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Purpuric rash of meningococcemia

Copyright © 2008 Society of Hospital Medicine

A previously healthy 62‐year‐old man presented to the emergency department with 4 days of headache, fever, and chills. Within several hours of presentation, he developed septic shock. His temperature was 39C, and his white blood count was 17,000/mm3 with 38% bands. He had acute renal failure (creatinine = 2.5) and mild mental status changes. His blood pressure decreased from 103/63 to 71/46 and was not responsive to intravenous fluid administration. He therefore was begun on pressors. Eight hours after arrival, a petechial and purpuric rash suddenly appeared on the patient's extremities, including the palms of his hands (Fig. 1). Ceftriaxone was added to his initial antibiotics (vancomycin and pipercillin‐tazobactam), and he was treated with stress‐dose hydrocortisone and activated drotrecogin alpha. The following day, blood cultures grew gram‐negative diplococci in pairs, and preventive measures were taken, including treating close contacts and placing the patient under droplet precautions. The cultures eventually confirmed Neisseria meningitidis. The patient made excellent progresshis mental status improved, he was weaned off pressors after 3 days, and his renal failure resolved. Figure 2 demonstrates the evolution of the purpuric lesions, which became more prominent as he otherwise made clinical improvement. He was discharged home after 2 weeks of intravenous ceftriaxone in good condition.

Figure 1

Day of admission.

Figure 2

Hospital day 7.

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