1

Group A Escherichia coli-related purpura fulminans: an unusual manifestation due to an 1

unusual strain? 2

Marlène Amara (1), Stéphane Bonacorsi (2, 3, 4), Jérôme Bedel (5), Jean-Paul Mira (6), Virginie 3

Laurent (5), Koryna Socha (7), Fabrice Bruneel (5), Béatrice Pangon (1), Jean-Pierre Bédos (5) 4

and David Grimaldi (5) 5

Corresponding author : Dr David Grimaldi 6

Mailing address : Centre Hospitalier Versailles, Service de réanimation, 177 rue de Versailles 7

78157 Le Chesnay, France. Phone : +33 1 39 63 88 42. Fax : +33 1 39 63 86 88. 8

Email : dgrimaldi@ch-versailles.fr 9

1. Laboratoire de Microbiologie, CH Versailles – Site André Mignot, Le Chesnay, France 10

2. IAME, UMR 1137, INSERM, F-75018 Paris, France 11

3. IAME, UMR 1137, Univ Paris Diderot, Sorbonne Paris Cité, F-75018 Paris, France 12

4. AP-HP, Hôpital Robert-Debré, Service de Microbiologie, Centre National de Référence 13

associé Escherichia coli, F-75018 Paris, France 14

5. Service de Réanimation, CH Versailles – Site André Mignot, Le Chesnay, France 15

6. Service de Réanimation, Centre Hospitalier Universitaire Cochin Saint Vincent de Paul, AP-16

HP, Paris, France 17

7. Service d’anatomo-pathologie, CH Versailles – Site André Mignot, Le Chesnay, France 18

Intended category: Case report 19

JCM Accepts, published online ahead of print on 17 September 2014J. Clin. Microbiol. doi:10.1128/JCM.01362-14Copyright © 2014, American Society for Microbiology. All Rights Reserved.

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Words count: 818 20

Keywords: Escherichia coli, purpura fulminans, CVP region, group A, ExPECs 21

Running title: Group A E. Coli purpura fulminans 22

Abstract: 23

We report an exceptional case of life-threatening group A Escherichia coli-induced purpura 24

fulminans. Genotyping of common polymorphisms in genes involved in innate immunity or 25

coagulation did not reveal known susceptibility to such manifestation. Genetic analysis of the 26

strain revealed an unusual Conserved Virulence Plasmidic region, pointing out its potential 27

virulence. 28

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Case report 30

A 53-year-old woman had a medical history of penicillin allergy and morbid obesity (Body Mass 31

Index, BMI: 46 kg/m2) treated by a Banding Gastroplasty in 2007. In 2009, she suffered from a 32

gastric necrosis complicated by a peritonitis associated with a first episode of E. coli bacteraemia. 33

At that time, she presented a septic shock without disseminated intravascular coagulation (DIC). 34

She underwent a total gastrectomy with oeso-jejunal anastomosis. Following gastrectomy, her 35

BMI decreased dramatically to 16 kg/m2. 36

In May 2013, she presented at the emergency department with weakness. Her central body 37

temperature was 38.6°C, heart rate: 144 beats/min and blood pressure 85/52 mmHg. Physical 38

exam did not point to a particular site of infection. Thoraco-abdominal CT scan did not show an 39

infectious process. Laboratory results showed evidence of severe sepsis: C-reactive protein 113 40

mg/L, leukocyte count 1.8x106 /L, arterial lactate level 7.3 mmol/L. The other results were 41

subnormal: creatininemia 80 µmol/L, platelet count 201x106/L, prothrombine ratio 59%, factor V 42

81 %, CPK 111 IU/ L (N <200). Vancomycin, aztreonam and gentamicin were initiated along 43

with a fluid loading of 3L crystalloids and continuous noradrenalin infusion up to 2,4 g/kg/min. 44

The patient was referred to the intensive care unit (ICU) and, 6 hours after admission, she 45

suddenly developed diffuse map-like purple skin lesions particularly prominent in the lower 46

limbs (Figure 1, A and B). The legs became cold and mottled. Simultaneously, she developed 47

multiorgan failure and severe DIC (platelet count 36x106/L, prothrombin rate 32%, factor V 31 48

%, D-dimers 1830 ng/mL). Arterial Doppler examination of the legs ruled out arterial thrombosis. 49

The diagnosis of purpura fulminans was made. Fresh frozen plasma and platelet concentrate were 50

transfused. The patient’s status slowly improved, the coagulation tests normalized at day 3, 51

norepinephrine was weaned off at day 7. By day 20, the patient underwent surgical debridement 52

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of cutaneous and subcutaneous tissues. After 12 weeks in the ICU, she was discharged in hospital 53

ward for renutrition. A skin graft was performed after 5 months. The two blood cultures drawn at 54

ICU admission as well as cutaneous biopsy of a necrotic lesion grew with a Penicillinase-55

producing E. coli strain identified using a MALDI-TOF mass spectrometer Microflex (Brucker, 56

Germany). Histopathological exam of the skin was in accordance with the diagnosis of purpura 57

fulminans (Figure 1, C). The cytobacteriological examination of urine was negative. Following 58

written consent, 32 well-characterized human genetic polymorphisms associated with severe 59

sepsis susceptibility were searched for (1). The patient’s genotyping did not reveal any variant of 60

the genes associated with Gram-negative detection (TLR2, TLR4 and CD14) (2) severity of 61

sepsis (TNF-α, IL-6, IL-10) (3) and coagulation disorders (coagulation factor V, Tissue Factor, 62

Protein C Receptor Endothelial, Thrombin and PAI-1) (4). The 2009 and 2013 E. coli strains 63

were further characterized by MLST sequence typing. Both of the 2009 and 2013 strains 64

belonged to the phylogenetic group A and harbored the sequence type ST398 and ST 10 65

respectively. The search for 14 virulence factors (VFs) was performed by PCR as previously 66

described (5,6). The 2013 strain did not carry any of the adhesin/invasin (Pap, Sfa, and IbeA) nor 67

any of the toxin (Hly, Cnf-1, Sat, Vat and colibactin) genes sought. Interestingly, it harbored two 68

iron acquisition systems, yersiniabactin and salmochelin, as well as the sit system ; plasmidic 69

OmpT (OmpTp) encoding a putative outer membrane protease (omptin) and cva encoding 70

colicinV, hlyF encoding α-haemolysin, a poreforming toxin, ets operon encoding a type I 71

secretion system and iss, the increased serum survival gene. This combination of genes, together 72

with the aerobactin gene, lacking in this observation, is considered to be the signature of the 73

Conserved Virulence Plasmidic (CVP), which contains eight operons or genes amplified by 74

multiplex PCR as previously described (7). Complete or almost complete CVP region was 75

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identified in sequenced plasmids, from human, avian and environmental origin (7–11). The 2009 76

strain did carry neither the CVP region genes nor any of the VFs sought. 77

78

Purpura fulminans is a life-threatening condition caused by a sudden and severe DIC, typically 79

caused by meningococcemia and sometimes pneumococcemia, but Escherichia coli-related 80

purpura fulminans remains exceptional (12,13). Extraintestinal pathogenic Escherichia coli 81

(ExPECs) infections represent a growing public health concern (14,15). Strains commonly belong 82

to phylogenic groups B2 and D (16) and lead to various clinical features, such as urinary tract 83

infections, meningitis and occasionally severe skin infections (17), (18). Phylogenic group A is, 84

with the B1 group, the group to whom belong almost all commensal strains (19). However, some 85

of these strains may be responsible for severe invasive infections and we recently showed that 86

CVP region contributes to the extra intestinal virulence of E. coli isolates belonging to these 87

phylogroups (7). 88

We report herein an unusual case of commensal group A E. coli-related purpura fulminans in a 89

patient that had previously exhibited an episode of E. coli bacteraemia without such presentation. 90

At the time of the second bacteraemia, the patient had experienced a total gastrectomy and a 91

severe weight loss. The alteration of the gastrointestinal tract anatomy may predispose to 92

bacterial translocation and malnutrition could increase the severity of the infection, however none 93

of these two factors are involved in DIC. The absence of DIC during the first episode of 94

bactaeremia, together with the fact that known genetic markers for increased susceptibility to DIC 95

were lacking in the host suggest that the unusual presentation was related to the pathogen’s 96

genotype and possibly to the presence of CVP region, since the strain does not carry other 97

particular VFs. 98

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In conclusion, this observation points out the potential virulence associated with the CVP region, 99

which could be involved in the emergence of “unconventional” ExPECs belonging to human 100

commensal phylogroups A/B1 (7) and should be explored in further studies. The role of bacterial 101

genetic determinants such as the CVP region in this life threatening syndrome remains to be 102

elucidated. 103

Acknowledgments: We thank Mr Christophe Rousseau for his technical help for the genotyping 104

and Dr Maher Anous for his help in the redaction of this manuscript. 105

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References: 107

1. Descheemaeker P-N, Mira J-P, Bruneel F, Houzé S, Tanguy M, Gangneux J-P, Flecher 108

E, Rousseau C, Le Bras J and Mallédant Y. 2009. Near-fatal multiple organ dysfunction 109

syndrome induced by Plasmodium malariae. Emerg Infect Dis. 15:832‑ 834. 110

2. Bochud P-Y, Bochud M, Telenti A, and Calandra T. 2007. Innate immunogenetics: a tool 111

for exploring new frontiers of host defence. Lancet Infect Dis. 7:531‑ 542. 112

3. Sutherland AM, and Walley KR. 2009. Bench-to-bedside review: Association of genetic 113

variation with sepsis. Crit Care Lond Engl. 13:210. 114

4. Texereau J, Pene F, Chiche J-D, Rousseau C, and Mira J-P. 2004. Importance of 115

hemostatic gene polymorphisms for susceptibility to and outcome of severe sepsis. Crit Care 116

Med. 32:S313‑ 319. 117

5. Mahjoub-Messai F, Bidet P, Caro V, Diancourt L, Biran V, Aujard Y, Bingen E and 118

Bonacorsi S. 2011. Escherichia coli isolates causing bacteremia via gut translocation and 119

urinary tract infection in young infants exhibit different virulence genotypes. J Infect Dis. 120

203:1844‑ 1849. 121

6. Bidet P, Mahjoub-Messai F, Blanco J, Blanco J, Dehem M, Aujard Y, Bingen E and 122

Bonacorsi S. 2007. Combined multilocus sequence typing and O serogrouping distinguishes 123

Escherichia coli subtypes associated with infant urosepsis and/or meningitis. J Infect Dis. 124

196:297‑ 303. 125

on February 19, 2018 by guest

http://jcm.asm

.org/D

ownloaded from

8

7. Lemaître C, Mahjoub-Messai F, Dupont D, Caro V, Diancourt L, Bingen E, Bidet P, 126

and Bonacorsi S. 2013. A Conserved Virulence Plasmidic Region Contributes to the 127

Virulence of the Multiresistant Escherichia coli Meningitis Strain S286 Belonging to 128

Phylogenetic Group C. PloS One. 8:e74423. 129

8. Johnson TJ, Siek KE, Johnson SJ, and Nolan LK. 2006. DNA sequence of a ColV 130

plasmid and prevalence of selected plasmid-encoded virulence genes among avian 131

Escherichia coli strains. J Bacteriol. 188:745‑ 758. 132

9. Peigne C, Bidet P, Mahjoub-Messai F, Plainvert C, Barbe V, Médigue C, Frapy E, 133

Nassif X, Denamur E, Bingen E and Bonacorsi S. 2009. The plasmid of Escherichia coli 134

strain S88 (O45:K1:H7) that causes neonatal meningitis is closely related to avian 135

pathogenic E. coli plasmids and is associated with high-level bacteremia in a neonatal rat 136

meningitis model. Infect Immun. 77:2272‑ 2284. 137

10. Johnson TJ, Jordan D, Kariyawasam S, Stell AL, Bell NP, Wannemuehler YM, 138

Alarcón CF, Li G, Tivendale KA, Logue CM and Nolan LK. 2010. Sequence analysis 139

and characterization of a transferable hybrid plasmid encoding multidrug resistance and 140

enabling zoonotic potential for extraintestinal Escherichia coli. Infect Immun. 141

78:1931‑ 1942. 142

11. Tivendale KA, Noormohammadi AH, Allen JL, and Browning GF. 2009. The conserved 143

portion of the putative virulence region contributes to virulence of avian pathogenic 144

Escherichia coli. Microbiol Read Engl. 155:450‑ 460. 145

on February 19, 2018 by guest

http://jcm.asm

.org/D

ownloaded from

9

12. Huemer GM, Bonatti H, and Dunst KM. 2004. Purpura fulminans due to E. coli 146

septicemia. Wien Klin Wochenschr. 116:82. 147

13. Helviz Y, Hersch M, Shmuelevitz L, Atrash J, and Einav S. 2011. Bad to worse. Am J 148

Med. 124:215‑ 217. 149

14. Russo TA, and Johnson JR. 2003. Medical and economic impact of extraintestinal 150

infections due to Escherichia coli: focus on an increasingly important endemic problem. 151

Microbes Infect Inst Pasteur. 5:449‑ 456. 152

15. De Kraker MEA, Jarlier V, Monen JCM, Heuer OE, van de Sande N, and 153

Grundmann H. 2013. The changing epidemiology of bacteraemias in Europe: trends from 154

the European Antimicrobial Resistance Surveillance System. Clin Microbiol Infect Off Publ 155

Eur Soc Clin Microbiol Infect Dis. 19:860‑ 868. 156

16. Johnson JR, and Russo TA. 2002. Extraintestinal pathogenic Escherichia coli: « the other 157

bad E coli ». J Lab Clin Med. 139:155‑ 162. 158

17. Grimaldi D, Bonacorsi S, Roussel H, Zuber B, Poupet H, Chiche J-D, Poyart C and 159

Mira JP. 2010. Unusual « flesh-eating » strain of Escherichia coli. J Clin Microbiol. 160

48:3794‑ 3796. 161

18. Petkovsek Z, Elersic K, Gubina M, Zgur-Bertok D, and Starcic Erjavec M. 2009. 162

Virulence potential of Escherichia coli isolates from skin and soft tissue infections. J Clin 163

Microbiol. 47:1811‑ 1817. 164

on February 19, 2018 by guest

http://jcm.asm

.org/D

ownloaded from

10

19. Escobar-Páramo P, Clermont O, Blanc-Potard A-B, Bui H, Le Bouguénec C, and 165

Denamur E. 2004. A specific genetic background is required for acquisition and expression 166

of virulence factors in Escherichia coli. Mol Biol Evol. 21:1085‑ 1094. 167

168

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Figure caption: 170

FIG. 1 Bilateral necrotic legs lesions of Purpura fulminans (A and B). Histopathological exam of 171

the skin revealed a sparse infiltrate of often altered neutrophils around the vessels, extravasated 172

erythrocytes and edema of the dermis (C). 173

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