Medical Image of the Month: Stercoral Colitis

Figure 1. Non-contrast CT acquired at the time of admission demonstrating diffusely dilated large bowel loops from cecum to rectum measuring up to 8 cm. Image on the left (Panel A) shows a near-complete intrathoracic sliding-type herniation of stomach adjacent to a herniated portion of transverse colon through the diaphragm into the chest. The image on the right (Panel B) shows a markedly distended rectum with impacted stool with circumferential rectal wall thickening consistent with stercoral colitis. 

Figure 2. Non-contrast CT thorax demonstrating on the left (Panel A) large hiatal hernia with intrathoracic herniation of stomach and transverse colon. The image on the right (Panel B) shows mild mass effect upon the left atrium related to the herniated transverse colon.

A 78-year-old- man with cerebral palsy requiring an in-home caregiver presented to the emergency room in hypovolemic shock post-sudden cardiac arrest in the setting of hematemesis. The caregiver noticed the patient become unresponsive after having one episode of bright red emesis. EMS arrived and found the patient to be pulseless and performed three rounds of CPR and gave 1 mg of epinephrine before return of spontaneous circulation was obtained. The caregiver reported the patient had been complaining of diarrhea for the past few days after being started on magnesium citrate for constipation by his PCP. In the ED patient was intubated, sedated, and started on pressors due to undifferentiated shock. CT abdomen pelvis demonstrated diffuse dilation of the colon with massive stool burden and markedly distended rectum with impacted stool and circumferential rectal wall thickening consistent with stercoral colitis (Figures 1 and 2). In addition, there was a large hiatal hernia with intrathoracic herniation of the stomach and a portion of the transverse colon, but it did not appear to represent a point of high-grade obstruction. The patient was deemed a poor surgical or endoscopic candidate due to high perioperative mortality. Manual disimpaction was attempted with minimal stool output, mineral oil enemas were given, and OG tube decompression of stomach. The patient had a ST segment elevated myocardial infarction (STEMI) noted on EKG and despite pressors and aggressive IV fluid resuscitation patient’s condition continued to decline with family deciding to pursue comfort care. The patient’s profound constipation, large hiatal hernia, and stercoral colitis were contributing factors to his shock.

Stool impaction can occur secondary to chronic constipation as the colon absorbs salt and colitis is colonic perforation which has a mortality rate between 32-57 percent (1). The modality of choice for diagnosis is CT and the common findings are colonic wall thickening, pericolonic fat stranding, mucosal discontinuity, pericolonic abscess, and free air indicating perforation. A small retrospective study found that the most consistent findings in stercoral colitis were rectosigmoid colon involvement, dilation of the colon >6 cm, and bowel wall thickening >3 mm in the affected segment. It also suggests that colonic involvement of >40 cm and perforation indicate increased mortality (2,3). Stercoral colitis most commonly occurs in the elderly, those who are bedridden due to cerebrovascular events or severe dementia, chronic opioid use, malignancy, and those with motor disabilities, such as this patient with cerebral palsy.  In patients without signs of peritonitis or who are poor surgical candidates can be managed non-operatively with laxatives, enemas, and manual/endoscopic disimpaction (4). Early diagnosis and treatment are imperative to avoid perforation. Patients with signs of perforation require surgical treatment which involves resection of the affected bowel segments.

Kirstin H. Peters MSIV, Angela Gibbs MD, Janet Campion MD

University of Arizona School of Medicine, Banner University Medical Center-Tucson, Tucson, AZ USA

References

1. Serpell JW, Nicholls RJ. Stercoral perforation of the colon. Br J Surg. 1990 Dec;77(12):1325-9. [CrossRef] [PubMed]
2. Ünal E, Onur MR, Balcı S, Görmez A, Akpınar E, Böge M. Stercoral colitis: diagnostic value of CT findings. Diagn Interv Radiol. 2017 Jan-Feb;23(1):5-9. [CrossRef] [PubMed]
3. Wu CH, Wang LJ, Wong YC, et al. Necrotic stercoral colitis: importance of computed tomography findings. World J Gastroenterol. 2011 Jan 21;17(3):379-84. [CrossRef] [PubMed]
4. Hudson J, Malik A. A fatal faecaloma stercoral colitis: a rare complication of chronic constipation. BMJ Case Rep. 2015 Sep 3;2015:bcr2015211732. [CrossRef] [PubMed]

Cite as: Peters KH, Gibbs A, Campion J. Medical Image of the Month: Stercoral Colitis. Southwest J Pulm Crit Care. 2021;23(3):73-5. doi: https://doi.org/10.13175/swjpcc027-21 PDF 

Medical Image of the Month: Hepatic Abscess Secondary to Diverticulitis Resulting in Sepsis

 

Figure 1. An axial, post-contrast CT of the abdomen and pelvis demonstrates an ill-defined, multiloculated, hypodense lesion in the right hepatic lobe most consistent with a hepatic abscess (red circle).

       Figure 2. Coronal and axial reconstructions of the post-contrast CT of the abdomen and pelvis demonstrate extensive diverticulosis of the descending and sigmoid colon (blue arrows) with a focal area of fat-stranding in the descending colon consistent with diverticulitis (red arrow) – likely the source of the patient’s hepatic abscess.

Clinical Scenario: A 73-year-old man with a previous history of hypertension presented to the hospital with a 4-day history of malaise, myalgias, syncope, nausea, and vomiting. He denied having any fevers, chills, diarrhea, abdominal pain, or recent travel. Upon arrival to the hospital, he was found to be febrile to 103.4°F, and hypotensive with systolic blood pressures in the 80’s. His baseline documented systolic blood pressures from numerous outpatient clinics were in the 110’s. In addition, he was hypoxemic requiring 6 L/min of supplemental oxygen to maintain an adequate oxygen saturation. Physical examination was significant for alteration of his mental status. He denied any abdominal pain with palpation, and there was no rebound tenderness or guarding. His lab work was significant for a leukopenia and thrombocytopenia - new from his previous lab work in our system. A CT of the abdomen and pelvis with contrast demonstrated a multiloculated abscess in the right hepatic lobe (Figure 1). He also had extensive diverticular disease of the descending and sigmoid colon with a focal area of diverticulitis in the descending colon (Figure 2). A CT-guided, percutaneous drain was placed in the right hepatic lobe abscess which grew Streptococcus anginosus and Bacteroides fragilis. With the combination of antibiotics and drainage of the abscess, his clinical condition markedly improved. He was discharged approximately 1 week after admission at his normal baseline.

Discussion: Liver abscess is the most common type of visceral abscess (1). Clinical manifestations include a broad spectrum of symptoms, but the most common are fever (70%–90% of patients) and abdominal pain, usually in the right upper quadrant (50%–75%) (2-4). Liver abscesses can occur because of multiple etiologies to include ascending cholangitis, hematogenous spread from the gastrointestinal tract via portal venous drainage of infectious entities such as diverticulitis and appendicitis, and from hematogenous spread via the hepatic artery. Other etiologies for the development of hepatic abscesses include penetrating trauma or after an invasive procedure (for example biliary instrumentation, transcatheter arterial chemoembolization, percutaneous liver biopsy, or abdominal surgery) (5).

Many bacteria have been described in the pathogenesis of pyogenic abscesses, reflecting the variability among patients and geographic areas. Many aspirated fluid cultures are positive, whereas blood cultures are positive in only 50% of cases (4). Most pyogenic liver abscesses are polymicrobial (4). Traditionally, Escherichia coli has been reported as the most common isolated microbe; however, recent data show that Klebsiella pneumoniae is the most common pathogen in pyogenic liver abscesses (3,4,6).

Management of pyogenic liver abscesses includes imaging-guided drainage and antibiotic therapy. There is considerable variation in clinical practice regarding total antibiotic duration (7). It is recommended that antibiotic therapy be continued for at least 4–6 weeks, but the optimal duration is still unclear (7). Although drainage of single abscesses with a diameter of 5 cm or less can be achieved in some cases, it may not improve outcomes compared with antibiotic treatment alone. In isolated abscesses with a diameter greater than 5 cm, catheter drainage should be considered and is preferred over needle aspiration, although some favor surgical intervention (8). Prompt diagnosis and imaging-guided drainage have been reported to reduce mortality from 65% to 2%–12% (2-4).

Reubender Randhawa MD¹, Alan Nyquist MD², and Tammer El-Aini MD²

¹Banner University Medical Center – South Campus, Department of Internal Medicine, Tucson, AZ USA

²Banner University Medical Center – Tucson Campus, Department of Pulmonary and Critical Care

References

1. Altemeier WA, Culbertson WR, Fullen WD, Shook CD. Intra-abdominal abscesses. Am J Surg. 1973 Jan;125(1):70-9. [CrossRef] [PubMed]
2. Mohsen AH, Green ST, Read RC, McKendrick MW. Liver abscess in adults: ten years experience in a UK centre. QJM. 2002 Dec;95(12):797-802. [CrossRef] [PubMed]
3. Rahimian J, Wilson T, Oram V, Holzman RS. Pyogenic liver abscess: recent trends in etiology and mortality. Clin Infect Dis. 2004 Dec 1;39(11):1654-9. [CrossRef] [PubMed]
4. Huang CJ, Pitt HA, Lipsett PA, Osterman FA Jr, Lillemoe KD, Cameron JL, Zuidema GD. Pyogenic hepatic abscess. Changing trends over 42 years. Ann Surg. 1996 May;223(5):600-7; discussion 607-9. [CrossRef] [PubMed]
5. Wisplinghoff H, Appleton DL. Bacterial infections of the liver. In: Weber O, Protzer U, eds. Comparative hepatitis. Basel, Switzerland: Birkhäuser, 2008; 143–160. [CrossRef]
6. Liu Y, Wang JY, Jiang W. An Increasing Prominent Disease of Klebsiella pneumoniae Liver Abscess: Etiology, Diagnosis, and Treatment. Gastroenterol Res Pract. 2013;2013:258514. [CrossRef] [PubMed]
7. Molton J, Phillips R, Gandhi M, Yoong J, Lye D, Tan TT, Fisher D, Archuleta S. Oral versus intravenous antibiotics for patients with Klebsiella pneumoniae liver abscess: study protocol for a randomized controlled trial. Trials. 2013 Oct 31;14:364. [CrossRef] [PubMed]
8. Zerem E, Hadzic A. Sonographically guided percutaneous catheter drainage versus needle aspiration in the management of pyogenic liver abscess. AJR Am J Roentgenol. 2007 Sep;189(3):W138-42. [CrossRef] [PubMed]

Cite as: Randhawa R, Nyquist A, El-Aini T. Medical image of the month: hepatic abscess secondary to diverticulitis resulting in sepsis. Southwest J Pulm Crit Care. 2021;23(1):5-7. doi: https://doi.org/10.13175/swjpcc019-21 PDF 

Medical Image of the Month: Pneumoperitoneum with Rigler’s Sign

Figure 1. CT of the abdomen with contrast showing a large quantity of free air within the peritoneal cavity. The etiology of her free intraperitoneal air was not evident on this imaging study.

Figure 2. An upright chest radiograph performed six months later again demonstrates a large amount of free air under the hemidiaphragms, outlining both the spleen and the superior surface of the liver. Rigler’s sign (air on both the peritoneal and luminal side of bowel wall (arrows) - which clearly delineates the bowel wall) is in noted and supports the diagnosis of free intraperitoneal air.

Clinical Presentation: A 70-year-old Asian-American woman presented to the hospital with a distended and tympanic abdomen. She was otherwise asymptomatic. Her past medical history was significant only for an uncomplicated colonoscopy the previous summer. A CT scan showed free air within the peritoneal cavity (Figure 1). She was managed conservatively without a surgical intervention. After six months without a chest x-ray continued to show free air (Figure 2). She underwent an elective exploratory laparotomy without identification of a cause for her free intraperitoneal air. Her pneumoperitoneum completely resolved on follow up imaging.

Discussion: Pneumoperitoneum is a condition which commonly presents as an acute abdomen (1). Causes are numerous and include penetrating and blunt abdominal trauma, perforation of viscus, diaphragmatic rupture, fistula formation – among other etiologies. Work-up of pneumoperitoneum varies depending on the suspected etiology. In the presence of hemodynamic instability or peritoneal signs, the patient should proceed to an exploratory laparotomy immediately following airway maintenance and resuscitation. In the setting of a perforation or sepsis, broad-spectrum intravenous antibiotics are indicated. Stable patients are managed expectantly with NPO status, intravenous fluids resuscitation, serial vitals/abdominal imaging/labs, and nasogastric tube decompression if indicated for obstructive etiologies.

Rigler’s sign is well-demonstrated in the abdominal radiograph (figure 2). Rigler’s sign is the presence of air on both the luminal and peritoneal side of the bowel wall – which clearly delineates the bowel wall (1). This sign is highly suggestive of free intraperitoneal air. Rigler’s sign can be seen on a supine abdominal radiograph and can be helpful in the identification of free intraperitoneal air in a patient who may be too ill for upright radiographs or CT imaging.

Mohammad A. Mahmoud MD DO, Jonathon P. Mahn DO, and Alexander E. Brahmsteadt, MSIV.

Midwestern University | Arizona College of Osteopathic Medicine

Canyon Vista Medical Center

Sierra Vista, AZ USA

Reference

1. Levine MS, Scheiner JD, Rubesin SE, Laufer I, Herlinger H. Diagnosis of pneumoperitoneum on supine abdominal radiographs. AJR Am J Roentgenol. 1991 Apr;156(4):731-5.

Cite as: Mahmoud MA, Mahn JP, Brahmsteadt AE. Medical image of the month: pneumoperitoneum with Rigler's sign. Southwest J Pulm Crit Care. 2019;19(6):156-7. doi: https://doi.org/10.13175/swjpcc047-19 PDF 

Medial Image of the Week: Purpura Fulminans

Figure 1.  A: Purpura fulminans. B: Close up view of the left lower extremity.

A 54-year-old man with coronary artery disease, fibromyalgia and chronic sacral ulcers was brought to the emergency department due to acute changes in mentation and hypotension. He suffered a cardiac arrest shortly after arrival to the emergency department during emergent airway management. After successful resuscitation, he was admitted to the medical intensive care unit and treated for septic shock with fluid resuscitation, vasopressors and broad spectrum antibiotics. Laboratory results were significant for disseminated intravascular coagulopathy (DIC)- thrombocytopenia, decreased fibrinogen and elevated PT, PTT and D-dimer levels. Profound metabolic acidosis and lactate elevation was also seen. Blood Cultures later revealed a multi-drug resistant E. coli bacteremia. Images of the lower extremities (Figure 1) were obtained at initial assessment and are consistent with purpura fulminans. He did not survive the stay.

Purpura fulminans, also referred to as skin mottling, is an evolving skin condition which is characterized by an acutely worsening reticular pattern of ecchymosis, tissue thrombosis and eventual hemorrhagic skin necrosis. Traditionally associated with either an inherited and/or acquired protein C deficiency, it is more commonly seen in DIC. It is generally considered a poor prognostic indicator when associated with DIC. In our patient, the DIC was secondary to septic shock. When encountered in this clinical scenario it should be considered an acute life threatening emergency.

Emilio Perez Power MD¹, Norman Beatty MD¹ and Bhupinder Natt MD²

¹Department of Internal Medicine and ²Division of Pulmonary, Allergy, Critical Care and Sleep

Banner-University Medical Center South Campus

University of Arizona

Tucson, AZ USA

Cite as: Power EP, Beatty N, Natt B. Medical image of the week: purpura fulminans. Southwest J Pulm Crit Care. 2016;13(6):307-8. doi: https://doi.org/10.13175/swjpcc129-16 PDF

Medical Image of the Week: Post-Anginal Sepsis Syndrome

Figure 1.  Computed tomography of soft tissue of neck showing enhancing fluid density (red arrow) within the left palatine tonsil compatible with peritonsillar abscess.

Figure 2. Anterior-posterior (panel A) and lateral (panel B) of the contrast-enhanced computed tomography of soft tissue of the neck showing filling defect throughout the entire left internal jugular vein from the skull base to its insertion at the left subclavian vein consistent with total occluding thrombus (yellow arrows).

A 22-year-old woman presented to our hospital with complaints of a persistent sore throat and intermittent low grade fever associated with chills for 10 days despite 5 days of antibiotics. During this time she had also developed progressive difficulty in swallowing due to associated pain that had progressed to limited mouth opening for past 2 days. Her vital signs were normal except for low grade fever. On limited oral cavity exam bilateral tonsils appeared enlarged and erythematous; tenderness was noted on palpation of left side of the antero-lateral neck with restriction of neck movements to the left. Basic labs revealed leukocytosis (WBC of 20.2 k/mm³) but was otherwise normal. Contrast-enhanced computed tomography of soft tissue of the neck was obtained which revealed bilaterally enlarged tonsils with  small abscess within left palatine tonsil, filling defect throughout the entire left internal jugular vein from the skull base to its insertion at the left subclavian vein consistent with acute thrombosis (Figures 1 and 2). She improved considerably with intravenous antibiotics. Rapid strep test, blood and throat culture were negative. HIV, Epstein-Barr virus and cytomegalovirus antibodies were also negative. As she clinically improved we discharged her home with oral antibiotics and did not start her on anticoagulation.

Lemierre's syndrome is a septic thrombophlebitis of the internal jugular vein (IJV) commonly caused by anaerobic oro-pharyngeal flora usually by Fusobacteirum necrophorum although a wide range of bacteria may cause the syndrome (1,2). Infection is usually followed by fulminant sepsis. The infection typically originates in the palatine tonsils or peritonsillar tissue which spreads into the lateral pharyngeal space causing septic thrombophlebitis of IJV which is usually followed by distal septic embolization, resulting in multi-organ involvement with lung being the most commonly affected. Diagnosis is usually established on the presence of thrombus in IJV and a positive blood culture, but cultures can be negative in about 12 % of cases. Computed tomography of neck with contrast is the diagnostic modality of choice to demonstrate the thrombus. Prolonged course of Intravenous antibiotic (3-6 weeks) covering F. necrophorum and oral streptococci is the cornerstone of treatment. Currently there are no clear guidelines for the use of anticoagulation due to its rarity and lack of randomized controlled studies.

Chandramohan Meenakshisundaram MD, Nanditha Malakkla MD and Venu Ganipisetti, MD

Department of Internal Medicine,

Presence Saint Francis Hospital

Evanston, IL

References

1. Srivali N, Ungprasert P, Kittanamongkolchai W, Ammannagari N. Lemierre's syndrome: An often missed life-threatening infection. Indian J Crit Care Med. 2014;18(3):170-2. [CrossRef] [PubMed]
2. Pinheiro PE, Miotto PD, Shigematsu NQ, Tamashiro E, Valera FC, Anselmo-Lima WT. Lemierre's syndrome: a pharyngotonsillitis complication. Braz J Otorhinolaryngol. 2015;81(1):115-6. [CrossRef] [PubMed]

Reference as: Meenakshisundaram C, Malakkla N, Ganipisetti V. Medical image of the week: post-anginal sepsis syndrome. Southwest J Pulm Crit Care. 2015;11(2):66-7. doi: http://dx.doi.org/10.13175/swjpcc074-15 PDF

January 2015 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 68-year-old woman with a history of myelodysplastic syndrome associated with transfusion-dependent anemia and thrombocytopenia presented with recent onset left chest pain and fever. The patient had a remote history of total right knee arthroplasty, hypertension, asthma, and schizoaffective disorder. Several months earlier the patient was hospitalized with methicillin-sensitive Staphylococcus aureus infection involving the right knee arthroplasty, associated with bacteremia and a septic right elbow. This infection was treated with incision and drainage of the elbow, antibiotic bead placement about the right knee arthroplasty with an antibiotic-impregnated spacer, and antibiotics (6 weeks intravenous cefazolin followed by chronic doxycycline suppression therapy, the former later switched to nafcillin and rifampin). The patient had been discharged from the hospital with only compression hose for deep venous thrombosis prophylaxis, owing to her episodes of epistaxis in the setting of transfusion-dependent anemia.

Upon presentation, the patient was hypotensive, tachycardic, and hypotensive. Laboratory data showed a white cell count of 3.9 cells x 10⁹ / L, a platelet count of 7000 x 10⁹ / L, and a hemoglobin level of 7 g/dL.

Frontal chest radiography (Figure 1A) was performed (a baseline chest radiograph- Figure 1B- is presented for comparison).

Figure 1. Panel A: Frontal chest radiography Panel B: Frontal chest radiograph obtained 3 months to presentation.

Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to proceed to the 2nd of 7 panels)

1. The frontal chest radiograph shows bilateral hilar and mediastinal lymph node enlargement
2. The frontal chest radiograph shows enlarged lung volumes with numerous cystic foci
3. The frontal chest radiograph shows linear and reticular abnormalities with architectural distortion associated with fibrotic lung disease
4. The frontal chest radiograph shows lingular and left lower lobe consolidation and left pleural effusion
5. The frontal chest radiograph shows multiple poorly defined bilateral pulmonary nodules

Reference as: Gotway MB. January 2015 imaging case of the month. Southwest J Pulm Crit Care. 2015;10(1):21-31. doi: http://dx.doi.org/10.13175/swjpcc003-15 PDF

Medical Image of the Week: Hemophagocytic Lymphohistiocytosis (HLH)

Figure 1. Axial (Panel A) and coronal (Panel B) PET-CT Scan Images showing numerous metabolically active pulmonary nodules and mediastinal lymph nodes.

Figure 2. Axial (Panel A) and Sagittal (Panel B) images of the chest CT showing consolidative pulmonary nodules with surrounding ground glass halo and mediastinal lymphadenopathy.

Figure 3. Bone Marrow Biopsy (x1000). Panel A: macrophage engulfing a neutrophil. Panel B: macrophage engulfing erythrocyte debris.

Figure 4. Panel A: Lower power view of the lung biopsy (H&E stain) showing the interface between the neoplastic lymphocytic infiltrate and benign, normal lung. Panel B: high power view showing the neoplastic B-cell lymphoma with sheets of large lymphocytes.

A 41-year-old African American woman with a history of diffuse large B cell lymphoma in remission was admitted to the hospital with severe dyspnea and abdominal pain. Recent imaging revealed extensive pulmonary and liver nodules with significant mediastinal lymphadenopathy (Figures 1 and 2).  She had an extensive outpatient evaluation of these abnormalities including multiple percutaneous and endoscopic biopsies which were nondiagnostic.  She deteriorated clinically and a ferritin level was elevated at 36,284 ng/mL.  Due to the markedly elevated ferritin, a bone marrow biopsy was performed and was normocellular with trilineage hematopoiesis and erythrophagocytosis consistent with hemophagocytic lymphohistiocytosis (HLH, Figure 3).  A VATS guided lung biopsy was performed revealing recurrence of the diffuse large B cell lymphoma (Figure 4).  She started chemotherapy with the E-SHAP (etoposide, methylprednisolone, cytarabine, cisplatin), however, became severely pancytopenic and developed acute respiratory failure, shock and multi-organ failure.  She died despite aggressive care in the intensive care unit.  Patients with HLH often present with sepsis like symptoms and multiorgan failure.  Measurement of serum ferritin level is a critical test in suggesting the diagnosis once infection is excluded.  Early recognition and prompt treatment is essential to preventing fatal outcomes.

Tauseef Afaq Siddiqi, MD¹; Carlos Tafich Rios, MD²; Carlos L Cantu, MD³; James Knepler, MD¹; Linda Snyder, MD¹

¹ Division of Pulmonary, Allergy, Critical Care and Sleep Medicine,

² Department of Medicine,

³ Department of Pathology, The University of Arizona, Tucson, AZ 85724, USA.

References

1. Raschke RA, Garcia-Orr R. Hemophagocytic lymphohistiocytosis: a potentially underrecognized association with systemic inflammatory response syndrome, severe sepsis, and septic shock in adults. Chest. 2011;140(4):933-8. [CrossRef] [PubMed] 
2. Okabe T, Shah G, Mendoza V, Hirani A, Baram M, Marik P. What intensivists need to know about hemophagocytic syndrome: an underrecognized cause of death in adult intensive care units. J Intensive Care Med. 2012;27(1):58-64. [CrossRef] [PubMed]

Reference as: 

Siddiqi TA, Rios CT, Cantu CL, Knepler J, Snyder L. Medical image of the week: hemophagoctyic lymphohistiocytosis (HLH). Southwest J Pulm Crit Care. 2013;7(6):351-2. doi: http://dx.doi.org/10.13175/swjpcc157-13 PDF

Medical Image of the Week: Purpura Fulminans

Figure 1: Purpura fulminans, a cutaneous manifestation of disseminated intravascular coagulation, due to Group A streptococcal septic shock (A), which improved with antibiotics, resuscitation, IVIG infusion, and topical nitroglycerin (B).

Jarrod Mosier, MD and John Bloom, MD

Emergency Medicine-Critical Care Program

Division of Pulmonary and Critical Care

University of Arizona

Tucson, Arizona

Reference as: Mosier J, Bloom J. Medical image of the week: purpura fulminans. Southwest J Pulm Crit Care. 2013;6(6):305.  doi: http://dx.doi.org/10.13175/swjpcc082-13 PDF