# Group A β-hemolytic streptococcus causing purpura fulminans: two case reports

## TL;DR

Two fatal cases of purpura fulminans caused by group A streptococcus are reported, emphasizing the importance of early recognition and aggressive treatment.

## Contribution

Highlights the rare but severe manifestation of group A streptococcus infection as purpura fulminans with gastrointestinal symptoms preceding severe complications.

## Key findings

- Two adult patients with gastrointestinal symptoms rapidly developed septic shock and purpura fulminans due to group A streptococcus.
- Next-generation sequencing confirmed Streptococcus pyogenes as the causative agent in both cases.
- Despite aggressive treatment, both patients experienced refractory multiorgan failure and died.

## Abstract

Purpura fulminans (PF) is a rare, life-threatening emergency characterized by rapidly progressive purpura evolving into hemorrhagic bullae and skin necrosis due to dermal microvascular thrombosis, typically accompanied by shock and disseminated intravascular coagulation (DIC). We report two fatal adult cases of infection-associated PF caused by Streptococcus pyogenes (group A streptococcus). Both patients presented with early gastrointestinal symptoms and rapidly developed septic shock, severe coagulopathy compatible with overt DIC, and extensive lower-limb purpura with bullae and necrosis. Pathogen identification was supported by next-generation sequencing from blood and/or tissue specimens. Management required immediate resuscitation, organ support, targeted anti–group A streptococcal therapy, and surgical source control; nevertheless, both patients deteriorated with refractory multiorgan failure. These cases highlight that gastrointestinal symptoms may precede fulminant invasive S. pyogenes infection with PF and streptococcal toxic shock syndrome overlap. Early recognition of the clinical pattern (shock + rapidly progressive purpura/bullae + DIC) and aggressive multidisciplinary management are essential.