A 51-year-old woman with a history of unilateral adnexectomy due to a fever of up to 40 oC and odynophagia after 24 hours of evolution presented with partial endometriosis (NSAID stenosis).
Later vomiting and several diarrheal stools appear, with persistence of the febrile syndrome, so he goes to the health center.
After medical evaluation, antipyretic treatment and home observation were prescribed.
Horses later suffered a worsening of the general condition, with hypotension, also referring headache and back pain, so the emergency department is advised to decide to transfer to the hospital.
Physical examination revealed a regular general condition, tachypnea at rest and tachycardia; blood pressure could not be measured and peripheral radial pulses could not be detected either.
There is no neck stiffness or neurological focality.
Blood gas analysis revealed marked leukocyte (2,440/ml) and metabolic acidosis (pH 7,21; HCO3 14/l; EB -11,1/l).
The patient was admitted to the Intensive Care Unit (ICU), where despite receiving treatment with corticosteroids and intravenous antibiotic therapy, she worsened and died 2 hours later, after performing cardiopulmonary resuscitation maneuvers.
Due to the torpid evolution and uncertain origin of shock, death is not certified.
Autopsy findings
As significant findings, in the external examination, a generalized skin exanthema is more pronounced at the level of the anterior third of the thorax and petechiae in the tarsal conjunctiva of both lower eyelids.
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Macroscopically, the internal examination showed:
- Moderate pulmonary congestion with significant alveolar and interstitial pulmonary oedema with bronchial foaming.
- right pleural effusion.
Mild pericardial effusion.
- Exudative fluid in subcutaneous retromammary tissue on both sides, with purulent appearance.
- hemorrhagic liver disease.
- Both adrenal glands with congestive heart failure.
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- The encephalon has a generalised congestive and edematous appearance, with a casual finding of a cyst in the left parietal lobe.
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Samples of the encephalon, lung, liver, spleen, adrenals, heart, peripheral blood, vitreous humor, pericardial fluid, pleural content, right pleural swab are sent for toxicological, microbiological and histopathological studies.
The results of the microbiological study performed by antigenic techniques, culture and real-time polymerase chain reaction (PCR) detect the presence of N. meningitidis serogroup C in peripheral blood, serum and sera.
The epidemiological characterization of the strain and the study of antibiotic resistance by minimum inhibitory concentration (MIC) were performed.
Histopathological findings are described as encephalon congestion and edema, as well as the existence of a transitional-psamomatous meningioma.
Both adrenal glands present severe hemorrhage; the liver shows signs suggestive of shock in the initial phase, and renal alterations compatible with ICD.
In addition, it is diagnosed as idiopathic dilated cardiomyopathy and certain neutrophilic myocarditis.
The toxicological study shows only positive result for metamizole.
Selected in the described findings are established as causes of death: multiorgan failure produced by septicemia fulminant by meningococci (N. meningitidis serogroup C) and Watersenhouse syndrome
