Clinical presentation of purpura fulminans is characterized by a sudden onset of initially erythematous macules and petechiae which progress within hours into massive ecchymoses with irregular and sharp borders, distributed on various parts of the body. In addition to skin lesions, symptoms that may appear include fever, hypotension, and often shock, if purpura fulminans is a complication of an acute infection. Neonatal purpura fulminans develops within the first 72 hours after birth, with a similar clinical presentation, and in all patients, because of massive infarction of the skin and organs, major organ dysfunction may occur, presenting with symptoms related to the target organ. In severe cases that accompany DIC, vascular thrombosis and pulmonary embolism may occur, and persistent bleeding from wounds and puncture sites is also observed. In severe cases, gangrene and necrosis of extremities may be observed, requiring amputation of fingers and even limbs.

• Fever

  PF though common with rocky mountain spotted fever (RMSF) is rarely seen in association with Indian tick typhus, the usual cause of spotted fever in India. [jpgmonline.com]

  […] in North America, and various hemorrhagic fevers in other parts of the world and in travelers. [clinicaladvisor.com]

  (se Scarlet Fever, [[Scarlet Fever]]) Streptococcal Pharyngitis (see Streptococcus, [[Streptococcus]]): Streptococcus species are the most common etiology in adults Upper Respiratory Infection Varicella (see Varicella-Zoster Virus, [[Varicella-Zoster [mdnxs.com]

• Acutely Ill Patient

  The acutely ill patient with fever and rash. [amjmed.com]

  In addition, it describes the manifestations in acutely ill patients in the ICU, as well as severe cutaneous manifestations occurring during pregnancy, after sun exposure, in cold weather, as a result of extreme poverty, and in other situations. [books.google.it]

• Easy Bruising

  There is evidence of bleeding under the skin, with easy bruising and the development of petechiae. In the acute form there may be bleeding from any of the body orifices, such as hematuria, nosebleed, vaginal bleeding, and bleeding gums. [medical-dictionary.thefreedictionary.com]

• Sputum

  Culture of a sputum sample obtained after intubation also grew much S. aureus, which produced SEC and PVL by PCR but not TSST-1 or SEB. Progressive ischemia of the legs necessitated bilateral below-knee amputations. [academic.oup.com]

  Samples of blood, sputum, stool, and urine were obtained for microbiological evaluation, and imipenem/cilastatin (IPM/CS) was administered as empirical therapy (0.5 g q12h). [jintensivecare.biomedcentral.com]

  On day two, the patient experienced pain in the skin lesions and in the back, headache with vertigo, sputum-free cough, diarrhea, and stomach ache, all gradually increasing in severity. On day seven, the patient developed abdominal pain. [dovepress.com]

  Development or exacerbation of gastrointestinal and pulmonary symptoms is seen, (A) and the detection of increased numbers of larvae in stool and or sputum is the hallmark. [ijccm.org]

• Blood in Stool

  Samples of blood, sputum, stool, and urine were obtained for microbiological evaluation, and imipenem/cilastatin (IPM/CS) was administered as empirical therapy (0.5 g q12h). [jintensivecare.biomedcentral.com]

• Protein S Deficiency

  Laboratory results were being consistent with disseminated intravascular coagulation secondary to protein S deficiency; treatment with fresh frozen plasma, intravenous immunoglobulins, and prednisone was started. [ncbi.nlm.nih.gov]

• Hypotension

  Patients present with high-grade fever, petechial or purpuric rash and rapid progression to purpura fulminans and hypotension [1]. [clinmedjournals.org]

  FOLLOW-UP RECOMMENDATIONS When to expect improvement: related to underlying cause of purpura fulminans Signs to watch for: Spread of purpura Hypotension Gangrene Treatment dur... Goldenberg NA, Manco-Johnson MJ. Protein C deficiency. [5minuteconsult.com]

  He progressed into hypotension, disseminated intravascular coagulation and refractory shock despite resuscitation and early antibiotic commencement. [ncbi.nlm.nih.gov]

  fever, and disseminated intravascular coagulation, usually following an infectious illness. purpura fulminans A life-threatening condition of acute onset occurring in infants, which is characterised by cutaneous haemorrhage and necrosis, hypotension [medical-dictionary.thefreedictionary.com]

• Vascular Disease

  disease.2 Purpura fulminans (PF) is a life-threatening disorder characterised by rapidly progressive cutaneous haemorrhage and necrosis caused by vascular thrombosis and disseminated intravascular coagulation. [pmj.bmj.com]

  Cutaneous vascular diseases. In: James WD, Berger TG, Elston DM, editors. Andrew’s diseases of the skin: clinical dermatology. 10th ed. Philadelphia, Pa: Saunders; 2006. 2. Rintala E, Kauppila M. [westjem.com]

  diseases (Kawasaki disease, other vasculitis) diseases, and adverse drug reactions are often kept in mind, and the index of suspicion for rickettsial illness is quite low. [scienceopen.com]

  CAPILLARITIS OF UNKNOWN CAUSE These are vascular diseases of undetermined cause with different manifestations and share the same histopathological features. [drmhijazy.com]

• Purpura

  Retiform purpura in patient with sepsis, DIC, and acquired protein C deficiency. Figure 2. More retiform purpura in same patient. [clinicaladvisor.com]

  In adults, purpura fulminans is most commonly caused by severe infection. However, the primary risk to life and limb is often the purpura fulminans (rather than the underlying infection). [emcrit.org]

  Related Images Left Arrow Button Right Arrow Button Figure 67-9 Purpura fulminans in a patient with meningococcemia. Figure 67-9 Purpura fulminans in a patient with meningococcemia. [5minuteconsult.com]

  A unique subset of inherited coagulation defects leading to fulminant purpura in neonates has also been well documented. [journals.lww.com]

• Petechiae

  The patient's condition aggravated, with need for invasive mechanical ventilation and intermittent haemodialysis, and evolution from a petechiae-like rash to purpura and gangrene, culminating in bilateral lower limb amputation. [ncbi.nlm.nih.gov]

  […] purpura [ per´pu-rah ] a hemorrhagic disease characterized by extravasation of blood into the tissues, under the skin, and through the mucous membranes, and producing spontaneous bruises, ecchymoses, and petechiae (small hemorrhagic spots) on the skin [medical-dictionary.thefreedictionary.com]

  Cutaneous examination revealed multiple erythematous, petechiae and ecchymotic patches over upper and lower extremities [Figure 1] and trunk. [ijpd.in]

  Often there is pain followed by petechiae. Ecchymoses develop and evolve into painful indurated, well-demarcated purple papules with erythematous borders (as you can see in the image this lesions are coalescent). [unboundedmedicine.com]

  BMJ 316:276–9 [CrossRef] [PubMed] [Google Scholar] Mandl KD, Stack AM, Fleischer GR (1997) Incidence of bacteremia in infants and children with fever and petechiae. [afmu.revuesonline.com]

• Hemorrhagic Bullae

  A and B, Initial presentation of localized erythema on the left leg and nonblanching retiform purpura, edema, and hemorrhagic bullae on both legs. [mdedge.com]

  Skin lesions enlarge rapidly and may evolve into hemorrhagic bullae with subsequent necrosis and black eschar formation. [jpgmonline.com]

  Later in the course, hemorrhagic bullae may form, which contribute to the classic hard eschars characteristic of NPF. Differential diagnosis with necrotizing fasciitis should be performed. Treatment of NPF should be multidisciplinary. [jpnim.com]

• Skin Disease

  Clinical interests: paediatric dermatology, psoriasis, rheumatological skin disease including cutaneous vasculitis, and cutaneous graft versus host disease. [books.google.it]

  Raised intravascular pressure may cause purpura in the absence of any other disease. Simple petechial lesions may develop after prolonged coughing, vomiting or by pressure on localized area of the skin. [drmhijazy.com]

  The patient was re-admitted one week later because of progression of his skin disease. Flexion contractures were noted at the elbows and knees. Laboratory values at readmission are shown in Table 1. [jmedicalcasereports.biomedcentral.com]

• Suggestibility

  This suggests that if anticoagulation is used, plasma exchange is not always necessary. As recovery occurred without plasmapheresis, we were able to track protein S levels. [ncbi.nlm.nih.gov]

  (Recent study suggesting benefit in neonatal septic DIC setting for protein C concentrate.) Fluri, S, Kaczala, GW, Leibundgut, K, Alberio, L. [clinicaladvisor.com]

  Current sepsis: fever, weakness, dizziness, nausea, vomiting, onset of petechial/purpuric rash Recent history of febrile illness Medications (e.g., warfarin ) Family history suggestive of... [5minuteconsult.com]

• Irritability

  The patient was drowsy and irritable on admission. His blood pressure was 70/50 and heart rate was 139 bpm. A provisional diagnosis of meningococcal septicaemia was considered. [ijdvl.com]

  Case report A 14-year-old female presented to the paediatric unit with a 12-h history of fever, irritability and diarrhoea. A few hours later this was followed by swelling around the left eye. [nature.com]

• Vertigo

  On day two, the patient experienced pain in the skin lesions and in the back, headache with vertigo, sputum-free cough, diarrhea, and stomach ache, all gradually increasing in severity. On day seven, the patient developed abdominal pain. [dovepress.com]

  Rickettsialpox is generally benign and self-limiting, but neurological symptoms such as photophobia, vertigo, pain on movement of the eyes, and nuchal rigidity may be severe enough to warrant lumbar puncture. [13] Q fever is a bacterial infection affecting [e-ijd.org]

• Hematuria

  No episodes of malena or hematuria were noted. The patient had pancytopenia, normal BT but prolonged aPTT; PT. D-dimer test levels were elevated. Protein C level was normal. [ijpd.in]

  In the acute form there may be bleeding from any of the body orifices, such as hematuria, nosebleed, vaginal bleeding, and bleeding gums. [medical-dictionary.thefreedictionary.com]

  Urine analysis revealed microscopic hematuria. A blood culture for Neisseria, however, proved to be negative and Weil Felix test was also negative. [ijdvl.com]

  Because of the association with severe septic shock, the patient may experience symptoms of end-organ damage such as hematuria, oliguria, and respiratory distress. Pain out of proportion to exam should always make one consider necrotizing fasciitis. [ncbi.nlm.nih.gov]

• Microscopic Hematuria

  Urine analysis revealed microscopic hematuria. A blood culture for Neisseria, however, proved to be negative and Weil Felix test was also negative. [ijdvl.com]

  Urine analysis revealed microscopic hematuria. A blood culture for Neisseria More Details, however, proved to be negative and Weil Felix test was also negative. [dx.doi.org]

After suspicion towards purpura fulminans arises, workup should involve a complete blood count (CBC), particularly focusing on the evaluation of platelet count. In addition to blood count, a coagulation panel including prothrombin time (PT) and activated partial thromboplastin time (aPTT) should be obtained, alongside values of fibrinogen and D-dimers. This is required in order to gain a full view of the coagulation cascade, and try to determine the cause [14]. 

Vital information can be obtained from patient history, which may reveal that the patient suffers from enzyme deficiencies, or had signs of infection prior to the development of purpura fulminans, which may indicate meningococcal infection. Physical examination should be performed, and together with laboratory findings, the cause of this condition will be identified. Idiopathic cases have been observed and are considered to have been caused by a latent viral or bacterial infection [15].

• Pericardial Effusion

  Because he did not show relevant changes of electrocardiography, pericardial effusion, or elevated cardiac enzyme levels, we assume that the possibility of septic cardiomyopathy is most probable in this case. [jintensivecare.biomedcentral.com]

  A computed tomography (CT) scan showed a large, fresh cerebral infarction, intracranial infection, lung infection, pleurisy, and pericardial effusion. [dovepress.com]

  Transthoracic echocardiography showed a hypercontractile left ventricle without pericardial effusion, regurgitation of valves, and vegetations. [bmcinfectdis.biomedcentral.com]

• Neutrophilia

  Initial laboratory investigation confirmed anemia (hemoglobin - 9.3 g/dl), total lung capacity 8.9 × 10 9 /L with neutrophilia, (neutrophil - 83%, lymphocyte - 11%, and eosinophil - 1%), and platelets 139 × 10 9 /L. [ijccm.org]

  The septic screen showed neutrophilia. WFT was positive for Ox-2 and Ox-19 Ag. Other relevant investigations were normal [Table 1]. [idoj.in]

  Neutrophilia or eosinophilia may occur. Hypocomplementaemia is usual. Circulating immune complexes are often demonstrated. [drmhijazy.com]

• C-Reactive Protein Increased

  Complement C3 reduced to 0.43 g/L (0.79–1.52 g/L), and high-sensitivity C-reactive protein increased between 97.10–354.00 mg/L (<10 mg/L). [dovepress.com]

• Chloride Increased

  On day 24, his blood chloride increased, his oxygen partial pressure was 48%, his carbon dioxide partial pressure was 23%, his HGB was 48 g/L, and he was transferred to the Intensive Care Unit (ICU). [dovepress.com]

• Capnocytophaga

  Epidemiology History : first described by Guelliot in 1884 Etiology Acute Infectious Purpura Fulminans Capnocytophaga Canimorsus (see Capnocytophaga Canimorsus, [[Capnocytophaga Canimorsus]]) Epidemiologic Exposure : dog bite Risk Factor for Bacteremia [mdnxs.com]

  We report 2 cases of Capnocytophaga canimorsus-induced septicaemia complicated by purpura fulminans in previously healthy individuals, both of whom had been exposed to dog saliva prior to disease. [ncbi.nlm.nih.gov]

  Leschinger, Marco Maggiorini Volume 29, Number 2 / February, 2003 Correspondence Fibrinolytic therapy in Capnocytophaga canimorsus sepsis after dog bite A. R. T. van de Ven, A. C. M. van Vliet, B. Maraha, H. H. [icmjournal.esicm.org]

  Pei Chia Eng et al. [6] published a very challenging case of purpura fulminans which involved the tip of the nose and was caused by Capnocytophaga septicemia following a dog bite. The patient was diagnosed by a blood film [6]. [karger.com]

  Capnocytophaga canimorsus sepsis with purpura fulminans and symmetrical gangrene following a dog bite in a shelter employee. Am J Med Sci. 2004; 327: 369-372 Keri J.E. Thomas K. Berman B. et al. Purpura fulminans in a patient with malaria. [amjmedsci.com]

Treating purpura fulminans is achieved through elimination of the underlying cause, since purpura itself cannot be treated by any means. 

While the cause is being investigated, replacement therapy must be initiated, including:

• Platelet transfusion, due to a potentially excessive rapid loss of thrombocytes.
• Cryoprecipitate transfusion for replacement of fibrinogen and factor VIII
• Fresh frozen plasma, which increases levels of natural anticoagulants and other clotting factors, including antithrombin, and proteins C and S
• Heparin can be sometimes useful, but under specific indications, because it is not advised to give patient with purpura fulminans that have excessive bleeding. However, for patients with prothrombotic symptoms such as venous thrombosis, may benefit from heparin.

If the cause is suspected to be an infection, broad-spectrum intravenous antibiotic therapy is absolutely necessary, and should primarily target Neisseria meningitidis, for which ceftriaxone is the primary choice, usually as 2gr q12h for at least 7 days. Other cause-related therapies include administration of intravenous immunoglobulins, while amputations may also be necessary in the case of severe gangrene.

Prognosis of purpura fulminans solely depends on the underlying cause, but the conditions accompanied by it are usually extremely severe. Neonatal forms of purpura fulminans are 100% fatal without replacement of deficient clotting factors, while meningococcal sepsis can still be a fatal condition, even despite therapy. Improvements in supportive therapy have been made within the last few decades and have improved patient outcomes, including prevention of secondary infections, and transfusion of necessary blood products.

Disorders of the coagulation system and purpuric lesions may occur due to various causes, but purpura fulminans implies a major coagulation disorder and has been observed in the following conditions:

• Disseminated intravascular coagulation (DIC) - Abnormal and excessive generation of prothrombotic factors in the circulation can occur because of various reasons, including infections, surgical complications, malignant diseases, and enzyme deficiencies. Depending on the rate and severity of DIC, it may either cause venous thrombosis, pulmonary embolism, with low rates of bleeding (slowly evolving), or it may cause thrombocytopenia and depletion of clotting factors (rapidly evolving), leading to bleeding and multiorgan failure. Regardless of the type, purpura fulminans can arise as a manifestation of this disorder. 
• Infection - Meningococcal infection [6] and the development of sepsis caused by Neisseria meningitidis is a life-threatening infection that is most commonly encountered in children [7], and is characterized by very high fever and constitutional symptoms. In 15-25% of the cases, abrupt development of disseminated purpuric lesions is observed. Despite all treatment strategies, this infection can still be fatal, due to its abrupt onset and severe damage to blood vessels and coagulation system [8].
• Neonatal purpura fulminans (congenital deficiency of protein C or S) - Although it is very rare [9], neonates who are born with a deficiency of either protein C or S develop extensive purpuric lesions on their first day of life, and the condition may be life-threatening if not supplemented with appropriate enzymes [10]. 
• Drug-induced  - Purpura fulminans can be caused by medications. Several drugs, including sulfonamides, penicillins, and phenytoin have been mentioned as potential causes of this disorder, through mechanisms still not fully understood [11].
• Thrombocytopenia - Any disease which accelerates platelet consumption, or decreases platelet production can predispose patients to purpura fulminans [12], including idiopathic thrombocytopenic purpura (ITP), thrombotic thrombocytopenic purpura (TTP), and malignant diseases which deplete platelets.
• Clotting factor deficiencies - Purpura can often be a manifestation of clotting factor deficiencies, and purpura fulminans can be observed in severer cases. Examples include von Willebrand disease, hemophilia A and B, antithrombin III deficiency, and other clotting factor deficiencies.

Purpura fulminans can be observed among patients of any age and gender, depending on the cause. This disorder is observed in neonates, young children, and adults of any age, because the conditions in which this disorder appears, may occur at any point in life.

Purpuric lesions on the skin occur due to extravasation of blood from blood vessels into the surrounding environment. This "pooling" of blood under the skin can occur either due to uncontrolled activation of the coagulation cascade, and subsequent depletion of platelets leading to massive bleeding, or due to slow and excessive activation of prothrombotic factors, leading to thrombosis and vascular infarctions, which cause blood vessel rupture and release of blood from the vessels.

In the case of clotting factor deficiency, the coagulation pathway cannot perform its regular functions, leading to a decreased capacity of blood for coagulation, resulting in bleeding. In cases of malignancies, such as lymphomas, or after chemotherapy, thrombocytes may be depleted, thus leading to purpura fulminans through a similar mechanism.

Infections, particularly meningococcal sepsis, cause rapid and possibly lethal damage to the vascular system. Proinflammatory cytokines, including tumor necrosis factor alpha (TNF)–α, and interleukin 1 (IL-1), rapidly consume clotting factors, and the effects of bacterial endotoxins lead to the development of microemboli in the circulation and widespread disruption of the endothelial barrier [13]. 

It is important to mention that purpura fulminans can occur only if the coagulation cascade is severely impaired, and should not be confused with the development of purpura and purpuric lesions that are commonly seen in some other disorders, such as Henoch-Schonlein purpura, autoimmune vasculitis, and some other diseases.

In order to prevent the development of purpura fulminans, early signs of this disorder must be identified, so that complications may be prevented. However, it is difficult to establish the diagnosis early because of the sudden onset of the purpuric rash. Nevertheless, in all patients who have predisposing conditions, such as clotting factor deficiencies, or disease-related thrombocytopenias, regular checkups should be performed in order to evaluate the status of the coagulation system. Proper management of existing conditions, such as ITP and TTP, may reduce the risk of this potentially fatal disorder.

Purpura fulminans arises due to severe damage of the coagulation system [1], and is one of the clinical manifestations of disseminated intravascular coagulation (DIC) [2], which develops as a result of various conditions, such as infections, autoimmune diseases and congenital enzyme deficiencies affecting the coagulation cascade. The pathogenesis comprises severe imbalance of coagulation factors and platelets, leading to extravasation of blood from the vessels, and cutaneous hemorrhage. In the case of massive vascular thrombosis, gangrenous tissue necrosis develops [3] and extensive damage to the skin and the surrounding tissues may occur.  Depending on the cause, purpura fulminans may be observed in patients of all ages, including neonates, children, and adults [4]. The clinical presentation is the sudden and abrupt appearance of initially small petechiae, accompanied by cutaneous pain. As the disease progresses, extensive and massive ecchymoses (purpura) with sharp and irregular borders are exhibited, either deep purple or blue in color. Symptoms such as fever and hypotension may be observed, as well as shock and gangrenous necrosis of extremities. Laboratory tests should include a full blood count (with an emphasis on platelet count), biochemical parameters including fibrinogen, D-dimer, as well as PT and PTT, to determine the status of the coagulation system. Patient history, as well as physical examination, may point to the underlying cause, and immediate treatment is absolutely necessary in order to achieve a good prognosis, which depends on the cause. Treatment also includes replacement therapy of necessary blood products, including platelets, coagulation factors and activated protein [5], which may be life-saving. 

Purpura fulminans is a form of skin rash which occurs in diseases which profoundly damage the coagulation system, and if this condition is observed on physical examination, it should be treated as a medical emergency. Purpura fulminans manifests as a deep purple to blue rash that develops on numerous locations on the body within hours and is usually accompanied by pain. This rash occurs because of the imbalance between the factors which are responsible for normal blood coagulation, resulting in leakage of blood from blood vessels. This blood concentrates under the skin, and bleeding into the external environment may occur.

This disorder may be seen in neonates and children who are suffering from deficiencies of some of the factors in the coagulation system, in patients suffering from meningococcal infection, or in those that are suffering from conditions that impair the number of thrombocytes or platelets. Diseases that cause this condition may be fatal, which is why a prompt diagnosis is necessary. Through patient history, physical examination, as well as certain laboratory tests, suspicion towards this disorder arises and immediate treatment must be initiated. Treatment should be directed at the underlying cause, but it also aims at replenishing blood products that are depleted, such as platelets and coagulation factors. Because of the rapid and abrupt course of this disease, prevention is not really possible, but patients with disorders known to cause purpura fulminans should manage their illnesses adequately, in order to prevent potentially life-threatening consequences. 

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