
1*Department of Pathology; and †Department of Dermatology and Pathology, Smilow Cancer Center, Yale School of Medicine, New Haven, CT.
Abstract:
Purpura fulminans (PF) is associated with several infections and most commonly with meningococcemia. However, there are only a few reports of this entity in association with toxic shock syndrome toxin-1-producing Staphylococcus aureus. We report a 53-year-old man who presented with fever, progressive hemodynamic instability, multiorgan failure, and thrombocytopenia following lobectomy for a solitary lung metastasis from rectal adenocarcinoma. He developed progressive generalized eruption of nonblanching red, purple, and black macules, papules, and plaques on the trunk and extremities consistent with PF. He died on postadmission day 3. Autopsy examination revealed purulent pleural exudate, which grew toxic shock syndrome toxin-1-producing S. aureus. Premortem and autopsy skin biopsies demonstrated epidermal necrosis, subepidermal bullae, and fibrin thrombi within small cutaneous vessels with minimal perivascular lymphocytic inflammation and without accompanying vasculitis. With this case report, we would like to draw attention to the fact that staphylococcal toxic shock syndrome-associated PF may be highly underrecognized and much more common than reflected in the literature.
Insights
Purpura fulminans (PF) associated with toxic shock syndrome toxin-1-producing Staphylococcus aureus is likely underrecognized. This case highlights the critical need to consider this bacterial cause in patients with severe skin manifestations and sepsis.
Area of Science:
- Medical Microbiology
- Dermatology
- Infectious Diseases
Background:
- Purpura fulminans (PF) is a rare, life-threatening condition often linked to infections, primarily meningococcemia.
- Reports associating PF with toxic shock syndrome toxin-1 (TSST-1)-producing Staphylococcus aureus are scarce.
Observation:
- A 53-year-old man developed PF with multiorgan failure and thrombocytopenia post-lung lobectomy.
- Clinical presentation included a progressive, non-blanching rash consistent with PF.
- Autopsy revealed TSST-1-producing S. aureus in pleural exudate.
Findings:
- Skin biopsies showed epidermal necrosis, subepidermal bullae, and dermal microvascular thrombosis.
- Histopathology revealed minimal inflammation and no vasculitis, distinguishing it from typical infectious PF.
- Microbiological analysis confirmed S. aureus producing TSST-1 as the causative agent.
Implications:
- This case suggests staphylococcal toxic shock syndrome-associated PF may be significantly underdiagnosed.
- Clinicians should consider TSST-1-producing S. aureus in the differential diagnosis of PF, especially in post-surgical or immunocompromised patients.
- Further research is warranted to determine the true incidence and clinical spectrum of this underrecognized condition.
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