(BMJ)—A 51-year-old woman with no PMHx presented with a 12-hour hx of fever, malaise, and abdominal pain. Exam: T 38.3°C, BP 87/55 mm Hg, facial petechiae, no meningismus, mild diffuse abdominal tenderness. WBC 11.6 x 109/L, platelets 4 x 109/L, INR 3.66, fibrinogen 0.6 g/L, D-dimer 33,964 mg/L. Peripheral smear confirmed the dx. What is it?
Acute promyelocytic leukemia
Fulminant meningococcemia
Staphylococcal toxic shock syndrome
Human granulocytic anaplasmosis
Thrombotic thrombocytopenic purpura
You are correct. The coagulation abnormalities indicate disseminated intravascular coagulation (DIC). The blood film shows neutrophils with intracellular, coffee bean–shaped diplococci; thrombocytopenia; and sporadic schistocytes. Gram stain showed intracellular gram-negative diplococci. Combined with the clinical picture, this is consistent with fulminant meningococcemia. No cells with Auer rods are present, which argues against acute promyelocytic leukemia; thrombotic thrombocytopenic purpura isn’t associated with DIC; and anaplasmosis typically presents with neutropenia and mulberry-like intraleukocytic inclusions (morulae).

The patient was started on ceftriaxone and transferred to the ICU. Neisseria meningitidis was isolated from blood cx 3 days later, confirming the dx. Peripheral gangrene, renal insufficiency, and secondary infections complicated her course, and sadly, she died after a prolonged hospitalization.

Emerg Med J 2021;38:72-84