Case 22-2024: A 30-Year-Old Woman With Postpartum Fever, Abdominal Pain, and Skin Ulcers

( N Engl J Med . 2024;391(3):260-271. doi: 10.1056/NEJMcpc2309500) This case study documents details surrounding a hospital admission of a 30-year-old woman, 6 days after giving birth due to her symptoms of fever and abdominal pain. When the woman delivered her child, her gestational age was 35 weeks 3 days. The birth was straightforward, with spontaneous rupture of membranes, vaginal delivery of infant and placenta, with ~300 mL of blood loss. Due to the baby being born prematurely, the baby remained under hospital supervision, while the mother was discharged on day 2 after birth. On the sixth day postdelivery, the mother developed fever and chills and visited the emergency department. An examination resulted in findings of erythematous pustules with fluid drainage within the right inguinal area as well as minor leg swelling the patient noted as reduced from the day of birth. After 6 days of hospital admission, an endometrial biopsy resulted in finding neutrophilic debris. MRI and magnetic resonance angiography of the pelvic region resulted in ascites and anasarca, with increases seen days later. Following the identification of a fluid collection in the parametrium, a catheter was inserted to drain purulent fluid. On day 11 of hospital admission, the patient reported increased abdominal pain and shortness of breath. Due to an oxygen saturation of 86%, a nasal cannula was used to deliver additional oxygen to the patient. A distended abdomen and marked jugular venous distention were present as well as diffuse anasarca and ankle edema. An echocardiogram resulted in identifying abnormalities of the heart chambers, arteries, and septum. On day 12, plaques developed on the left upper arm, which subsequently ulcerated. Concurrently, new skin lesions arose within the right inguinal crease and upon the mons pubis. The development of a bulla on the left abdominal wall also occurred, which began to ulcerate over the next 2 days, with a similar lesion forming at the site of the drainage catheter. Those ulcers arising on day 12 all increased in area and depth, with a new ulcer forming in the left inguinal crease.