Diagnosis

Abstract

The Figure demonstrates the presence of petechiae and purpura on the patient's foot and ankle. The emergency physician immediately placed the patient on isolation, began intravenous fluids, drew appropriate laboratory tests, and instituted antibiotic coverage for presumed meningococcemia (later confirmed). The patient rapidly decompensated in the ED, requiring intubation and pressor support. Despite aggressive hospital therapy, the patient died.Neisseria meningitidis is a leading cause of bacterial meningitis and sepsis in older children and young adults in the United States.1Prevention and control of meningococcal disease—recommendations of the Advisory Committee on Immunization Practices (ACIP).MMWR. 2000; 49: 1-10PubMed Google Scholar The incidence of meningococcal infection is 0.8 to 1.3 per 100,000 population, with a case-fatality ratio of 10% to 15%.1Prevention and control of meningococcal disease—recommendations of the Advisory Committee on Immunization Practices (ACIP).MMWR. 2000; 49: 1-10PubMed Google Scholar, 2Stephens D.S. Zimmer S.M. Pathogenesis, therapy, and prevention of meningococcal sepsis.Curr Infect Dis Rep. 2002; 4: 377-386Crossref PubMed Scopus (26) Google Scholar Meningococcemia occurs when N meningitidis is present in the blood. The clinical presentation can vary widely, from mild “flu-like” illness to fulminate shock. Skin lesions are associated with meningococcemia in approximately two thirds of cases, with petechiae or purpura present in half of the cases. The petechiae are most often noted on the trunk and extremities, especially at pressure points.3Ferguson L.E. Hormann M.D. Parks D.K. et al.Neisseria meningitidis: presentation, treatment, and prevention.J Pediatr Health Care. 2002; 16: 119-124PubMed Scopus (22) Google Scholar This case emphasizes the importance of thoroughly undressing and evaluating patients in the ED. The Figure demonstrates the presence of petechiae and purpura on the patient's foot and ankle. The emergency physician immediately placed the patient on isolation, began intravenous fluids, drew appropriate laboratory tests, and instituted antibiotic coverage for presumed meningococcemia (later confirmed). The patient rapidly decompensated in the ED, requiring intubation and pressor support. Despite aggressive hospital therapy, the patient died. Neisseria meningitidis is a leading cause of bacterial meningitis and sepsis in older children and young adults in the United States.1Prevention and control of meningococcal disease—recommendations of the Advisory Committee on Immunization Practices (ACIP).MMWR. 2000; 49: 1-10PubMed Google Scholar The incidence of meningococcal infection is 0.8 to 1.3 per 100,000 population, with a case-fatality ratio of 10% to 15%.1Prevention and control of meningococcal disease—recommendations of the Advisory Committee on Immunization Practices (ACIP).MMWR. 2000; 49: 1-10PubMed Google Scholar, 2Stephens D.S. Zimmer S.M. Pathogenesis, therapy, and prevention of meningococcal sepsis.Curr Infect Dis Rep. 2002; 4: 377-386Crossref PubMed Scopus (26) Google Scholar Meningococcemia occurs when N meningitidis is present in the blood. The clinical presentation can vary widely, from mild “flu-like” illness to fulminate shock. Skin lesions are associated with meningococcemia in approximately two thirds of cases, with petechiae or purpura present in half of the cases. The petechiae are most often noted on the trunk and extremities, especially at pressure points.3Ferguson L.E. Hormann M.D. Parks D.K. et al.Neisseria meningitidis: presentation, treatment, and prevention.J Pediatr Health Care. 2002; 16: 119-124PubMed Scopus (22) Google Scholar This case emphasizes the importance of thoroughly undressing and evaluating patients in the ED. Images in Emergency MedicineAnnals of Emergency MedicineVol. 45Issue 5PreviewA 19-year-old man presented to the emergency department (ED) with a complaint of headache, fever, anorexia, arthralgia, and fatigue beginning the previous day. The patient had no significant past medical history and denied taking any medications other than acetaminophen. On initial evaluation by the emergency physician, the patient had not been undressed. After placing the patient in a hospital gown, the patient was noted to have the findings noted in the Figure. Full-Text PDF