A49-19 A Clue in Plain Sight: Purpura Fulminans in Fatal Invasive Meningococcal Disease

Abstract Introduction Invasive meningococcal disease (IMD) is rare in the US, with most cases involving young children and adolescents. We report a fatal case involving a 79-year-old female with purpura fulminans, highlighting its severity in the elderly. Case Description A 79-year-old female with a past medical history of coronary artery disease, recent percutaneous coronary intervention, heart failure with severely reduced ejection fraction, atrial fibrillation, and chronic lower extremity wounds presented to the emergency department for dyspnea and leg pain. She was found to be hypotensive, hypoxic requiring escalation of O2 support to BPAP, and was in atrial fibrillation with RVR. Initial laboratory evaluation revealed leukocytosis 12.65 K, hemoglobin of 6.5, procalcitonin of 2.23, acute kidney injury, BNP of 27,466, and troponin of 165. She was diagnosed with mixed septic and cardiogenic shock, with purulent lower extremity wounds being the presumed septic source. She received intravenous vancomycin and piperacillin-tazobactam, and intravenous diuretics. Unfortunately, she continued to decompensate, requiring a norepinephrine infusion. She was admitted to the ICU and hours later, she experienced a ventricular fibrillation arrest. Return of spontaneous circulation was attained. Her examination at that time showed a faint petechial rash, with retrospective concern for purpura fulminans. Vasopressor support continued to escalate, but despite these measures, she remained hypotensive, became bradycardic, and experienced recurrence of cardiac arrest. Just 90 minutes after her death, blood cultures resulted with growth of Neisseria meningitidis. Discussion N. meningitidis is a gram-negative diplococcus that causes IMD when it invades the CSF or blood. In adults, especially the elderly, IMD is rare, and comorbidities like heart failure can often obscure diagnosis and delay treatment. Purpura fulminans, a hallmark of meningococcal sepsis, can present as hemorrhagic purpuric or petechial lesions and is a signal of severe sepsis. In this case, purpura fulminans was a critical clue that could have prompted suspicion of IMD, despite atypical symptoms. This case underscores the importance of quick identification of purpura fulminans and to utilize it as a diagnostic tool to narrow diagnosis and ensure early treatment. This abstract is funded by: None