Purpura Fulminans and Necrotizing Fasciitis: A Lethal Combination Following Varicella Infection

Abstract

Aims: Varicella is typically a self-limiting infection; however, secondary bacterial infections can lead to severe complications such as necrotizing fasciitis (NF) and purpura fulminans (PF). This case highlights an unusual presentation of NF and PF secondary to varicella, caused by Burkholderia cepacia, in an immunocompetent child. Presentation of Case: A 2-year-10-month-old unvaccinated male presented with fever, vesicular rash, and progressive skin necrosis over the neck, shoulders, and abdomen. He developed septic shock and disseminated intravascular coagulation (DIC), requiring intensive care. Blood cultures identified Burkholderia cepacia, an uncommon pathogen in pediatric NF. The child was treated with intravenous antibiotics, inotropic support, blood product transfusions, and emergency surgical debridement. Over 20 days of hospitalization, he showed significant recovery and was discharged on oral antibiotics. Discussion: Varicella predisposes children to bacterial superinfections due to skin barrier disruption, immune dysregulation, and a prothrombotic state. NF is typically caused by Group A Streptococcus or Staphylococcus aureus; however, Burkholderia cepacia, primarily an opportunistic pathogen, caused extensive soft tissue necrosis in this case. Early surgical debridement and targeted antibiotic therapy were crucial for survival. Conclusion: This case highlights the importance of early recognition of secondary bacterial infections in varicella and emphasizes the rare occurrence of Burkholderia cepacia as a causative agent of NF. Vaccination remains the most effective strategy in preventing severe varicella-related complications.