Key Point

Purpura fulminans due to S aureus infection has symptoms identical to those for fulminant meningococcemia but requires additional treatment against methicillin-resistant S aureus.

MINNEAPOLIS–ST. PAUL—Researchers at the University of Minnesota have identified a newly emerging illness, staphylococcus purpura fulminans. The disease begins as a respiratory tract infection, which then is infected by Staphylococcus aureus. The infection moves to the lungs, making superantigens (bacterial toxins that activate large numbers of T cells), often leading to death due to hypertension and shock.

Purpura fulminans—widespread, severe purpura with extensive tissue damage and sloughing of the skin—is a condition usually associated with meningococcemia, not S aureus infection. However, the researchers studied five patients from the Minneapolis–St. Paul area who had purpura fulminans and found that the S aureus strains from these patients all produced toxic shock syndrome toxin-1 (TSST-1) or staphylococcal enterotoxin serotypes B and C. They concluded that purpura fulminans due to S aureus may be an emerging clinical entity.¹

Patients were studied between 2000 and 2004. Bacteriologic and methicillin susceptibility testing were performed for all patients. Levels of TSST-1 and of staphylococcal enterotoxin serotypes B and C were assessed using antibody tests.

The patients, four of whom were women, ranged in age from 21 to 56. Three had purpura fulminans and staphylococcal sepsis and two had blood cultures that were negative for S aureus but had sputum or endotracheal secretions positive for the pathogen. Three patients died, and of the two that survived, one required amputation of both legs below the knee.

The authors proposed that the clinical features of purpura fulminans and toxic shock syndrome observed in the five patients resulted from massive cytokine release induced by the S aureus strains. However, only one patient developed the “sunburn rash” typical of toxic shock syndrome. The purpuric rash seen in most of the patients may indicate a more severe form of toxic shock syndrome.

Based on their experience, the investigators identified three treatments for purpura fulminans. First, patients presenting with symptoms of purpura should receive antibiotic therapy—against Neisseria meningitidis, streptococci, and methicillin-resistant S aureus. Patients should also be given early therapy with activated protein C to minimize purpuric injury and slow the inflammatory cascade before irreparable tissue injury occurs. Intravenous immunoglobulin therapy may also be indicated because toxic shock syndrome is mediated by superantigens.

The authors also noted that the clinical presentations for all five patients were identical to those seen in patients with fulminant meningococcemia—which was the original clinical diagnosis in two patients. Their findings show that S aureus illness can lead to an identical clinical syndrome. Because S aureus infections are not notifiable, it is not possible to determine the rate of occurrence of purpura fulminans caused by this organism.

—Gale Jurasek

Reference
1. Kravitz GR, Dries DJ, Peterson ML, Schlievert PM. Purpura fulminans due to Staphylococcus aureus. Clin Infect Dis. 2005;40:941-947.

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