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Purpura Fulminans (PF) is a rare disorder of the skin large areas of necrosis blueblack hemorrhagic. Patients are typical laboratory signs of disseminated intravascular coagulation (DIC). Our case describes a 37-year old previously healthy man who presented at 3 days of generalized malaise, headache, vomiting, photophobia, and ecchymotic rashes on the skin. Initial laboratory examination showed DIC without apparent infectious trigger including unremarkable cerebrospinal fluid (CSF) biochemical analysis strattera price. There was further progression of skin ecchymosis and multiple organ damage according to PF. The final CSF culture showed

pneumococcus. Despite normal initial CSF biochemical analysis, bacterial meningitis should always be considered in patients with unexplained other engine, as it can be an early manifestation of infection. PF is a clinical diagnosis that requires early diagnosis and prompt treatment of empirical, especially in patients with progressive changes in mental status, ecchymotic skin rash, and internal combustion engines. A. Introduction

purpura Fulminans (PF) is an unusual manifestation of the skin of disseminated intravascular coagulation (DIC) associated with infection and / or sepsis. It is characterized by tissue necrosis, thrombosis of small vessels in the installation engine. PF often leads to end organ damage, followed by profound morbidity and mortality. We describe a case of PF secondary infection

pneumococcus. 2. Case Presentation

37-year old previously healthy man presented to the emergency department with 3 days of generalized malaise, headache, nausea, vomiting, photophobia, and ecchymotic rashes on the skin. Admission physical assessment showed that he was tachycardic, sleepy but oriented without occipital stiffness or focal neurological signs. He was a diffuse ecchymotic rash macular nonblanching his limbs and abdomen (figures, and

). / L), thrombocytopenia (32 10

/ l) and normal hemoglobin. Coagulation studies showed prothrombin time 15 years. 6 seconds, partial thromboplastin time 37 seconds, fibrinogen 10. 9

mol / L, and D-dimer 20000

g / l according to the engine. Liver and kidney showed AST 117U / L, ALT 65U / L, total bilirubin 20. 2

mol / l, urea 20. 3mmol / l, creatinine and 247. 52

mol / L. The initial cerebrospinal fluid (CSF) analysis was within normal limits (WBC Jan. 10

/ l, erythrocyte October 1

/ l, glucose 2. 9mmol / l, protein 0. 47h / l, and saw no organisms on Gram). Serologic HIV, EBV, CMV, and hepatitis B virus was negative, and serological testing for

rickettsiae. Other tests showed serum lactic 2mmol / l, CPK 512U / L, and LDH 1008U / l antinuclear antibody and rheumatoid factor were negative with normal levels of serum complement. Admission chest radiography and CT head were normal. Peripheral smear showed thrombocytopenia with low-grade microangiopathic hemolytic anemia (Mach). He was put on intravenous (IV), empirical antibiotics including vancomycin, cefepime, and metronidazole on clinical suspicion of sepsis and received transfusion of platelets and IV heparin for DIC. Several blood cultures done during hospitalization did not grow any organisms. Two days of admission, CSF cultures grew

Streptococcus pneumonia, antibiotics were switched to IV Ceftriaxone (2 g every 12:00). His skin lesions progressed rapidly hemorrhagic bullae. Skin biopsy showed extensive hemorrhage with focal thrombosis. The clinical picture of rapidly progressive ecchymotic skin rash in our patient with DIC secondary infection

pneumoniae is consistent with a diagnosis of PF, and skin biopsy confirmed the same. Certainly hospital patients was complicated transitional deterioration of her mental state, the distal extremity thrombosis, worsening renal function requiring hemodialysis. With care support and antibiotic therapy (a total of two weeks), he improved clinically. At discharge the patient returned to his baseline mental status, his skin lesions cleared, but the defeat of his lower limbs, and he remained on hemodialysis. 3. Discussion

purpura Fulminans rare, serious disease of the skin associated with DIC, which primarily affects children and adolescents. Large areas of skin necrosis developing blueblack hemorrhagic, biopsy shows small vessel microthrombi, and sometimes mild vasculitis. In our patient clinical data suggest the reflection of microangiopathic thrombosis of hemolysis secondary to DIC and purpura Fulminans. Pathogenesis is unknown, but histological results were compared with animal models of consumer coagulopathy [

]. He also suggested that the development of acquired defects in the way of protein C is similar to two other protein C deficient states, namely, neonatal purpura Fulminans and warfarin induced skin necrosis [

]. In our patient, protein C was 87 (normal) and protein S was 15 (low). Mortality rates have recently declined significantly in purple Fulminans, mainly through increased use of therapeutic heparinisation in these patients and aggressive replacement of platelets and clotting factors [

]. Our patient also improved clinically with these measures. The most common organisms of DIC is bacterial, especially Gram-negative bacteria (meningococcus

,

Haemophilus influenzae,

Aerobacter etc.) as well as gram-positive bacteria (Staphylococcus

staphylococcus, streptococcus group B,

Streptococcus pneumonia and

anthrax bacillus). DIC is also associated with virus spread (chicken pox, measles and rubella), rickettsiae (Rocky Mountain spotted fever), fungal, mycoplasma, and parasitic infections. In our patient,

pneumococcus was eventually raised from the CSF. Clinically, patients with PF present with painful, erythematous macular lesions and bruises. These changes in painful fixed, well-differentiated purple papules with erythematous borders. Finally, switch to necrosis with formation of bullae and vesicles. In our patient, the damage to the skin helps in early diagnosis and ultimately successful treatment of PF. Pneumococcus is the most common cause of meningitis in adults, especially in the elderly [

]. It is often quite normal cellular biochemistry and CSF in patients with bacterial meningitis [

]. Although these results are typical CSF, range of values ​​of CSF in bacterial meningitis is so wide that lack one or more typical of the results should not matter [

]. As our patient, where no violations were found in the initial analysis of cerebrospinal fluid in series with 696 episodes of community acquired bacterial meningitis, 12 percent was not one of the typical results of CSF [

]. Explanation minimal disruption SMZH usually can not be identified. Possible causes include early last presentation to antibiotics, and neutropenia. Normal CSF seen initially in our patient may be due to its early presentation to the ED. Bacterial meningitis should be kept in differential diagnosis in patients with some incomprehensible internal combustion engines, especially with progressive changes in mental status, despite initial normal cerebrospinal fluid analysis. Early clinical recognition of PF is essential for a successful outcome. The authors declare that they have no conflict of interest. .