Purpura fulminans due to Staphylococcus aureus.
BACKGROUND
Purpura fulminans is an acute illness commonly associated with meningococcemia or invasive streptococcal disease, and it is typically characterized by disseminated intravascular coagulation (DIC) and purpuric skin lesions. In this article, we report the first 5 cases (to our knowledge) of purpura fulminans directly associated with Staphylococcus aureus strains that produce high levels of the superantigens toxic shock syndrome toxin-1 (TSST-1), staphylococcal enterotoxin serotype B (SEB), or staphylococcal enterotoxin serotype C (SEC).


METHODS
Cases were identified in the Minneapolis-St. Paul, Minnesota, metropolitan area during 2000-2004. S. aureus infection was diagnosed on the basis of culture results, and susceptibility to methicillin was determined. The ability of the isolated organisms to produce TSST-1, SEB, SEC, and Panton-Valentine leukocidin (PVL) was determined. TSST-1, SEB, and SEC levels were also quantified after in vitro growth of the organisms.


RESULTS
In 3 of the 5 cases, the infecting S. aureus strain was isolated from the blood cultures. In 2 of the 5 cases, the infecting S. aureus strain was isolated only from the respiratory tract, indicating that purpura fulminans and toxic shock syndrome resulted from exotoxin and/or other host factors, rather than septicemia. One of these latter 2 patients also had necrotizing pneumonia, and the isolated S. aureus was a methicillin-resistant strain that produced both SEC and PVL. Only 2 of the 5 patients survived, and 1 of the survivors received activated protein C.


CONCLUSIONS
Staphylococcal purpura fulminans may be a newly emerging illness associated with superantigen production. Medical practitioners should be aware of this illness.
Kravitz
Gary R
GR
St. Paul Infectious Disease Associates, St. Paul, Minnesota, USA.
Dries
David J
DJ
Peterson
Marnie L
ML
Schlievert
Patrick M
PM
D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001427:Bacterial Toxins / Q000378:metabolism; D004768:Enterotoxins / Q000378:metabolism; D005098:Exotoxins / Q000378:metabolism; D005260:Female; D006801:Humans; D011695:IgA Vasculitis / Q000209:etiology* / Q000382:microbiology / Q000473:pathology; D007956:Leukocidins; D008297:Male; D008875:Middle Aged; D018805:Sepsis / Q000150:complications / Q000382:microbiology; D012772:Shock, Septic / Q000209:etiology / Q000473:pathology; D013203:Staphylococcal Infections / Q000150:complications* / Q000188:drug therapy / Q000382:microbiology* / Q000473:pathology; D013211:Staphylococcus aureus / Q000302:isolation & purification* / Q000378:metabolism; D018089:Superantigens / Q000378:metabolism
D000900:Anti-Bacterial Agents; D001427:Bacterial Toxins; D004768:Enterotoxins; D005098:Exotoxins; D007956:Leukocidins; C078284:Panton-Valentine leukocidin; D018089:Superantigens; C030107:enterotoxin F, Staphylococcal; C031818:enterotoxin B, staphylococcal; C034959:enterotoxin C, staphylococcal