Acute infectious purpura fulminant due to Enterococcus faecium infection: a case report

Purpura fulminant is a rare life-threatening disorder characterized by a dysregulated response that is often associated with poor prognosis and lethal outcomes. It is often associated with disseminated intravascular coagulation, skin necrosis, and protein C deficiency leading to thrombotic occlusion of skin arterioles, causing palpable purpuric lesions, spreading ecchymosis, and gangrene, along with hypotension and fever. Purpura fulminant is classified into three distinct categories according to the trigger mechanisms, including neonatal, idiopathic, and acute infectious. Acute infectious purpura fulminant is the most common manifestation, which occurs after bacterial infections caused by acquired protein C deficiency. Although traditionally occurring in Neisseria meningitidis infection and Streptococcus infection, acquired protein C deficiency causing purpura fulminant due to Enterococcus faecium has not been described in the literature. This case report highlights the fact that purpura fulminans can also be a rare presentation of Entercoccus faecium infection.

A 61-year-old Arab man who is immunocompetent presented with sepsis, which later escalated into septic shock due to Enterococcus faecium bacteremia. The patient's hospitalization rapidly developed into multiorgan dysfunction, disseminated intravascular coagulation, and purpura fulminans. Aggressive interventions were initiated, involving the administration of broad-spectrum antibiotics, multiple vasopressors, and mechanical ventilation. Despite these intensive measures, the patient ultimately succumbed to the complications of multiorgan failure and death.

This case illustrates the devastating outcomes that can present from purpura fulminant. However, physicians should consider purpura fulminant caused by Enterococcus faecium infection in the workup of patients presenting with purpuric rash and fever.