Primary Meningococcal Arthritis Leading to Neisseria Meningitidies Purpura Fulminans
A homeless, 60-year-old man with a history of HIV presented to the emergency department (ED) with chief complaint of bilateral wrist pain and left ankle swelling and pain for a day. Patient stated pain was 10/10, constant, increased with movement and was not relieved by ibuprofen. He stated that he had a history of gout attack and this presentation was similar to previous gouty attacks. He denied intravenous drug abuse, fever, or recent illness. In regards to his HIV status, the patient had a CD4 count of 604 and an HIV RNA PCR quantity of 120,000 1 month prior to presentation. On physical examination his vital signs were positive for a low grade fever of 37.5 °C and tachycardia of 120 beats per minute (bpm). He appeared non-toxic and was without rashes, but showed limitation of active movement of bilateral wrists and left ankle due to pain with warmth and tenderness to palpation in all 3 joints. He had trace edema of the left ankle. No labs were drawn on the initial visit, and he was treated with 1.2 mg colchicine, followed by 4 subsequent doses of 0.6 mg, 800 mg ibuprofen, and 5/325 mg tab of hydrocodone/acetaminophen with significant decrease in his pain and ability to move all joints and bear weight. He was subsequently discharged home with a prescription for ibuprofen and hydrocodone/acetaminophen with diagnosis of HIV and acute gout attack.\nThe patient returned 3 days after discharge with worsening pain, erythema, and swelling in his left ankle and new right ankle and left knee pain, erythema, and edema. His vitals were normal without a low grade fever, but tachycardia of 122 bpm. The patient remained non-toxic appearing without a rash. Labs were obtained, arthrocentesis of his left knee was performed, and he was treated with ketorolac for pain with improvement. His laboratory analysis showed a peripheral WBC of 9.4, uric acid of 6.9 mg/dL, and joint aspirate WBC count of 8.7 × 103 cells/μL without crystals. He was discharged with nonsteroidal anti-inflammatory drugs, rheumatology follow up and diagnosis of inflammatory arthritis.\nTwo days after being discharged the second time, the patient was found sitting on a bench across from the homeless shelter unresponsive. He had been there all night. Emergency medical services were called and he was given naloxone without response. On presentation to the ED he was unresponsive with vitals showing hypertension of 151/84, temperature of 36.3°C and tachycardia of 138 bpm. On physical examination he was noted to have entire left lower extremity edema with purpura noted throughout left leg and right ankle (). A computed tomography (CT) of his left leg showed edema only, and a head CT was negative. His labs showed acute renal failure with Cr of 2.2 and a peripheral WBC of 6.6 with 17% bands. His knee cultures from the previous ED visit were growing gram negative coccobacilli. The orthopedic service was consulted and took the patient to the operating room (OR) for washout.\nPost-operatively he was admitted to the intensive care unit where he was subsequently intubated for airway protection due to declining mental status. His blood and cerebral spinal fluid cultures grew N. meningitides, and he required xigris and levophed for septic shock. He had a prolonged hospital course that included multiple surgical procedures for debridement/washouts, I&Ds of bilateral lower extremities due to infected wounds from purpura fulminans (requiring wound vac management), and skin grafts to the left lower extremity. He had another episode of acute renal failure due to urinary retention, causing hydronephrosis that required a urology consult without causal finding, and he was taught to perform in-and-out catheterizations.\nThe patient was diagnosed with mild syndrome of inappropriate antidiuretic hormone and placed on fluid restriction. He experienced left-sided hearing loss due to meningitis After developing a right upper extremity deep vein thrombosis he was bridged from enoxaparin to warfarin for treatment. He also had to be treated for hospital-acquired urinary tract infections, required multiple blood transfusions due to the operations, and was placed on nutritional supplementation for malnourishment.\nIt should be noted that neurology was consulted due to prolonged altered mental status after extubation. The patient had a negative magnetic resonance image of the brain and electroencephalography. Infectious disease was also consulted and treated the initial infection with a 14-day course of ceftriaxone and the lower extremity wound infections with a course of vancomycin and meropenem. After 62 days of hospitalization, he was discharged to a sub-acute rehabilitation facility for further management.