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Purpura fulminans in pneumococcal sepsis: case report and review
1Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.
Abstract:
Purpura fulminans is classically defined by ecchymotic skin lesions, fever, and hypotension. The majority of cases occur in association with bacterial sepsis, and disseminated intravascular coagulation (DIC) is usually present. Prompted by our experience with a patient with pneumococcal sepsis and purpura fulminans in whom hypotension was never observed, we evaluated the important parameters of sepsis in reports of this syndrome. 42 additional cases of pneumococcal bacteremia and purpura fulminans were identified. Hypotension was present in only 51%. Although DIC was present in 85% of patients, hypofibrinogenemia was documented in only 26%. By contrast, both hypotension and hypofibrinogenemia are present in the vast majority of patients described with purpura fulminans in association with meningococcal sepsis. These data confirm that hypotension is not a necessary feature of the syndrome of purpura fulminans associated with pneumococcal sepsis and suggest further that qualitative or quantitative differences exist in the DIC cascade of pneumococcal vs meningococcal sepsis.
Insights
Purpura fulminans in pneumococcal sepsis often lacks hypotension, unlike meningococcal cases. This suggests distinct differences in how these bacteria trigger disseminated intravascular coagulation (DIC).
Area of Science:
- Infectious Diseases
- Hematology
- Critical Care Medicine
Background:
- Purpura fulminans is a severe condition characterized by skin lesions, fever, and hypotension, typically linked to bacterial sepsis and disseminated intravascular coagulation (DIC).
- The classic definition often includes hypotension as a key feature.
Observation:
- A review of 42 cases of pneumococcal bacteremia with purpura fulminans revealed hypotension in only 51% of patients.
- Disseminated intravascular coagulation (DIC) was present in 85%, but hypofibrinogenemia was documented in only 26%.
Findings:
- Hypotension is not a universal feature of purpura fulminans associated with Streptococcus pneumoniae sepsis.
- Compared to meningococcal sepsis, pneumococcal sepsis presents different patterns of DIC markers like hypofibrinogenemia.
Implications:
- These findings challenge the necessity of hypotension in the diagnosis of pneumococcal purpura fulminans.
- Qualitative or quantitative differences in the DIC cascade between pneumococcal and meningococcal sepsis are suggested, impacting clinical management and research.