An ADL-independent 75-year-old woman with a history of diabetes who was receiving insulin therapy visited our emergency department owing to fever and chills, which had started 3 days before the visit. At that time, her consciousness level was GCS E4V4M6, temperature was 36.8°C, pulse rate was 83 beats/minute, blood pressure was 82/46 mmHg, and respiratory rate was 34 times/minute. The patient also had acute renal failure. As septic shock was suspected, she was admitted to the intensive care unit. Subsequently, we started antibiotic therapy, norepinephrine, and CHDF treatment. After a few days, blood and urine culture revealed Escherichia coli. During the course of the treatment, purpura appeared on the face and extremities; subsequently, black necrosis developed on these sites. She was diagnosed with acute infectious purpura fulminans (AIPF) caused by E. coli. Owing to the black necrosis on the lower extremities, both legs were amputated on the 26th day of hospitalization. Thereafter, the fever gradually subsided, and inflammation reaction showed some improvement; we administered antimicrobials on a continuous basis. The patient was discharged from the hospital on the 185th day. She is currently being monitored at the outpatient department. For black necrosis on the fingers, we perform debridement on a continuous basis.
Discussion:
Symmetric peripheral gangrene is defined as ischemic necrosis of the extremities. Two or more extremities are simultaneously affected, without any proximal arterial occlusion. Of these cases, necrosis due to acute infection is referred to as AIPF. Typically, Neisseria meningitidis and Streptococcus pneumoniae are the causative pathogens. However, in this case, the causative pathogen was E. coli, which is uncommon. Only a few studies have reported on AIPF cases, because of which it is considered to be rare. Furthermore, an immunocompromised state, such as that owing to splenectomy and spleen hypoplasia, is considered to be a risk factor for AIPF. While our patient did not have a history of splenectomy or spleen hypoplasia, she had poorly controlled type 2 diabetes, which may have been related to the onset of AIPF.
Conclusions:
We encountered a case of AIPF due to E. coli in an elderly woman with poorly controlled diabetes. Most cases of AIPF in adults are caused by N. meningitidis or S. pneumoniae. Our findings show that E. coli can also cause AIPF. Thus, if purpura is observed on the limbs or face of a patient with septic shock, it is important to consider AIPF regardless of the causative pathogens and to initiate systemic management.