Microsoft Word - DRM240BF

A case is reported of a 70-year-old woman with chronic meningococcemia. She had intermittent fever, purpuric papules disseminated on the trunk and limbs, headache, arthralgia and myalgia for 5 weeks. Treatment with ceftriaxone was rapidly successful. Dr P. Morier, Service de Dermatologie, Centre Hospitalier Universitaire Vaudois, CH–1011 Lausanne (Switzerland) Chronic meningococcemia is defined [1] as a meningococcal septi-cemia of more than 1 week’s duration without meningeal symptoms. Its clinical manifestations are recurrent fever accompanied by a skin rash (usually maculopapular or petechial). arthralgia, headache and minimal debility. It is a rarely reported disease whose frequency is probably underestimated due to the great sensitivity of meningococci to different antibiotics often prescribed without precise diagnosis. We report a case of chronic meningococcemia diagnosed 5 weeks after onset. Case Report At the end of April 1989, a 70-year-old woman had tonsillitis, for which she received no treatment. In May 6, she developed severe muscular and joint pain of the lower limbs accompanied by fever and multiple nonconfluent papules with a purpuric center disseminated on the trunk and limbs (fig. 1). She was treated by aspirin and paracetamol, and the symptoms subsided in about 2 days. General examination was normal. The biopsy of a skin lesion showed a leukocytoclastic vasculitis (fig. 2). Bacteria were not detected on Gram-stained sections. Bacteriological examination of a biopsy fragment was negative. Immuno-fluorescence revealed immunoglobulin M and complement deposits in the vessel walls of the superficial dermis. Erythrocyte sedimentation rate was 75 mm/h, platelet count was 654,000/mm3, C3 antigen level was 1.29 g/l (normal 0.5–0.9 g/l), C4 antigen level was 0.4 g/l (normal 0.1–0.4 g/l). Alkaline phosphatase showed a twofold increase and γ-glutamyltransferase a threefold increase. Antinuclear antibodies were positive with a titer of 1/2,560 and a homogeneous aspect. Chest Xray showed calcifying pachypleu-ritis. Abdominal echography revealed cholelithiasis. All the other laboratory tests were negative including two pairs of blood cultures at a time when the fever had already subsided. Between May 18 and May 31. the patient presented four new episodes similar to the first one. Blood culture done during a febrile peak detected Neisseria meningitidis group B. Throat swabs were negative for meningococci. There was no deficiency in the late complement components (C5-C9). Treatment consisted of ceftriaxone, 2 g/day i.v. for 10 days, and produced recovery within 24 h. D ow nl oa de d by : 54 .1 91 .4 0. 80 9 /1 6/ 20 17 2 :4 0: 58 P M Case Reports · Fallberichte · Cas Cliniques241 Fig. 1. Papules with a purpuric center disseminated on the trunk and limbs.Fig. 2. Histology from a lesion of the thigh: perivascular infiltrate of the superficial andmiddermis consisting mainly of neutrophils with leukocytoclasia; invasion and necrosis of thevessel walls as well as intravascular thrombi. HE. ×4().DiscussionChronic meningococcemia was well reviewed by Benoit [1]. Our patient had typical features ofthis disease. More recently, inherited late complement deficiencies were reported to occur inassociation with chronic meningococcemia [2. 3]. Such a defiency was not found in our case.Our observation stresses the usefulness of repeated blood cultures in the investigation of anyrecurrent vasculitis associated with fever and joint pain.ReferencesBenoit FL: Chronic meningococcemia. Case report and review of the literature. Am J Med1963;35:103–112.Clough JD. Clough ML. Weinstein A, et al: Familial late complement component (C6, C7)deficiency with chronic meningococcemia. Arch Intern Med 1980;140:929–933.Adams EM, Hustead S, Rubin M: Absence of the seventh component of complement in a patientwith chronic meningococcemia presenting as vasculitis. Ann Intern Med 1983;99:35–38.Delayed Skin Reaction Caused by a CoelenterateE. Frenk, A. Mancarella, B. VionUniversity Department of Dermatology, Lausanne, Switzerland