Comprehensive Analysis of Purpura Fulminans as an Uncommon Postoperative Complication: A Case Series

Background: Acute infectious purpura fulminans (AIPF) is a rare but potentially fatal postoperative complication characterised by rapidly progressing disseminated intravascular coagulation (DIC), widespread purpura, and multi-organ dysfunction. Despite its severe and critical outcomes, the literature on this condition in the postoperative context is limited.

Objectives: This study aimed to analyse and evaluate the incidence, clinical presentation, laboratory findings, management strategies, and outcomes of postoperative AIPF in patients who underwent various surgical procedures.

Methods: A retrospective case series was conducted, identifying adult patients diagnosed with AIPF within 30 days post surgery from January 2017 to December 2022. Inclusion was based on the International Classification of Diseases, Tenth Revision (ICD-10) coding for purpura fulminans and DIC. Clinical data, including demographic details, type and duration of surgery, onset of symptoms, laboratory findings, microbiology results, treatment strategies, and outcomes, were collected from electronic medical records. Data analysis included descriptive statistics and differences in survival among surgical subgroups were assessed using Kaplan-Meier survival analysis and the log-rank test.

Results: Seven cases of AIPF were identified, with a mean patient age of 57.1 ± 12.5 years, out of which 71.4% (n = 5) were male. Surgical procedures included vascular (42.9%, n = 3), abdominal (28.6%, n = 2), thoracic (14.3%, n = 1), and orthopaedic (14.3%, n = 1) surgeries. The average surgical duration was 5.2 ± 2.7 hours and the mean onset of AIPF was 3.9 ± 1.9 days postoperatively. Clinically, all patients presented with widespread purpura, fever, hypotension, and multi-organ dysfunction, including renal, hepatic, and respiratory failure. Laboratory findings revealed severe coagulopathy, with a low platelet count, higher levels of D-dimer, prolonged prothrombin time, and activated partial thromboplastin time. Gram-negative bacteria were the most prevalent pathogens, particularly Klebsiella pneumoniae and Escherichia coli (28.6% each), while gram-positive Staphylococcus aureus was isolated in one case (14.3%). Despite comprehensive ICU management, including mechanical ventilation, fluid resuscitation, broad-spectrum antibiotics, and administration of fresh frozen plasma/cryoprecipitate (71.4%, n = 5), the mortality rate was 57.1% (n = 4). The median time to death was 48 hours (IQR = 36-72). The highest mortality was observed in vascular (33.3% survival) and thoracic (0% survival) surgery subgroups. Orthopaedic surgery demonstrated a 100% survival rate.

Conclusion: AIPF after surgery is associated with significant morbidity and mortality, particularly following vascular and thoracic procedures. The findings underscore the need for heightened postoperative vigilance, early detection, and aggressive management to improve patient outcomes. Future studies should focus on identifying strategies for risk mitigation and early intervention protocols.