Case Study #4
An 18-year-old Caucasian college student comes to the ER with a chief complaint of a headache and skin
rash. The patient reported having a sore throat within the past week. One day prior to admission, he
experienced nausea and vomiting. On the day of admission, while attending class, he noticed “spots” on
his arms, legs, trunk, and abdomen. Shortly before his presentation to the emergency department, he
developed fatigue, headache, neck pain, and photophobia. The patient had no history of abdominal
pain, tick bites, sick contacts, sexually transmitted diseases, or recent travel. The patient received
quadravalent Neisseria meningitidis vaccination at the County Health Department 6 months prior to his
admission. Physical Exam Vital signs: temperature, 98.2 °F; heart rate, 114 beats per minute; respiratory
rate, 24 per minute; blood pressure, 88/34 mm Hg. Pertinent physical exam findings included
tachycardia, hypotension, and purpuric lesions on his arms, legs, trunk, and genitals . He was acutely ill
in appearance, but oriented with nuchal rigidity on neurologic exam (positive Brudzynski and Kernig
signs). Principal laboratory findings at presentation (Table 1). Additional diagnostic results were
echocardiography revealed mild left ventricular enlargement with decreased function [estimated
ejection fraction = 30% (Normal >60%)]. A chest x-ray demonstrated pulmonary edema.
Principal Laboratory Findings Test Patient’s Result “Normal” Reference Interval Hematology WBC Count
5.4 4.5-11.0 x109/L 28.4 (24 hours) 46.7 (48 hours) RBC 3.51 4.50-5.90 x1012/L Hgb 11.6 Hct 33.0 41.053.0% MCV 94 80-100 fL Platelets 87 150-440 x109/L 67 (24 hours) 46 (48 hours) Chemistry Sodium 136
135-145 mmol/L Potassium 4.1 3.5-5.0 mmol/L Chloride 104 98-107 mmol/L CO2 22 22-30 mmol/L BUN
19 7-21 mg/dL 36 (24 hours) Creatinine 2.7 0.8-1.4 mg/dL Calcium 7.0 8.5-10.2 mg/dL Magnesium 1.0
1.6-2.2 mg/dL Phosphorus 1.4 2.4-4.5 mg/dL AST 51 15-45 U/L 673 (24 hours) ALT 48 484 (24 hours) 1040 U/L ALP 126 65-260 U/L GGT 45 13-68 U/L CK 181 70-185 U/L CK-MB 1.2 0.0-6.0 ng/ml Lactate
Dehydrogenase 874 340-670 U/L Troponin T. Gram stain shows a Gram negative intracellular diplococci.
1) What are this patient’s most striking clinical and laboratory findings?
2) How do you explain this patient’s most striking clinical and laboratory findings?
3) What condition(s) is (are) suggested by this patient’s most striking clinical and laboratory
findings?
4) What additional test(s) should be ordered on this patient and why?
5)
What is this patient’s most likely diagnosis?
6) 6. How is this patient’s condition typically treated?