# Atypical Presentation of Toxic Shock Syndrome in a Patient With Postpartum Necrotizing Endometritis

## TL;DR

A 42-year-old woman developed a rare form of toxic shock syndrome after a cesarean section, marked by skin necrosis and linked to a genetic clotting risk.

## Contribution

This case presents an atypical dermatologic manifestation of TSS and suggests a potential role for MTHFR polymorphisms in postpartum thromboinflammatory complications.

## Key findings

- The patient exhibited peripheral skin necrosis as a rare feature of postpartum toxic shock syndrome.
- MTHFR C677T/A1298C polymorphism may contribute to thromboinflammatory complications in the postpartum period.
- Early surgical intervention and anticoagulation improved the patient's condition despite severe symptoms.

## Abstract

A 42-year-old woman with a history of two first-trimester miscarriages and a known prothrombotic polymorphism (MTHFR C677T/A1298C compound heterozygote) developed postpartum toxic shock syndrome (TSS) complicated by peripheral skin necrosis eight days after emergency cesarean section for preeclampsia exacerbation. She presented with fever, hypotension, tachycardia, severe diarrhea, and a purpuric rash on the nose and distal lower extremities, rapidly evolving to necrosis. Although she had been prescribed prophylactic nadroparin during pregnancy, anticoagulation was discontinued upon discharge following the cesarean section. Laboratory findings revealed markedly elevated inflammatory markers, mild coagulopathy, and acute kidney injury. Coagulation abnormalities were mild and did not meet criteria for disseminated intravascular coagulation. On the second day of hospitalization, a hysterectomy was performed, and histopathology confirmed necrotizing endometritis. With early surgical source control, broad-spectrum antibiotics, anticoagulation, and intensive supportive care, the patient’s condition improved significantly. Skin lesions gradually stabilized with desquamation and partial healing by day 14. This case highlights an unusual dermatologic manifestation of TSS and underscores the potential contribution of MTHFR C677T/A1298C polymorphisms to thromboinflammatory complications in the postpartum period.