Rotational Thromboelastometry (ROTEM)-Guided Assessment of Hemorrhagic Disseminated Intravascular Coagulation in Septic Shock: A Case Report of Purpura Fulminans and Multiorgan Failure.

Sepsis-associated coagulopathy may progress rapidly from early thromboinflammation to overt disseminated intravascular coagulation (DIC) with mixed thrombotic and hemorrhagic manifestations. We report the case of a 30-year-old man with a history of methamphetamine use who presented after generalized tonic-clonic seizure activity, severe neurological impairment, hypoxemia, shock, and suspected sepsis. Initial evaluation showed severe metabolic derangement, acute kidney injury, aspiration risk during airway management, and suspected central nervous system infection. During intensive care unit evolution, the patient developed refractory septic shock, severe hypoxemic respiratory failure, rhabdomyolysis, recurrent hypoglycemia, profound mixed acidosis, anuric acute kidney injury requiring continuous renal replacement therapy, progressive thrombocytopenia, gastrointestinal bleeding, airway bleeding, catheter-site bleeding, and rapidly progressive violaceous bullous and necrotic skin lesions compatible with purpura fulminans. Clinical and laboratory findings were consistent with overt DIC with a prominent hemorrhagic phenotype. Serial rotational thromboelastometry (ROTEM) assessment demonstrated progressive coagulation failure, with late fibrin-based thromboelastometry (FIBTEM) findings showing severely reduced fibrin-based clot firmness consistent with fibrinogen-dependent clot failure. Hemostatic management included fibrinogen replacement, blood component therapy, tranexamic acid, and local hemostatic measures. Despite invasive mechanical ventilation, dual vasopressor therapy, corticosteroids, antimicrobial therapy, bicarbonate therapy, continuous renal replacement therapy, and targeted hemostatic resuscitation, the patient progressed to irreversible shock and cardiac arrest without return of spontaneous circulation. This case highlights the value of integrating clinical bleeding phenotype, conventional coagulation testing, DIC scoring, and viscoelastic assessment in critically ill septic patients with rapidly evolving coagulopathy.