What is a common cause of sepsis presenting with petechiae and purpura?

Meningococcal Sepsis: The Primary Cause of Sepsis with Petechiae and Purpura

Neisseria meningitidis (meningococcus) is the causative organism in 92% of cases when a petechial or purpuric rash presents in the context of meningitis or sepsis, making it the most common and critical diagnosis to consider. 1

Key Diagnostic Features

Classic Presentation

• Meningococcal sepsis characteristically presents with a purpuric or petechial rash in combination with signs of sepsis (hypotension, altered mental state, fever, tachycardia) 1
• The rash was petechial in 89% of confirmed meningococcal cases with rash 1
• However, 37% of meningococcal meningitis patients do not have a rash, so absence of rash does not exclude the diagnosis 1

Critical Clinical Pitfall

Patients with meningococcal sepsis can deteriorate rapidly and must be monitored frequently even if they initially appear well. 1 Young, healthy patients may maintain alertness despite severe cardiovascular collapse due to preserved cerebral perfusion until late in the disease course, potentially causing clinicians to underestimate the severity 1

Other Important Causes to Consider

Haemophilus influenzae

• Can present identically to meningococcal disease with sepsis, purpura, and coagulopathy 2
• Patients with H. influenzae are more likely to be lethargic or comatose at presentation (10/12 vs 15/30 with meningococcus) 2
• H. influenzae sepsis has higher mortality (75% vs 17%) and more rapid progression to death (mean 20.7 hours vs 120 hours from symptom onset) 2

Streptococcus pneumoniae

• Less common but can cause purpura fulminans and septic shock with petechiae 3, 4
• More frequently associated with underlying immunodeficiency or splenic dysfunction 3
• Can cause Waterhouse-Friderichsen syndrome (adrenal hemorrhage with septic shock) 4

High-Risk Features for Fatal Outcome

The following features indicate increased mortality risk in meningococcal disease: 1

• Rapidly progressing rash
• Coma
• Hypotension and shock
• Lactate >4 mmol/L
• Low or normal peripheral white blood cell count
• Low acute phase reactants
• Low platelets and coagulopathy
• Absence of meningitis (sepsis alone carries worse prognosis)

Immediate Management Algorithm

Pre-Hospital/Community Setting

Antibiotics must be given immediately if there are signs of meningococcal disease (rash with meningism or severe sepsis) or if hospital arrival will be delayed >1 hour: 1

• Benzylpenicillin 1200 mg IM/IV, OR
• Ceftriaxone 2g IM/IV, OR
• Cefotaxime 2g IM/IV 1

Hospital Setting

Empiric antibiotics should be initiated within 1 hour and should not be delayed for lumbar puncture or imaging: 5

• Ceftriaxone 2g IV PLUS vancomycin 15-20 mg/kg IV (covers N. meningitidis and resistant S. pneumoniae) 5
• Add ampicillin 2g IV every 4 hours if patient is >50 years old, immunocompromised, or has risk factors for Listeria 5

Pathophysiology Driving Clinical Urgency

Meningococcal sepsis causes rapid deterioration through: 1

• Capillary leak syndrome leading to hypovolemia
• Myocardial dysfunction
• Altered vasomotor tone
• Potential adrenal insufficiency
• Disseminated intravascular coagulation causing the characteristic purpuric rash 6, 7

The combination of these mechanisms can lead to ischemia of skin and entire limbs, requiring amputation in severe cases. 6