Atypical skin manifestation of purpura fulminans in Chikungunya infection on elderly patients: A case report

Atypical skin manifestation in Chikungunya infection on elderly patients


  • Parita Dankul Division of Critical care, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand, 10700
  • Ranistha Ratanarat Division of Critical care, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand, 10700



Chikungunya infection, Hemorrhagic bleb, Atypical manifestations


Background: Chikungunya is a vector-borne infectious disease that is usually characterized by fever, joint pain, muscle ache, headache, rash, or fatigue. Severe life-threatening complications such as septic shock, acute respiratory distress syndrome, and multiple organ dysfunction can develop during the acute phase of the disease. Purpura fulminans were rarely reported.

Case presentation: A previously healthy 69-year-old male patient with no known medical history presented with a 3-day history of fever, malaise, and arthralgia at both knees. He developed dyspnea, purpura, and hemorrhagic blebs at the right leg for 1 day. He was initially diagnosed with sepsis and oliguric renal failure with severe lactic acidosis. After fluid therapy was given to maintain stable hemodynamics, his lactate level increased rapidly. Continuous renal replacement therapy and hemoperfusion with cytokine adsorbent were then initiated simultaneously. On the second day of admission, the skin and soft tissue lesions progressed rapidly, and the patient experienced refractory shock and multiple organ dysfunction. Finally, he was diagnosed with a Chikungunya infection. Three days following the onset of edema in his extremities, he expired.

Conclusion: Purpuric skin manifestations and shock are rare but serious in Chikungunya infections. Clinicians should be aware of the potential for life-threatening complications. Aggressive management and adjunctive therapy such as hemoperfusion and intravenous immunoglobulins should be further studied.


Robinson MC. An epidemic of virus disease in Southern Province, Tanganyika Territory, in 1952-53. I. Clinical features. Trans R Soc Trop Med Hyg. 1955;49(1):28-32.

Hammon WM, Rudnick A, Sather GE. Viruses associated with epidemic hemorrhagic fevers of the Philippines and Thailand. Science. 1960;131(3407):1102-1103.

Mohan A, Kiran DH, Manohar IC, Kumar DP. Epidemiology, clinical manifestations, and diagnosis of Chikungunya fever: lessons learned from the re-emerging epidemic. Indian J Dermatol. 2010;55(1):54-63.

Economopoulou A, Dominguez M, Helynck B, Sissoko D, Wichmann O, Quenel P, et al. Atypical Chikungunya virus infections: clinical manifestations, mortality and risk factors for severe disease during the 2005-2006 outbreak on Réunion. Epidemiol Infect. 2009;137(4):534-541.

Kumar R, Sharma MK, Jain SK, Yadav SK, Singhal AK. Cutaneous manifestations of chikungunya fever: Observations from an outbreak at a Tertiary Care Hospital in Southeast Rajasthan, India. Indian Dermatol Online J. 2017;8(5):336-342.

Lemant J, Boisson V, Winer A, Thibault L, André H, Tixier F, et al. Serious acute chikungunya virus infection requiring intensive care during the Reunion Island outbreak in 2005-2006. Crit Care Med. 2008;36(9):2536-2541.

Renault P, Josseran L, Pierre V. Chikungunya-related fatality rates, Mauritius, India, and Reunion Island. Emerg Infect Dis. 2008;14(8):1327.

Rollé A, Schepers K, Cassadou S, Curlier E, Madeux B, Hermann-Storck C, et al. Severe sepsis and septic shock associated with Chikungunya virus infection, Guadeloupe, 2014. Emerg Infect Dis. 2016;22(5):891-894.

Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, et al. Surviving sepsis campaign: International guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021;47(11):1181-1247.

Steinberg BE, Goldenberg NM, Lee WL. Do viral infections mimic bacterial sepsis? The role of microvascular permeability: A review of mechanisms and methods. Antiviral Res. 2012;93(1):2-15.

Amin P, Amin V. Viral sepsis. Annual Update in Intensive Care and Emergency Medicine 2015. 2015:37–59.

Perera TB, Murphy-Lavoie HM. Purpura fulminans. 2023 Jul 17. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2024 Jan.

Torres JR, Leopoldo Códova G, Castro JS, Rodríguez L, Saravia V, Arvelaez J, et al. Chikungunya fever: Atypical and lethal cases in the Western hemisphere: A Venezuelan experience. IDCases. 2014;2(1):6-10.

Benjamanukul S, Chansaenroj J, Chirathaworn C, Poovorawan Y. Atypical skin manifestation in severe acute chikungunya infection in a pregnant woman: a case report. J Med Case Rep. 2022;16(1):5.

Fernandes AIV, Souza JR, Silva AR, Cruz SBSC, Castellano LRC. Immunoglobulin therapy in a patient with severe Chikungunya fever and vesiculobullous lesions. Front Immunol. 2019;10:1498.

Knoebl P, Schellongowski P, Staudinger T, Wolfgang RS, Scheibenpflug C. Treatment of infection-associated purpura fulminans with protein C zymogen is associated with a high survival rate. Blood. 2013;122(21):3606.

Elsinga J, Halabi Y, Gerstenbluth I, Tami A, Grobusch MP. Consequences of a recent past dengue infection for acute and long-term chikungunya outcome: A retrospective cohort study in Curaçao. Travel Med Infect Dis. 2018;23:34-43.




How to Cite

Dankul P, Ratanarat R. Atypical skin manifestation of purpura fulminans in Chikungunya infection on elderly patients: A case report: Atypical skin manifestation in Chikungunya infection on elderly patients. Clin Crit Care [Internet]. 2024 Jun. 20 [cited 2024 Jul. 20];32(1):e240013. Available from:



Case Report