Case Presentation: A 48-year-old man presents with chief complaints of fever, nausea, vomiting, rash and discoloration of hands and feet for 1 day. He was admitted to intensive care unit for septic shock and altered mental status. Patient was intubated and started on intravenous fluids, pressor medications and broad-spectrum antibiotics (vancomycin and piperacillin/tazobactam). On day 2 of admission, he had progressive worsening of purpura and discoloration over the hands and feet that rapidly progressed to peripheral symmetrical gangrene. With the concern for ischemic limb, Orthopedics and Plastic Surgery were consulted. Patient required multiple debridement procedures of the limbs followed by bilateral below knee amputations and below elbow amputations. Blood cultures came back positive for Capnocytophaga canimorsus and upon questioning, wife reported having a dog at home.After a 2-month hospital course, patient was discharged to inpatient rehab service, but continues to be admitted for multiple surgical interventions for infection related to the amputation sites. He had extensive workup that ruled out connective tissue disease, hypercoagulable conditions and immunodeficiency, including asplenia. Based on clinical presentation and laboratory results, the patient was diagnosed with acute infectious purpura fulminans.Of note, patient continues to have the dog that he had before onset of illness.
Discussion: Purpura Fulminans (PF) is a potentially disabling and life-threatening disorder caused by microvascular occlusion followed by hemorrhagic infarction of the dermis, resulting in large purpura and bullae. Three distinct categories of PF can be identified: Inherited or acquired coagulation abnormalities, acute infectious PF and idiopathic PF.Most cases of acute infectious PF are associated with meningococcal sepsis. It occurs rarely in the course of infection with other organisms, even in the setting of septicemia with disseminated intravascular coagulation (DIC). Other organisms reported to cause acute infectious PF include Capnocytophaga canimorsus (C. canimorsus). Approximately 60 to 70% of acute purpura fulminans cases have been reported amongst children below 2 years of age, our patient was 48 years old at time of onset. C. canimorsus is a facultative, anaerobic, gram‐negative bacteria found in the normal oral flora of dogs. This bacterium, commonly transmitted by dog bites, can cause severe sepsis, especially in immunocompromised patients, with an overall mortality rate of approximately 30%. Our case is unique as the patient had no underlying immunodeficiency, and transmission is assumed to have occurred from a lick due to the absence of a dog bite.
Conclusions: This case highlights the need for a high index of suspicion of infectious purpura fulminans associated with sepsis in the inpatient setting and the importance of recognizing a pathogen and disease associated with one of the world’s most popular pets.