Purpura fulminans in probable scrub typhus group of rickettsioses from hilly region in Nepal - A case report

INTRODUCTION: Purpura fulminans is an acute and fatal condition presenting with acute progressive hemorrhagic infarction of the skin and disseminated intravascular coagulation. Scrub typhus, is an emerging disease of Nepal, despite being a rickettsioses has been rarely associated with Purpura fulminans. The non-specific clinical presentation and limited diagnostic facility make it difficult for clinicians to diagnose the disease. Knowing the prevalence of the disease, suspecting the disease early and treatment with appropriate antibiotics can limit the course of the disease. CASE PRESENTATION: A 46-year-old female with no comorbidity presented with febrile illness and generalized weakness in the emergency department. During the course in hospital, she developed purpura followed by painful hemorrhagic bullae in bilateral lower limb with bluish discoloration in bilateral feet. IgM antibodies against the Orientia Tsutsugamushi antigen came out to be positive making diagnosis of purpura fulminans secondary to scrub typhus. She recovered with anti rickettsial therapy. DISCUSSION: Purpura fulminans is an emergency condition. Scrub typhus, one of the rare cause, is diagnosed with Rickettsial DNA by PCR or by Indirect Immunofluorescence Assay (IFA) or Indirect Immunoperoxidase Assay (IPA). Medical management includes Doxycycline, fluid therapy, antipyretics and surgical management includes escharotomies and fasciotomies if required. CONCLUSION: We feel that clinicians should be aware of rickettsia as a differential of acute febrile illness, especially when the patient presents from endemic areas. In addition to it, they should be aware of rare presentations such as purpura fulminans which can help with early suspicion of the disease and appropriate antibiotic therapy.