Atypical Presentation of Toxic Shock Syndrome in a Patient With Postpartum Necrotizing Endometritis

A 42-year-old woman with a history of two first-trimester miscarriages and a known prothrombotic polymorphism (MTHFR C677T/A1298C compound heterozygote) developed postpartum toxic shock syndrome (TSS) complicated by peripheral skin necrosis eight days after emergency cesarean section for preeclampsia exacerbation. She presented with fever, hypotension, tachycardia, severe diarrhea, and a purpuric rash on the nose and distal lower extremities, rapidly evolving to necrosis. Although she had been prescribed prophylactic nadroparin during pregnancy, anticoagulation was discontinued upon discharge following the cesarean section. Laboratory findings revealed markedly elevated inflammatory markers, mild coagulopathy, and acute kidney injury. Coagulation abnormalities were mild and did not meet criteria for disseminated intravascular coagulation. On the second day of hospitalization, a hysterectomy was performed, and histopathology confirmed necrotizing endometritis. With early surgical source control, broad-spectrum antibiotics, anticoagulation, and intensive supportive care, the patient's condition improved significantly. Skin lesions gradually stabilized with desquamation and partial healing by day 14. This case highlights an unusual dermatologic manifestation of TSS and underscores the potential contribution of MTHFR C677T/A1298C polymorphisms to thromboinflammatory complications in the postpartum period.