Escherichia coli septicaemia induced purpura fulminans

Purpura fulminans is a relatively uncommon dermatological emergency that manifests with widespread cutaneous thrombosis and necrosis. Most cases of purpura fulminans are seen in infancy and adolescents with up to 80% of cases occurring in patients under the age of 20. Disseminated intravascular coagulation (DIC), protein deficiencies and severe septicaemia preceding the clinical presentation is common with bacterial pathogens such as Neisseria mengitidis, Streptococcus and Staphylococcus. We present the rare case of Escherichia coli related purpura fulminans in a 48 year old immunocompetent male requiring ICU admission and extensive skin grafting. Blood cultures isolated Escherichia Coli and incisional skin biopsies revealed paucicellular subepidermal blisters and thrombus in the small vessels of the papillary dermis consistent with purpura fulminans. His fibrinogen level did not drop to the level of DIC and his protein C levels were normal. The manifestation of purpura fulminans in the absence of vitamin-K dependent plasma protein deficiency and disseminated intravascular coagulation is uncommon and even more so in the context of an infrequently reported triggering pathogen such as Escherichia coli.
Early recognition, administration of antibiotics and intensive care support are critical for the initial management of the condition. The published reports of E. coli purpura fulminans have been limited to date. Cases of extraintestinal E. coli causing the condition are very rare. The increase in extraintestinal and B-lactamase enzyme producing strains of E. Coli has become a public health concern. In this context, the case highlights the significant risk for insufficient empirical antibiotic treatment in the acute phase.

Dr. Justin Bui

Department of Dermatology, Fiona Stanley Hospital, Murdoch, Western Australia

Justin is the dermatology resident at Fiona Stanley Hospital in Western Australia. He also the Chair of the Postgraduate Medical Council of Western Australia JMO Forum and recipient of the 2016 Junior Doctor of the Year Award for outstanding contribution to prevocational medical education