Literature review and case report of septic arthritis and purpura fulminans leading to a child limb amputation as chickenpox complications

Abstract

Introduction and significance: Chickenpox, induced by the varicella-zoster virus (VZV), generally presents with an itchy rash and fluid-filled blisters. While complications such as pneumonia and sepsis are well-documented, occurrences of septic arthritis and purpura fulminans are exceedingly rare. Septic arthritis following varicella infection is infrequently reported and often attributed to Staphylococcus aureus. Purpura fulminans encompasses disorders characterized by rapidly progressing purpuric lesions, often fatal and associated with consumptive coagulopathy.

Case presentation: The authors present the case of an 8-year-old boy diagnosed with chickenpox who concurrently developed severe left knee pain, erythema, and swelling indicative of septic arthritis, along with a single pustular lesion on his right foot that progressed to purpura fulminans. Laboratory investigations revealed elevated inflammatory markers. Knee ultrasound findings were consistent with septic arthritis, corroborated by synovial fluid analysis. Immediate initiation of empiric antibiotics was undertaken. Further investigation disclosed unusual coagulation parameters, positive autoantibodies, and reduced protein S levels. Treatment included anticoagulation, immunomodulation, and ultimately, amputation.

Clinical discussion: This rare case underscores the complexity of varicella-related complications, representing the first documented instance of simultaneous septic arthritis and purpura fulminans in a pediatric patient. It highlights the necessity of a multidisciplinary approach for accurate diagnosis and management, emphasizing the importance of recognizing rare complications to improve patient outcomes.

Conclusion: This case exemplifies the complexity of varicella-associated complications, showcasing a rare simultaneous occurrence of septic arthritis and purpura fulminans in a pediatric patient. It underscores the importance of a thorough understanding and collaborative management approaches for timely intervention and enhanced clinical outcomes.

Keywords: chickenpox; pediatrics; purpura fulminans; septic arthritis; varicella.

Figure 1

Single pustular lesion with a dark base on the right foot.

Figure 2

Bluish discoloration spreading from the lesion, involving the ankle and proximal tibia, with severe pain.

Figure 3

Increased edema and tense tenderness in the foot, with darker lesions as symptoms progressed.

Figure 4

Increased edema and tense tenderness in the foot, with darker lesions as symptoms progressed.

Figure 5

Literature-reported locations of septic arthritis post-varicella infection (Y=number of reported events).