Question 14.2

College Answer

a)   What  lesion  is shown  in the  picture  below  in  a patient  presenting  with septic shock?

Purpura fulminans

b)   List 5 other causes of this lesion

•   Meningococcemia 
•  Post-splenectomy pneumococcemia
•   DIC 
•  Rickettsial infections
•  High dose inotropes
•   Endocarditis

A clinical photograph of purpura fulminans was supplied.

Discussion

This photograph of purpura fulminans was acquired legally (according to usage rights) fromwww.unboundedmedicine.com to whom I am grateful. The specific image is of a child suffering from menigococcal sepsis.

An excellent review presents a breakdown of the differential causes of puprura fulminans, which include the following:

• DIC from any cause
• Sepsis due to the following organisms:
  • S.pneumoniae - but mainly in asplenic patients for some reason
  • S.aureus
  • H.influenzae
  • N.meningitides
  • Endocarditis of any bacterial aetiology
• MAHA (microangiopathic haemolytic anaemia)
• TTP (thrombotic thrombocytopenic purpura)
• Varicella infection
• Rickettsial infection
• Plasmodium falciparum malaria
• Vasopressor excess
• Warfarin-induced skin necrosis
• Congenital Protein C anticoagulant pathway defect
• Post-infectious purpura fulminans (due to autoimmune destruction of proteins C or S)

Gürses, Nuran, and Ismail Ilek. "Causes of purpura fulminans." The Pediatric infectious disease journal 14.6 (1995): 552.

Spicer, Thomas E., and Jerold M. Rau. "Purpura fulminans." The American journal of medicine 61.4 (1976): 566-571.

Chalmers, E., et al. "Purpura fulminans: recognition, diagnosis and management." Archives of disease in childhood 96.11 (2011): 1066-1071.