J Med Cases

Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc

Journal website https://www.journalmc.org

Case Report

Volume 14, Number 4, April 2023, pages 130-136

An Uncommon Presentation of Vasopressin-Induced Purpura Fulminans

Figure 1. Skin findings the morning following initial vasopressin use. (a) Left lower leg. (b) Right lower leg. (c) Right lateral knee. (d) Scrotum.

Figure 3. Skin findings 9 days after initial vasopressin use. (a) Left lower leg. (b) Right lower leg. (c) Right lateral knee. (d) Scrotum.

**Table 1.** Initial Laboratory Values on Admission
Lab tests	Value	Reference range
ALP: alkaline phosphatase; ALT: alanine aminotransferase; AST: aspartate aminotransferase; BUN: blood urea nitrogen; Cl: chloride; CO₂: carbon dioxide; K: potassium; Na: sodium; WBC: white blood cell count.
WBC	23.9	3.8 - 10.6 × 10³/mm³
Hemoglobin	15.1	13.5 - 16.0 g/dL
Hematocrit	32.8	41.0-53.0%
Platelet count	254	140 - 440 × 10³/mm³
Na	124	136 - 145 mmol/L
K	3.0	3.4 - 5.1 mmol/L
Cl	88	98 - 107 mmol/L
CO₂	< 10.0	20.0 - 31.0 mmol/L
BUN	44	9 - 23 mg/dL
Creatinine	2.3	0.6 - 1.3 mg/dL
Anion gap	26	7 - 16
Lactic acid	4.7	0.4 - 2.0 mmol/L
Corrected calcium	10.8	8.5 - 10.6 mg/dL
Phosphorus	< 0.05	2.4 - 5.1 mg/dL
Beta-hydroxybutyrate	5.7	< 0.6 mmol/dL
Procalcitonin	6.70	< 0.05 ng/dL
AST	41	0 - 34 U/L
ALT	23	10 - 49 U/L
ALP	228	46 - 116 U/L
Albumin	3.4	3.5 - 5.0 g/dL
Arterial blood gas	7.19/14/125/5	7.35 - 7.45/32.0 - 48.0 mm Hg/83 - 108 mm Hg/20 - 26 mEq/L

Table 1. Initial Laboratory Values on Admission

Lab tests

Value

Reference range

ALP: alkaline phosphatase; ALT: alanine aminotransferase; AST: aspartate aminotransferase; BUN: blood urea nitrogen; Cl: chloride; CO₂: carbon dioxide; K: potassium; Na: sodium; WBC: white blood cell count.

WBC

23.9

3.8 - 10.6 × 10³/mm³

Hemoglobin

15.1

13.5 - 16.0 g/dL

Hematocrit

32.8

41.0-53.0%

Platelet count

254

140 - 440 × 10³/mm³

124

136 - 145 mmol/L

3.0

3.4 - 5.1 mmol/L

98 - 107 mmol/L

CO₂

< 10.0

20.0 - 31.0 mmol/L

BUN

9 - 23 mg/dL

Creatinine

2.3

0.6 - 1.3 mg/dL

Anion gap

7 - 16

Lactic acid

4.7

0.4 - 2.0 mmol/L

Corrected calcium

10.8

8.5 - 10.6 mg/dL

Phosphorus

< 0.05

2.4 - 5.1 mg/dL

Beta-hydroxybutyrate

5.7

< 0.6 mmol/dL

Procalcitonin

6.70

< 0.05 ng/dL

AST

0 - 34 U/L

ALT

10 - 49 U/L

ALP

228

46 - 116 U/L

Albumin

3.4

3.5 - 5.0 g/dL

Arterial blood gas

7.19/14/125/5

7.35 - 7.45/32.0 - 48.0 mm Hg/83 - 108 mm Hg/20 - 26 mEq/L

**Table 2.** Laboratory Values on the Second Day of Hospitalization
Lab tests	Value	Reference range
BUN: blood urea nitrogen; Cl: chloride; CO₂: carbon dioxide; INR: international normalized ratio; K: potassium; Na: sodium; PT: prothrombin time; PTT: partial thromboplastin time; WBC: white blood cell count.
WBC	44.0	3.8 - 10.6 × 10³/mm³
Hemoglobin	12.0	13.5 - 16.0 g/dL
Hematocrit	32.7	41.0-53.0%
Platelet count	74	140 - 440 × 10³/mm³
PT	18.1	9.0 - 12.2 s
INR	1.8	0.9 - 1.3
PTT	55.0	22.0 - 36.0 s
Na	151	136 - 145 mmol/L
K	3.2	3.4 - 5.1 mmol/L
Cl	117	98 - 107 mmol/L
CO₂	27.4	20.0 - 31.0 mmol/L
BUN	42	9 - 23 mg/dL
Creatinine	1.6	0.6 - 1.3 mg/dL
Anion gap	19	7 - 16
Lactic acid	3.8	0.4 - 2.0 mmol/L
Corrected calcium	9.8	8.5 - 10.6 mg/dL
Phosphorus	0.08	2.4 - 5.1 mg/dL
Albumin	2.6	3.5 - 5.0 g/dL
Arterial blood gas	7.47/36/153/26	7.35 - 7.45/ 32.0 - 48.0 mm Hg/83 - 108 mm Hg/20 - 26 mEq/Ls

Table 2. Laboratory Values on the Second Day of Hospitalization

Lab tests

Value

Reference range

BUN: blood urea nitrogen; Cl: chloride; CO₂: carbon dioxide; INR: international normalized ratio; K: potassium; Na: sodium; PT: prothrombin time; PTT: partial thromboplastin time; WBC: white blood cell count.

WBC

44.0

3.8 - 10.6 × 10³/mm³

Hemoglobin

12.0

13.5 - 16.0 g/dL

Hematocrit

32.7

41.0-53.0%

Platelet count

140 - 440 × 10³/mm³

18.1

9.0 - 12.2 s

INR

1.8

0.9 - 1.3

PTT

55.0

22.0 - 36.0 s

151

136 - 145 mmol/L

3.2

3.4 - 5.1 mmol/L

117

98 - 107 mmol/L

CO₂

27.4

20.0 - 31.0 mmol/L

BUN

9 - 23 mg/dL

Creatinine

1.6

0.6 - 1.3 mg/dL

Anion gap

7 - 16

Lactic acid

3.8

0.4 - 2.0 mmol/L

Corrected calcium

9.8

8.5 - 10.6 mg/dL

Phosphorus

0.08

2.4 - 5.1 mg/dL

Albumin

2.6

3.5 - 5.0 g/dL

Arterial blood gas

7.47/36/153/26

7.35 - 7.45/ 32.0 - 48.0 mm Hg/83 - 108 mm Hg/20 - 26 mEq/Ls

**Table 3.** Laboratory Values
Lab tests	Value	Reference range
Fibrinogen (day 3)	425	175 - 375 mg/dL
D-dimer (day 3)	3,150	< 600 ng/mL
Fibrinogen (day 5)	641	175 - 375 mg/dL
D-dimer (day 5)	> 3,820	< 600 ng/mL
Heparin platelet Ab optical density	0.026	< 0.300 OD units
Heparin-induced platelet Ab screen	Negative
Lactate dehydrogenase	334	120 - 246 U/L
ADAMTS 13	0.52	0.68 - 1.63 U/mL

Table 3. Laboratory Values

Lab tests

Value

Reference range

Fibrinogen (day 3)

425

175 - 375 mg/dL

D-dimer (day 3)

3,150

< 600 ng/mL

Fibrinogen (day 5)

641

175 - 375 mg/dL

D-dimer (day 5)

> 3,820

< 600 ng/mL

Heparin platelet Ab optical density

0.026

< 0.300 OD units

Heparin-induced platelet Ab screen

Negative

Lactate dehydrogenase

334

120 - 246 U/L

ADAMTS 13

0.52

0.68 - 1.63 U/mL