Two Cases of COVID-19 Patients with Associated Purpura Fulminans.

Purpura fulminans (PF) is a life threatening emergency involving coagulopathy and widespread skin necrosis. Early treatment, especially surgical management, is imperative as prognosis can be very poor. PF is most commonly associated with severe bacterial illness; however, viral causes are also possible. Currently in the literature, there have only been a handful of PF cases associated with COVID-19. We present two cases of PF in the setting of COVID-19 infection. Both patients had a history of underlying coagulopathies. PF can be a sign of underlying coagulopathy in a COVID-19 patient, who is already at increased risk for thromboembolic events due to the inflammatory nature of COVID itself. Due to how quickly PF can develop into life threatening necrosis and multi organ failure, it is imperative that these patients are referred early to a burn center for more advanced care.

Purpura fulminans due to Streptococcus pneumoniae bacteraemia in an unsplectomised immunocompetent adult without primary hypocomplementaemia.

Invasive pneumococcal disease occurs in high-risk patient population which includes patients with asplenia and primary hypocomplementaemia. Pneumococcal sepsis can rarely cause disseminated intravascular coagulation (DIC) and intravascular thrombosis of small and medium sized vessels called purpura fulminans which is associated with a high mortality rate. We present the case of an immunocompetent woman in her 50s with an intact spleen who presented with septic shock from Streptococcus pneumoniae bacteraemia. Her hospital course rapidly progressed to multiorgan dysfunction, DIC and purpura fulminans. She was treated aggressively with broad spectrum antibiotics, coagulation factor replacement, multiple vasopressor support, renal replacement therapy and mechanical ventilator support. Despite aggressive measures, she succumbed to the multiorgan failure.

COVID-19 association with purpura fulminans: report of a life threatening complication in a fully vaccinated patient.

SARS-CoV-2 manifestations have been an ongoing evolving topic that has spread beyond its initial respiratory associations. Recently, there have been reports of COVID-19 infections found to be associated with vascular pathologies. Here, we describe a case of a fully vaccinated COVID-19 adult male with past medical history of purpura fulminans that presented with diffuse necrotic cutaneous tissue sequelae resulting in intensive care unit management and dry gangrene of upper extremity. On admission, it was found that the patient had decreased activity rather than quantity of coagulation pathway protein S. Early recognition and work up are essential in patients with known history of vascular disease and confirmed cases of SARS-CoV-2 positive polymerase chain reaction.

Kawasaki Disease with Peripheral and Facial Gangrene: A Case report and review of literature.

With the onset of the SARS-CoV-2 pandemic, Kawasaki Disease (KD) has come to the fore with its many atypical manifestations. Atypical clinical neurological, ophthalmological, musculoskeletal, gastrointestinal and pulmonary manifestations in a febrile child with raised markers should prompt the clinician to think of Kawasaki disease. Peripheral gangrene is a rare atypical manifestation of KD reported in infancy. We present a three-and-a-half-year-old boy with extensive gangrene all four limbs and face along with purpura fulminans. He was successfully treated with two doses of intravenous immunoglobulin (IVIG) and infliximab, with no residual gangrene. This case highlights that very severe forms of Kawasaki disease require IVIG, pulse steroids as well as infliximab for adequate control and complete resolution of the disease.

New-onset diabetic ketoacidosis with purpura fulminans in a child with COVID-19-related multisystem inflammatory syndrome.

BACKGROUND: Coronavirus disease 2019 (COVID 19) usually causes a mild illness among children. However, in a minority of children, it may be associated with the life-threatening multisystem inflammatory syndrome (MIS-C), or thrombotic microangiopathy, or sequelae like type-1 diabetes mellitus (T1DM). We describe a previously healthy, 12-year-old boy with new-onset T1DM with diabetic ketoacidosis (DKA) in the setting of MIS-C, with a course complicated by thrombotic microangiopathy. CASE PRESENTATION: The patient presented with four days history of fever, non-bilious vomiting, polyuria and polydipsia. On evaluation, he was noted to have diabetic ketoacidosis. Although Diabetic ketoacidosis with insulin and intravenous fluids, his hospital course was notable for shock requiring vasopressor, purpura fulminans with eschar formation, neurological manifestations (left hemiparesis due to right middle cerebral artery territory infarct, mononeuritis multiplex) and thrombotic microangiopathy. MIS-C-like illness secondary to COVID-19 was suspected due to diabetic ketoacidosis, thrombotic microangiopathy, elevated inflammatory markers, history of contact with COVID-19-infected individual and detectable COVID-19 IgG antibodies. He improved following management with methylprednisolone, intravenous immunoglobulin, low-molecular-weight heparin and aspirin, and was discharged on hospital day 48. CONCLUSION: MIS-C-like illness should be considered in children and adolescents presenting with complex multisystem involvement in this era of COVID 19. Management with immunomodulatory agents can be lifesaving.

Severe Acute Respiratory Syndrome Coronavirus-2 Pneumonia Presenting Concomitantly With Purpura Fulminans: A Case Report.

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is a novel coronavirus that has been extensively described in its most common presentations. Its pathogenetic process is poorly understood, although it is theorized that endothelial damage and inflammation play a central role. Its prothrombotic nature affects multiple organs, including lungs, kidneys, and the central nervous system. Rarer are cutaneous presentations that can be triggered or displayed concomitantly with COVID-19. Purpura fulminans is a life-threatening syndrome that results in skin thrombosis and hemorrhagic infarction. While its association is explicit in critically ill patients with sepsis, few or rare cases have been described to be linked with COVID-19. In this report, we present a case of a critically ill patient with COVID-19 who showed signs of purpura fulminans while in the intensive care unit.

Association of COVID-19 Infection and Purpura Fulminans

Coronavirus disease 2019 (COVID-19) was officially declared as a pandemic on March 11, 2020. Although most patients with COVID-19 manifest fever and respiratory tract symptoms, extrapulmonary and atypical presentations, such as gastrointestinal, neurologic, and cardiovascular involvement as well as thromboembolic events have been reported amongst COVID-19 patients. Herein, we aim to describe a COVID-19 patient who progressed to purpura fulminans. © 2021, Author(s).

Disseminated intravascular coagulation: A devastating systemic disorder of special concern with COVID-19.

Disseminated intravascular coagulation (DIC) is linked with severe COVID-19, prompting considerable concern. DIC can be a devastating systemic disorder. It is often markedly manifest on the skin as acrocyanosis or as petechiae and purpura with progression to hemorrhagic bullae. Subcutaneous hematomas may occur, as may thrombotic findings including necrosis and gangrene. The most common cause is infection, with special emphasis now on COVID-19. We have reviewed the medical literature under the search terms "Disseminated intravascular coagulation" and "consumption coagulopathy" for the past two decades in the English language using Medline and Google Scholar to update special concerns and considerations, focusing on those with COVID-19. Skin findings with DIC may be prominent. The severity of cutaneous lesions often correlates with the gravity of systemic disease. DIC is most effectively treated by addressing the underlying cause and resuscitating the patient using supportive measures. It is pivotal to recognize and treat DIC early, before deadly complications, such as multiple organ failure, arise.