Septic Shock and Purpura Fulminans Due to Streptococcus pneumoniae Bacteremia in an Unvaccinated Immunocompetent Adult: Case Report and Review

L-Thyroxine and L-thyroxine-based antimicrobials against Streptococcus pneumoniae and other Gram-positive bacteria

Objectives

The rise of antibiotic-resistant Streptococcus pneumoniae (Sp) poses a significant global health threat, urging the quest for novel antimicrobial solutions. We have discovered that the human hormone l-thyroxine has antibacterial properties. In order to explore its drugability we perform here the characterization of a series of l-thyroxine analogues and describe the structural determinants influencing their antibacterial efficacy.

Method

We performed a high-throughput screening of a library of compounds approved for use in humans, complemented with ITC assays on purified Sp-flavodoxin, to pinpoint molecules binding to this protein. Antimicrobial in vitro susceptibility assays of the hit compound (l-thyroxine) as well as of 13 l-thyroxine analogues were done against a panel of Gram-positive and Gram-negative bacteria. Toxicity of compounds on HepG2 cells was also assessed. A combined structure-activity and computational docking analysis was carried out to uncover functional groups crucial for the antimicrobial potency of these compounds.

Results

Human l-thyroxine binds to Sp-flavodoxin, forming a 1:1 complex of low micromolar Kd. While l-thyroxine specifically inhibited Sp growth, some derivatives displayed activity against other Gram-positive bacteria like Staphylococcus aureus and Enterococcus faecalis, while remaining inactive against Gram-negative pathogens. Neither l-thyroxine nor some selected derivatives exhibited toxicity to HepG2 cells.

Conclusions

l-thyroxine derivatives targeting bacterial flavodoxins represent a new and promising class of antimicrobials.

Infectious purpura fulminans associated with pneumococcal septicaemia in a patient with unacknowledged functional asplenia

Purpura fulminans (PF) is a life-threatening complication of septic shock that can occur due to disseminated infections with Streptococcus pneumoniae The spleen is an important organ in the immunisation process against encapsulated bacteria. Patients with asplenia, either functional or anatomical, are therefore at increased risk of developing serious infections and complications, such as PF, if infected with such bacteria.This case report presents a woman in her late 40s with unacknowledged functional asplenia who was admitted to the hospital with signs of an acute disseminated infection causing septic shock, signs of disseminated intravascular coagulation and infectious PF. A few days after admission, the blood cultures showed growth of S. pneumoniae With early sepsis treatment, the patient survived although with some complications. Clinical presentation, investigations, differential diagnosis, treatment and outcome are presented. Treatment and early recognition of PF are presented and discussed. Relevant recognition and preventative treatment strategies for patients with asplenia are also reviewed and discussed.This case demonstrates the importance of early recognition and treatment of PF in septic patients and the importance of preventive treatment strategies for patients with asplenia to avoid serious infections and complications.

Purpura fulminans in a hyposplenic patient arising from pneumococcal sinusitis

We report a previously healthy woman in her 50s who presented with sepsis, rapidly progressive purpuric rash and disseminated intravascular coagulation. She was diagnosed with acute infective purpura fulminans due to invasive pneumococcal infection likely secondary to sinusitis. Our case report discusses our initial diagnostic uncertainty and approach in investigating and treating such a critically unwell patient.

The Successful Management of Gangrenous Pneumococcal Infection in an Infant With Polysplenia Syndrome

This study describes the successful management of gangrenous pneumococcal infection in an infant with polysplenia, a rare congenital malformation characterized by multiple aberrant nodules of splenic tissue. The patient, a three-month-old girl with congenital heart defects and incomplete vaccination, presented with fever, irritability, and oxygen desaturation, followed by erythematous skin changes. The diagnosis revealed sepsis caused by Streptococcus pneumoniae, accompanied by extensive gangrenous skin lesions and signs of disseminated intravascular coagulation. Polysplenia was incidentally discovered during radiological investigation. Aggressive resuscitation measures and prolonged antibiotic administration led to significant improvement, including regression of skin lesions. This case emphasizes the importance of timely immunization and parental awareness for infants with spleen-related congenital malformations. Screening for undiagnosed malformative defects in congenital heart disease patients can aid in early detection and prevention of life-threatening complications. The successful management demonstrates the critical role of pediatric intensive care units in treating severe systemic infections.

Sternoclavicular Septic Arthritis Due to Invasive Pneumococcal Infection After Type A Influenza Virus Infection

A 24-year-old female patient who had a type A influenza virus infection prior to admission visited our hospital complaining of a fever and right sternoclavicular pain. Blood culture was positive for penicillin-sensitive Streptococcus pneumoniae (pneumococcus). Magnetic resonance imaging of the right sternoclavicular joint (SCJ) showed a high signal intensity area on the diffusion-weighted images. Consequently, the patient was diagnosed with septic arthritis due to invasive pneumococcus. When a patient complains of gradually increasing chest pain after an influenza virus infection, SCJ septic arthritis should be considered in the differential diagnosis.

Alcohol Abuse as a Silent Risk Factor for Purpura Fulminans and the Importance of Pneumococcal Vaccination

Purpura fulminans (PF) is a rare presentation of disseminated intravascular coagulopathy (DIC) and a life-threatening complication of septic shock. DIC can present with bleeding and thrombosis in acute settings, making its management exceptionally challenging. Common causative organisms include Neisseria meningitidis, Streptococcus pneumoniae, andHaemophilus influenzae. We report a case of a 47-year-old patient with a history of alcohol abuse and marijuana use with a bizarre presentation of copious diarrhea and altered mental status. The patient was subsequently admitted to the intensive care unit (ICU) for acute respiratory failure and septic shock secondary to Streptococcus pneumoniae bacteremia complicated by DIC. Unfortunately, the patient's condition worsened with multiorgan failure and purpura fulminans, leading to extensive necrosis of all his extremities, with the involvement of his lips, nose, and genitals. Unfortunately, despite aggressive interventions, he continued to deteriorate and ultimately was transitioned to comfort care before he expired. In the literature, there is only one reported case of PF in an individual with alcohol abuse. However, the frequency and severity of pneumococcal infections in individuals with a history of alcohol abuse are much higher than in the general population. PF is a devastating complication of Streptococcus pneumoniae, with a mortality of 43%. We hope that this case will continue highlighting the importance of vaccinating patients with a history of alcohol abuse with the pneumococcal vaccine.

Right Lower Extremity Phlegmasia Cerulea Dolens Due to Iliotibial Vein Thrombosis With Compartment Syndrome and Circulatory Shock: Case Report and Review

Phlegmasia cerulea dolens (PCD) is a rare and life-threatening complication of extensive deep vein thrombosis (DVT) characterized by severe pain, swelling, and cyanosis of the affected limb. It results from total or near-total occlusion of the deep and superficial veins of a limb, leading to venous congestion and ischemia. It is associated with 40% mortality, more commonly affecting the left lower extremity, with up to 50% of patients requiring limb amputations. PCD complicated by compartment syndrome (CS) with shock and multiorgan failure is very rare. We report the case of a 55-year-old female who presented with sudden onset, severe right lower extremity pain and swelling with associated limb discoloration, paresthesias, and inability to move the toes of her right foot. On examination, there was cyanosis, pulselessness, and tense right leg and thigh compartments. Doppler ultrasonography revealed DVT of the right external iliac extending to the posterior tibial vein. A diagnosis of PCD with CS was made and the patient was immediately started on anticoagulation with unfractionated heparin and emergent decompressive fasciotomies of the right leg and thigh were performed. Following the fasciotomies, she developed circulatory shock and went into cardiac arrest. Despite successful resuscitation, her hemodynamic instability and multiorgan failure precluded further life-saving interventions including thrombolysis or thrombectomy. Limb amputation was declined given her poor prognosis and she passed away shortly thereafter. This case illustrates the rare occurrence of right lower extremity PCD complicated by CS, circulatory shock, and multiorgan failure, which can sometimes occur despite emergency fasciotomy but can be averted with prompt intervention. These complications often preclude immediate thrombolysis and/or thrombectomy. Its recognition, therefore, warrants timely and more aggressive interventions to prevent limb loss or death.

Complementary Sets of Autoantibodies Induced by SARS-CoV-2, Adenovirus and Bacterial Antigens Cross-React with Human Blood Protein Antigens in COVID-19 Coagulopathies

COVID-19 patients often develop coagulopathies including microclotting, thrombotic strokes or thrombocytopenia. Autoantibodies are present against blood-related proteins including cardiolipin (CL), serum albumin (SA), platelet factor 4 (PF4), beta 2 glycoprotein 1 (β2GPI), phosphodiesterases (PDE), and coagulation factors such as Factor II, IX, X and von Willebrand factor (vWF). Different combinations of autoantibodies associate with different coagulopathies. Previous research revealed similarities between proteins with blood clotting functions and SARS-CoV-2 proteins, adenovirus, and bacterial proteins associated with moderate-to-severe COVID-19 infections. This study investigated whether polyclonal antibodies (mainly goat and rabbit) against these viruses and bacteria recognize human blood-related proteins. Antibodies against SARS-CoV-2 and adenovirus recognized vWF, PDE and PF4 and SARS-CoV-2 antibodies also recognized additional antigens. Most bacterial antibodies tested (group A streptococci [GAS], staphylococci, Escherichia coli [E. coli], Klebsiella pneumoniae, Clostridia, and Mycobacterium tuberculosis) cross-reacted with CL and PF4. while GAS antibodies also bound to F2, Factor VIII, Factor IX, and vWF, and E. coli antibodies to PDE. All cross-reactive interactions involved antibody-antigen binding constants smaller than 100 nM. Since most COVID-19 coagulopathy patients display autoantibodies against vWF, PDE and PF4 along with CL, combinations of viral and bacterial infections appear to be necessary to initiate their autoimmune coagulopathies.

Purpura fulminans due to Streptococcus pneumoniae bacteraemia in an unsplectomised immunocompetent adult without primary hypocomplementaemia

Invasive pneumococcal disease occurs in high-risk patient population which includes patients with asplenia and primary hypocomplementaemia. Pneumococcal sepsis can rarely cause disseminated intravascular coagulation (DIC) and intravascular thrombosis of small and medium sized vessels called purpura fulminans which is associated with a high mortality rate. We present the case of an immunocompetent woman in her 50s with an intact spleen who presented with septic shock from Streptococcus pneumoniae bacteraemia. Her hospital course rapidly progressed to multiorgan dysfunction, DIC and purpura fulminans. She was treated aggressively with broad spectrum antibiotics, coagulation factor replacement, multiple vasopressor support, renal replacement therapy and mechanical ventilator support. Despite aggressive measures, she succumbed to the multiorgan failure.

Pneumococcal purpura fulminans in a 25-year-old patient with liver cirrhosis due to autoimmune hepatitis

Purpura fulminans (PF) is a skin disorder with high morbidity and mortality which is characterized by microvascular thrombosis and development of hemorrhagic necrosis. PF can be caused by acute infection, most commonly due to Neisseria meningitidis, followed by Streptococcus pneumoniae. Prior reports describe cases of pneumococcal PF occurring in patients with asplenia or hyposplenia, though cases have also been reported in otherwise healthy adults without known splenic disease. Herein, we report a young adult patient with cirrhosis due to autoimmune hepatitis who had not received pneumococcal vaccination and developed rapidly progressive fatal S. pneumoniae sepsis with PF.

The Many Faces of Purpura: Vancomycin-Induced Leukocytoclastic Vasculitis

Leukocytoclastic vasculitis is a rare form of immune-mediated vasculitis that might be caused by infections or autoimmune diseases or might be precipitated by specific medications. We describe a 65-year-old patient, who was receiving vancomycin for a methicillin-sensitive Staphylococcus aureus permacath infection. Vancomycin was chosen due to medication non-adherence and the patient's desire to receive antimicrobial therapy in conjunction with his scheduled dialysis sessions. The patient's medical history was notable for untreated hepatitis C infection and end-stage renal disease, requiring hemodialysis three times a week. Vancomycin was administered during dialysis sessions. After one week of therapy, the patient developed bilateral lower extremity purpura. Skin biopsy was suggestive of leukocytoclastic vasculitis with an absence of intravascular thrombi. Serum cryoglobulins were negative, making cryoglobulinemia due to HCV infection unlikely. Following cessation of vancomycin therapy, the rash gradually disappeared with scarring in the form of post-purpuric hyperpigmentation. Despite its widespread use, vancomycin is a rare cause of leukocytoclastic vasculitis. Clinicians should keep in mind a wide range of differential diagnosis of bilateral lower extremity purpura as treatment differs depending on its underlying etiology.