However, despite the above treatment, she continued to deteriorate rapidly with worsening of symptoms. On the 2nd day of admission (10th day of illness) the patient rapidly developed a painful rash over the breasts (Fig. 1) which progressed to involve the rest of the body, mainly on the abdomen, upper limbs & hands (Fig. 2) and lower limbs (Fig. 3) with sparing of the face. Examination of the rash revealed multiple subcutaneous hemorrhagic skin lesions in a ‘fern leaf’ pattern together with a vasculitic rash over the soles (Fig. 4). She also had splinter hemorrhages, persistent tachycardia (120/min), tachypnea (33/min) and a high fever indicative of systemic inflammatory response syndrome.Fig. 1Patches of subcutaneous necrosis over the breasts Fig. 2Subcutaneous necrosis mainly involving the dorsal aspects of the joints of hands Fig. 3Areas of subcutaneous necrosis over the thighs and the knees Fig. 4Evidence of subcutaneous vasculitis over the soles of the feet