Purpura fulminans due to Stenotrophomonas maltophilia infection

An 84-year-old man with a medical history of chronic ischemic cardiomyopathy and diabetes mellitus underwent bursectomy of the left elbow due to purulent bursitis with Staphylococcus aureus infection. Despite initiating treatment with amoxicillin and clavulanic acid, inflammatory parameters progressed further. After switching antibiotic treatment to piperacillin/tazobactam, inflammatory parameters ameliorated, wound healing had been apparent, and the patient had been discharged. However, on the twelfth postoperative day, the patient was readmitted with a palpable, purpuric rash of all extremities with livid-colored, partly bullous and partly necrotic skin lesions (Fig. 1). Parainfectious leucocytoclastic vasculitis was suspected and prednisolone 50 mg once daily was initiated, however, wound healing, skin lesions and patient's clinical condition deteriorated with additional acute heart failure, melena and epistaxis during the next six days. Furthermore, skin biopsy could not confirm leucocytoclastic vasculitis. Laboratory testing revealed mild hypofibrinogenemia, thrombocytopenia, antithrombin III deficit, elevated D-dimer and C-reactive protein of 24 mg/l, while antinuclear, antineutrophilic cytoplasmatic and C1q antibodies were negative. Consecutively, the patient revealed increasing signs of acute heart failure, so a scheduled skin grafting due to postoperative wound healing disorder was waived. Despite maximum therapy escalation, patient's condition further deteriorated, and he finally died due to cardiac arrest. A repeated wound swab of the elbow revealed Stenotrophomonas maltophilia, sensitive to trimethoprim/sulfonamide but no MRSA was found. At the time the patient died, this information was not available due to delayed swab results. Therefore, no appropriate antibiotic treatment could be initiated, and no blood cultures were done. Due to laboratory and clinical changes, incipient disseminated intravascular coagulation was suggested.