Chikungunya is a viral disease transmitted by mosquitoes of the Aedes genus, characterized by high fever and arthralgia/arthritis. Although atypical neurological manifestations are rare, they may occur, including encephalitis, meningitis, and Guillain-Barré syndrome. Other described manifestations include vesiculobullous lesions in children and purpuric lesions with a vascular appearance. This report aims to describe a rare case of chikungunya meningoencephalitis, initially diagnosed as purpura fulminans compatible with meningococcal disease. The case is part of a cohort approved by the HSJ ethics committee (CAAE: 52811521.7.0000.5044). A female patient, 49 years old, from the countryside of Ceará, previously diabetic, arrived at the emergency department with high fever (38.9°C), tachycardia (150 bpm), and hypotension, with a history of high fever, headache, arthralgia, nausea, and vomiting for 4 days. On physical examination, she appeared toxemic, comatose, with multiple erythematous-violaceous and petechial lesions on the upper limbs, lower limbs, and trunk, as well as a necrotic lesion on the tip of the nose (Figure 1). The cranial CT scan was normal. Cerebrospinal fluid (CSF) analysis revealed a turbid and xanthochromic appearance, with CSF glucose of 161 mg/dL (reference: ⅔ of blood glucose), CSF protein of 823.5 mg/dL, and cell count of 172 cells/mm³, with 68% neutrophils and 22% lymphocytes. Gram stain and cultures for pyogenic bacteria, fungi, and mycobacteria were negative. Multiplex PCR Filmarray® (bioMérieux, Marcy l'Étoile, France) was also negative. RT-PCR and serology for dengue, chikungunya, and zika in the CSF resulted in positive chikungunya RT-PCR and IgM serology. The patient required definitive airway management, vasoactive drugs, and intensive support, and was initially treated as meningococcemia with ceftriaxone 2g every 12 hours. After 48 hours, she developed disseminated intravascular coagulation and died. This rare case shows a fulminant course in a young patient with severe chikungunya and central nervous system manifestations, in addition to purpura. Cases like this challenge the paradigm of symptomatic but non-fatal disease and raise discussion about underreporting of deaths not investigated for arboviruses. Purpura fulminans may be the initial manifestation of bacterial diseases such as S. pneumoniae and N. meningitidis. It is crucial that the infectious disease specialist be prepared for this differential diagnosis in endemic areas.
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