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Purpura fulminans complicating scrub typhus and acute hepatitis E coinfection
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  1. Dhriti Sundar Das,
  2. Rashmi Ranjan Mohanty,
  3. Anupama Behera and
  4. Srikant Behera
  1. General Medicine, All India Institute of Medical Sciences Bhubaneswar, Bhubaneswar, Odisha, India
  1. Correspondence to Dr Dhriti Sundar Das; genmed_dhriti{at}aiimsbhubaneswar.edu.in

https://doi.org/10.1136/bcr-2023-255790

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    Description

    An admitted elderly man presented with a history of fever, jaundice and altered sensorium for 7 days and blackish discolouration of both upper and lower limbs for 1 day. Physical examination revealed multiple non-palpable retiform purpura over the involved limbs and abdomen (figures 1–3). The patient appeared toxic and febrile and gradually went into shock. Laboratory investigations revealed total serum bilirubin of 7.4 mg/dL with direct fraction of 4 mg/dL, alanine transaminase of 540 IU, aspartate transaminase fo 352 IU, serum creatinine of 1.5 mg/dL, haemoglobin of 6.5 g/dL, platelet count of 100×109/L, total leucocyte count of 17 000×109/L and International Normalised Ratio (INR) of 1.87. On further evaluation, scrub typhus IgM came positive along with HEV IgM. HEV PCR could not be tested due to unavailability. Blood and urine cultures showed no growth. Epstein Barr Virus (EBV) and Cytomegalovirus (CMV) IgM were negative. Malaria rapid test and leptospira IgM were also negative. However, potein C and potein S were found to be low. Cerebrospinal fluid (CSF) analysis showed 20 white cells with 60% polymorphonuclear cells. Ultrasound (USG) of the whole abdomen was normal. Skin biopsy from the calf area showed vasculopathic changes. CSF cultures revealed no growth of any organism. The patient was initially started on meropenem, doxycycline and linezolid for 7 days and other supportive measures like intravenous fluids and inotropes. Thereafter, doxycycline was continued for total of 14 days. Diagnosis of purpura fulminans complicating scrub typhus and acute hepatitis E coinfection was made. The patient’s clinical condition improved with healing of the skin lesions (figures 4 and 5).

    Figure 1
    Figure 1

    Multiple extensive retiform purpura involving upper and lower limbs as well as abdomen.

    Figure 2
    Figure 2

    Multiple extensive retiform purpura involving upper and lower limbs as well as abdomen.

    Figure 3
    Figure 3

    Multiple extensive retiform purpura involving upper and lower limbs as well as abdomen.

    Figure 4
    Figure 4

    Healing of the skin lesions after treatment.

    Figure 5
    Figure 5

    Healing of the skin lesions after treatment.

    Purpura fulminans is a life-threatening, often fatal condition, if left untreated.1 Rickettsial infections like scrub typus presenting as purpura fulminans are quite rare, more so when it is coinfected with acute hepatitis E infection.2–4 Protein C and protein S deficiency, inherited or acquired, are related to this often lethal condition, yet the pathogenesis remains elusive. So, a high index of clinical suspicion is required to improve patient outcome in such cases.

    Patient's perspective

    • I am very happy that I have recovered from my illness after admission in the hospital. I express my deep gratitude to all the staffs and doctors.

    Learning points

    • Treating clinicians in certain geographical areas need to be more vigilant about common rickettsial infections such as scrub typhus causing purpura fulminans.

    • Coinfection need also to be probed into in such life-threatening illness.

    • Untreated scrub typhus can lead to severe illness, so it is pertinent for clinicians to consider scrub typus in patients presenting with acute febrile illness with rashes in endemic areas.

    Ethics statements

    Patient consent for publication

    References

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    Footnotes

    • Contributors The following authors were responsible for drafting of the text, sourcing and editing of clinical images, investigation results, drawing original diagrams and algorithms, and critical revision for important intellectual content: DSD: drafting of the text and editing of clinical images; AB: critical revision of the manuscript; RRM: critical revision of the manuscript; SB: critical revision of the manuscript. The following authors gave final approval of the manuscript: DSD, AB, RRM and SB.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.