C51-31 A Rare Case of Multifactorial Immunocompromised State Revealed by Purpura Fulminans Secondary to Acinetobacter Baumannii Sepsis

Abstract Introduction Acinetobacter Baumannii (AB) is an aerobic gram-negative coccobacillus implicated as an important cause of nosocomial infections but rarely a cause of Purpura Fulminans (PF). PF remains relatively rare and consists of three subtypes, neonatal, idiopathic, and acute. All types of PF involve dysfunction of the coagulation cascade allowing for a procoagulant state and thus thrombosis of dermal vasculature with resultant dermal necrosis. Here, we present a case of a middle-aged female who presented with lower extremity (LE) swelling/pain, which later progressed to PF secondary to AB sepsis with concomitant new Human Immunodeficiency Virus (HIV), Hepatitis B, and Syphilis. Case Presentation A 65-year-old female with a history of recurrent pulmonary embolism (PE), multiple myeloma, uterine malignancy, asthma, and obstructive sleep apnea presented with left lower extremity swelling/pain and shortness of breath. Physical examination was significant for hypotension, tachycardia, tachypnea, fever, and a lacy erythematous rash with diffuse tenderness of the left lower extremity. Chest x-ray was unremarkable, and computed tomography (CT) pulmonary angiography showed no evidence of acute PE. The patient deteriorated while in the emergency department and began vomiting with decline in mentation, prompting intubation. CT head showed no acute intracranial findings. Her mean arterial pressures were in the 40s-50s despite already being placed on two vasopressors and was subsequently transferred to the intensive care unit. Blood cultures grew Acinetobacter Baumannii, and the patient was switched to antibiotics based on sensitivity. Laboratory studies were significant for thrombocytopenia, elevated coagulation factors, and low fibrinogen - all consistent with disseminated intravascular coagulation (DIC). Incidentally, she was found to have HIV (CD4 45/13%), Hepatitis B, and Syphilis, all of which were treated during this hospital course. CT of the left LE showed findings consistent with cellulitis with no evidence of necrotizing fasciitis or compartment syndrome. Despite resolution of AB sepsis/return to baseline mentation and multiple courses of antibiotics, the left LE wounds continued to worsen; prompting biopsy which showed occlusive vasculopathy-findings consistent with PF. Discussion Acute PF is the most common type of PF and occurs during an acute illness such as in this case of AB sepsis. Immunodeficiency, such as in this case, can result in increased susceptibility to AB sepsis. Early skin findings include painful petechial rashes which than progress to larger ecchymotic areas and finally hemorrhagic bullae. Prompt recognition of these skin findings in addition DIC/immunodeficiency laboratory studies can aid in the differential diagnosis of PF. This abstract is funded by: None