Myocarditis and purpura fulminans in meningococcaemia.
A 17-year-old boy presented with fever and upper respiratory symptoms of 5-day duration. These symptoms were accompanied by the presence of blackish discoloration of the toes and red-brown rash, over the lower limbs. There was no history of drug intake, recent travel or rat-bite. At presentation, he had tachycardia, tachypnea and blood pressure of 90/60 mmHg. Physical examination revealed cervical lymphadenopathy and pedal oedema. Petechiae and palpable non-blanching confluent purpura were seen over bilateral upper and lower limbs (Figure 1A and B), trunk, tip of the nose and angle of mouth. He had dry gangrene of fingers and toes as depicted. There was no evidence of eschar or exfoliation. Viral exanthems, bacterial infections, rickettsial fever, vasculitides and drug reaction were entertained as differential diagnoses. Evaluation revealed anaemia, thrombocytopenia, leucocytosis, raised serum creatinine, D-dimer of 2214 ng/mL and international normalized ratio (INR) of 3.1 suggesting consumption coagulopathy. ECG revealed diffuse T wave inversion and chromatographic-immunoassay was positive for cardiac troponin I. NS1 antigen, Dengue and Scrub typhus serologies were negative. Blood culture was sterile and skin biopsy showed fibrin thrombi in the small vessels. Transthoracic echocardiography showed global hypokinesia with left-ventricular ejection fraction of 30% and no evidence of vegetations. Latex-agglutination for meningococcal antigen was positive, confirming the diagnosis of meningococcemia with purpura fulminans and myocarditis. He was started on intravenous ceftriaxone (continued for 7 days) along with nor-epinephrine infusion and platelet transfusion. Over the next 2 days, hypotension resolved and progression of rash declined. Platelet count and coagulation parameters improved and repeat echocardiography showed resolution of hypokinesia with left-ventricular ejection fraction of 50%. He was discharged following completion of antibiotic therapy and partial resolution of the rash. Close contacts were given chemoprophylaxis with oral ciprofloxacin.