Fever and a rash.

Accepted 30 October 1996 A 37-year-old man presented with acute confusion following five days of back pain, and two days of fever and diarrhoea. On examination he had a fever of 38.7°C, jaundice, neck stiffness, conjunctival suffusion, and a purpuric rash (figures 1 and 2). His pulse was 100 beats/min and blood pressure 100/80 mmHg. The heart sounds were normal. He was tachypnoeic with scattered wheezes in the chest. The rest of the examination was unremarkable. Laboratory results revealed thrombocytopenia, mild disseminated intravascular coagulation, hyponatraemia, marked renal and hepatic impairment, and hypoxia. Cerebrospinal fluid (CSF) white cell count was 150/mm' (80% polymorphs), erythrocytes 800/mm3, protein 1.18 g/l, glucose 2.6 mmol/l (plasma glucose 6.8 mmol/l) with no organisms on Gram stain. CSF culture was negative. Gram staining of an aspirate from the vasculitic lesions showed Gram-positive cocci in clusters. An organism was grown in blood and urine cultures on the following day. A diagnostic procedure was performed.