title: Purpura fulminans due to Staphylococcus aureus.
abstract: 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.
authors.affiliation: St. Paul Infectious Disease Associates, St. Paul, Minnesota, USA.
authors.forename: Gary R
authors.initials: GR
authors.lastname: Kravitz
authors.forename: David J
authors.initials: DJ
authors.lastname: Dries
authors.forename: Marnie L
authors.initials: ML
authors.lastname: Peterson
authors.forename: Patrick M
authors.initials: PM
authors.lastname: Schlievert
mesh_terms: 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
chemical_list: 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