72 Emerg Med J January 2021 Vol 38 No 1

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Diagnosis from the blood film

CliniCal introDuCtionA 51- year- old woman was transferred to the emergency depart-ment with fever, malaise and abdominal pain, all of which had started 12 hours earlier. Her medical history was unremarkable.

On arrival, she was alert, febrile (38.3°C) and hypotensive (87/55 mm Hg). She had several petechiae on her face. Exam-ination of the abdomen revealed mild diffuse tenderness without rebound. There was no meningismus. Blood tests showed leuco-cytosis (11.6×109/L), thrombocytopenia (4×109/L) and coagu-lation disturbances (INR 3.66, PTT 125.84 s, fibrinogen 0.6 g/L, D dimers 33 964 mg/L). An image of the peripheral- blood film is shown in figure 1.

QuestionWhat is the most likely diagnosis?1. Acute promyelocytic leukaemia.

2. Thrombotic thrombocytopenic purpura.3. Fulminant meningococcaemia.4. Human granulocytic anaplasmosis.

For answer see page 84

Figure 1 Peripheral blood film stained with May- Grünwald- Giemsa stain (×1000 magnification).

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84 Emerg Med J January 2021 Vol 38 No 1

Letter

IMAGE CHALLENGE

Diagnosis from the blood film

For question see page 72

ANSWER: CThe coagulation abnormalities indicate disseminated intravascular coagulation (DIC). The blood film shows neutrophils with intracel-lular, coffee bean shaped diplococci, thrombocytopenia, and sporadic schistocytes (figure 2). No cells with Auer rods are present charac-teristic of acute promyelocytic leukaemia; thrombotic thrombocyto-penic purpura is not associated with DIC; and anaplasmosis typically presents with neutropenia and mulberry- like intraleucocytic inclu-sions (morulae). Gram’s staining of the blood film revealed intracel-lular gram- negative diplococci (figure 3). The clinical presentation of this fulminant illness, combined with the presence of organisms with this morphological pattern, is suggestive of fulminant meningococ-caemia (FM). The patient was started on ceftriaxone, and transferred to the ICU. Neisseria meningitidis was isolated from blood cultures 3 days later, confirming our diagnosis. Peripheral gangrene, renal insufficiency, and secondary infections complicated her course and, sadly, she died after a prolonged hospitalisation.

FM is characterised by the sudden appearance of fever and a petechial or purpuric rash which may progress to purpura fulmi-nans and is often accompanied by DIC and shock.1 The lack of meningeal signs does not argue against this diagnosis as meningitis is typically not present in these patients.2

The crucial challenge of recognising meningococcaemia is that its symptoms may be difficult to distinguish from those of more common but less serious illnesses.3 Modern technology has revo-lutionised medical diagnosis but in some cases of purpuric sepsis a blood film may establish the diagnosis more promptly than is possible by any other means—a conclusion worth emphasising.

Konstantinos Marousis ,1 Vasileios Asmanidis,1 Konstantinos Liapis2

1Department of Internal Medicine, Peripheral General Hospital Athens Giorgos Gennimatas, Athens, Greece2Clinical Haematology, Peripheral General Hospital Athens Giorgos Gennimatas, Athens, Greece

Correspondence to Dr Konstantinos Marousis, Department of Internal Medicine, Georgios Gennimatas Hospital, Athina 115 27, Greece; kapamar88@ gmail. com

Contributors All authors were involved in the diagnosis and care of the patient. All authors have contributed to the writing of the manuscript. All authors agree to the submission of this article to the Emergency Medicine Journal.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not- for- profit sectors.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Patient consent for publication Next of kin consent obtained.

Provenance and peer review Not commissioned; internally peer reviewed.

© Author(s) (or their employer(s)) 2021. No commercial re- use. See rights and permissions. Published by BMJ.

To cite Marousis K, Asmanidis V, Liapis K. Emerg Med J 2021;38:84.

Accepted 4 March 2020

Emerg Med J 2021;38:84.doi:10.1136/emermed-2020-209536

ORCID iDKonstantinos Marousis http:// orcid. org/ 0000- 0002- 0277- 0805

REFERENCES 1 Stephens DS, Greenwood B, Brandtzaeg P. Epidemic meningitis, meningococcaemia,

and Neisseria meningitidis. The Lancet 2007;369:2196–210. 2 van Deuren M, Brandtzaeg P, van der Meer JWM. Update on meningococcal disease with

emphasis on pathogenesis and clinical management. Clin Microbiol Rev 2000;13:144–66. 3 McGill F, Heyderman RS, Michael BD, et al. The UK joint specialist societies guideline

on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect 2016;72:405–38.

Figure 2 Peripheral blood film showing vacuolated neutrophils, some of which contain intracytoplasmic blue- staining inclusions with a coffee- bean shape (arrows), thrombocytopenia, and sporadic fragmented erythrocytes (schistocytes) consistent with DIC (arrowhead).

Figure 3 Gram’s staining of the peripheral blood film showing intracellular gram- negative diplococci (arrow).

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