Fatal group A Streptococcus purpura fulminans in a child receiving TNF-α blocker

Inhibition of tumor necrosis factor alpha (TNF-alpha) is effective in the treatment of many pediatric autoimmune diseases and inflammatory conditions. Commonly available biologic agents blocking TNF-alpha are infliximab, etanercept, and adalimumab. These agents have changed the management of rheumatic diseases in the adult population and are being used more and more in pediatric patients as safety and efficacy have been demonstrated. Infections have been the most commonly reported adverse effects of TNF-alpha inhibition. Granulomatous infections such as tuberculosis are well-known complications, but serious bacterial infections are also reported. We describe a fatal case of purpura fulminans caused by group A Streptococcus in an 8-year-old child with systemic juvenile idiopathic arthritis treated with etanercept. This case highlights the clinical association of severe bacterial infection and TNF-alpha inhibition in children. Pediatricians should educate their patients who are treated with TNF-alpha blockers regarding early warning symptoms and should also have a lower threshold for initiating antibiotic therapy in case of fever.