Meningococcal Septic Shock with Polyarticular Arthritis and Hemorrhagic Skin Lesions in a 70-Year-Old Immunocompetent Woman

Abstract

Aim: To describe a case of meningococcal polyarthritis and hemorrhagic skin lesions in an immunocompetent woman with meningococcal septic shock. Case Presentation: Α 70-year-old woman was presented to the emergency room with fever, chest pain, and purpura. Vital signs: 98 bpm, 26 breaths/min, blood pressure: not measurable. She had no photophobia or neurologic-meningeal signs. Chest radiograph showed bilateral bronchopneumonia infiltrates and 6th left rib fracture, which was attributed to a fall at home due to hypotension. Blood tests showed acute kidney injury and disseminated intravascular coagulation, while inflammatory markers were markedly elevated. Due to hemorrhagic lesions and the unresponsiveness to vasopressors, brain and adrenal CT was performed, which revealed subarachnoid haemorrhage, while it excluded Waterhouse-Friderichsen syndrome. Aggressive hydration with crystalloids and ceftriaxone plus vancomycin was initiated as empirical treatment of sepsis due to primary bacteremia. Blood cultures revealed penicillin-sensitive N.meningitidis (MIC: 0,094 μg/mL). The patient was afebrile on the 3rd hospital day. On the 4thday she presented new fever along with arthritis of left proximal mesophalangic and carpal joints, and afterwards of the left elbow and right metacarpophalangeal joints. Lornoxicam was added to therapy. Fever resolved after 1 week. The patient continued NSAID treatment for 1 month until CRP and ESR values returned to normal. Conclusion: Meningococcal arthritis is found in up to 12% of patients with invasive meningococcal disease and is presenting 3 days to 2 weeks after disease onset when the patient’s status is otherwise improving. Clinicians should be aware of this complication because fever and inflammatory markers’ rebound can lead to the unnecessary initiation of nosocomial antibiotics.