A 50-year-old diabetic female has been admitted to your unit with worsening gas exchange in the setting of precipitous hypotension and acute confusional state requiring initiation of mechanical ventilation and inotropic and vasopressor support. She is febrile with deranged liver and renal function. She has anaemia and profound thrombocytopenia, and a widespread rash (see Figure 15.1 below).

List four likely causes to account for these findings.    (40% marks)

Figure 15.1
let's play "name that rash"

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College answer

Differential diagnoses

  • DIC secondary to sepsis
  • TTP
  • Catastrophic Antiphospholipid Syndrome (APL accepted)
  • HITTS
  • Warfarin induced skin necrosis
  • Protein C deficiency-with sepsis

Discussion

This question resembles Question 14.2 from the second paper of 2010, and - though the original rash image is absent from the college paper- a reasonable replacement can be found if one searches for "purpura fulminans" in Google Images. The patient comes with a history of:

  • Shock
  • Fever
  • Purpura
  • Renal failure
  • Altered level of consciousness
  • Deranged LFTs
  • thrombocytopenia

Thus, TTP and sepsis with MOSF and DIC have to be somewhere in the four answers. For a more complete list of possibilities, 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:
  • 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)

References

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.