Case 2 Discussion

1) In addition to the history provided by the Emergency Room Physician, what other questions would you want to ask the patient?

1. Where does patient live (college dorm)?
2. Any sick contacts?
3. Sexually active?
4. New medications?
5. Vaginal discharge? Abdominal pain?
6. Tick bite?
7. Recent travel?
8. Joint pain?
9. History of heart defects?

2) What other physical examination findings would you look for to narrow your differential diagnosis?

1. Splinter hemorrhages, Osler nodes, Janeway lesions, heart murmur (endocarditis)
2. Joint swelling (gonococcemia or collagen-vascular disease)
3. Photophobia, neurologic defects (meningiococcemia)
4. Tick bite (Rocky mountain spotted fever)

3) What is your Differential Diagnosis (please include the reason for listing each diagnosis)?

1. Meningiococcemia (fever, palpable purpura, altered mental status)
2. Gonococcemia (fever, palpable purpura)
3. Endocarditis emboli (fever, palpable purpura, altered mental status-brain emboli)
4. Rocky mountain spotted fever (fever, palpable purpura)
5. Vasculitis from medication or collagen-vascular (fever, palpable purpura)

4) What tests would you suggest to the Emergency Room Physician?

1. Skin biopsy (stain for organisms)
2. Blood cultures
3. ANA
4. CBC
5. Echo (if cardiac exam suspicious)
6. Lumbar puncture
7. Clotting panel
8. ESR

5) What would be your initial treatment plan?

Broad spectrum antibiotic coverage

6) Summarize your most likely diagnosis

The diagnosis in this case was meningiococcemia. The patient was treated wtih vancomycin and cefotaxime. She recovered fully with no sequelae.

Meningiococcemia is a communicable disease caused by Neisseria meningitidis. It is transmitted person to person from respiratory secretions. Skin changes can often be the the first clinical sign. Classic cutaneous findings of meningiococcema include numerous palpable purpuric lesions, stellate in shape and a characteristic "slate gun metal gray" hue. 300-400 cases reported in California annually. Treatment of choice used to be penicillin G; third generation cephalosporins are most commonly utilized now due to increased cases of penicillin resistance. Vaccination for prevention of disease is recommended. The Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination of all persons aged 11-18 years of age with 1 dose of MCV4, the meningococcal conjugate vaccine known as Menactra®, at the earliest opportunity. Pre-teens should be routinely vaccinated at the 11-12 year old check-up as recommended by ACIP. College freshmen living in dormitories are at increased risk for meningococcal disease and should be vaccinated with MCV4 before college entry if they have not previously been vaccinated. Use of MPSV4, the meningococcal polysaccharide vaccine known as Menomune®, is recommended among adults over 55 years of age.

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