Purpura fulminans due to pneumococcal infection

A 33yearold woman presented with rapid progressive rash. She complained of a headache, arthralgia, with fever since the previous day, treated with Laninamivir for influenza. She had laparotomy due to androgen insensitivity syndrome when she was in high school. On physical examination, she was agitated, hypotensive, and febrile. She had purpura on her face and extremities (Panel A1, 2, 3). These rapidly spread during the examination. Laboratory data revealed disseminated intravascular coagulation (DIC), acute renal failure, and rhabdomyolysis. Computed tomography confirmed spleen hypoplasia with no obvious source of infection. Streptococcus pneumonia was detected by urinary antigen and rapid molecular testing. Peripheral blood smear denied HowellJolly body. She was treated with broadspectrum antibiotics, vasoconstrictive agents, and glucocorticoids. She also received mechanical ventilation and continuous hemodiafiltration. Penicillinsusceptible S. pneumoniae (PSSP) was isolated from two sets of blood cultures. She died with peripheral necrosis (Panel B1, 2, 3) 31 days after hospitalization despite these aggressive supportive therapies. This severe prognosis indicated importance of Pneumococcal vaccination. It is recommended for those ≥65 years old, and those