Sloughing skin in intravenous drug user

A 32 year old female, an active intravenous drug user, was admitted for fever, myalgias and an erythematous macular rash on her distal extremities. She quickly decompensated and developed septic shock. Her examination was significant for a progressive rash which within two days developed bullae and necrosis with progression to a confluent rash involving her palms and soles (Figs. 1 and 2). Her rash involved nearly one third of her body with what was equivalent to a third degree burn. Her labs were significant for leukocytosis with bandemia, elevated liver function tests with worsening thrombocytopenia and fibrinogen levels consistent with disseminated intravascular coagulation (DIC) Her transthoracic echocardiogram (Fig. 3) showed a 5 cm vegetation on the tricuspid valve. Her blood cultures were positive for methicillin-sensitive Staphylococcus aureus. She was meeting the clinical criteria for toxic shock syndrome (TSS) and subsequent testing for toxic shock syndrome toxin antibody was positive. She was treated with antibiotics and intravenous gamma globulin (IVIG). Due to her worsening rash she was transferred to a burns unit. She was diagnosed with Purpura fulminans (PF) which is a skin manifestation of DIC and has a rare association with Staphylococcus aureus infection.The main focus of this case report is to emphasise this rare association, prompt an early diagnosis and referral to prevent life threatening complications.