Mark Crislip, MD


November 03, 2011

Clinical Presentation

A 48-year-old woman presented with sepsis and purpura.

History and Physical Examination

History. The patient had an abrupt onset of fevers, rigors, and progressive altered mental status. She was transported to the emergency department by ambulance where she was found to be hypotensive and, after initial stabilization, was moved to the intensive care unit. Initial evaluation did not reveal an obvious source for the sepsis.

  • Medical history: splenectomy after a motor vehicle accident 15 years earlier; hypertension;

  • Medications: hydrochlorothiazide;

  • Allergies: none;

  • Habits: drinks 1 glass wine daily; no tobacco;

  • Pets: 3 dogs;

  • Diet: regular;

  • Travel: recent trip to Oregon coast; waded in water, ate seafood;

  • Social: married; 2 children at home; and

  • Immunizations: unknown.

Physical examination. On physical examination, the following were noted:

  • Vital signs: temperature: 103.1°F, pulse: 140 beats/minute, respirations: 20 breaths/minute, blood pressure: 80/60 mm Hg on Levophed® (norepinephrine bitartrate);

  • General: ill-appearing;

  • HEENT: normal;

  • Lungs: clear;

  • Heart: normal;

  • Abdomen: nontender, no rebounding or guarding;

  • Extremities: cool and mottled. A few well-healed scratches on arms and legs reportedly from gardening;

  • Skin: multiple purpura involving tips of fingers and toes;

  • Genitourinary: normal;

  • Neurologic: nonfocal

Diagnostic Evaluation

Lab results. The following results were obtained:

  • White blood cell count: 35,000/µL;

  • Hemoglobin: 11.9 g/dL;

  • Differential: 34% bands, remainder normal;

  • Platelets: 80,000/mL;

  • D dimer: elevated;

  • Fibrinogen: 50 mg/L;

  • Basic metabolic panel: normal;

  • Glucose/A1c: normal;

  • Bilirubin: 2.3 mg/dL;

  • Transaminases: 2 times normal; and

  • Blood culture results: negative at 48 hours.

Imaging. Chest radiograph: no infiltrates.


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