1. Clinical syndromes

1. Acute infectious-toxic syndrome
   • Hyperacute onset, temperature 40.2°C, chills, severe headache, vomiting.
2. Meningeal syndrome
   • Severe headache, repeated vomiting, marked neck stiffness, positive Kernig and Brudzinski signs.
3. Cerebral syndrome / impaired consciousness
   • Unconsciousness, suggesting severe meningoencephalitic involvement, cerebral edema, shock-related cerebral hypoperfusion, or both.
4. Hemorrhagic-purpuric syndrome
   • Large, stellate, raised hemorrhagic rash on the back and hips, characteristic of meningococcemia with vasculitis and coagulopathy.
5. Septic shock / infectious-toxic shock
   • BP 80/40 mmHg, pulse 136/min weak, cyanosis, tachypnea, coma, likely poor peripheral perfusion.
6. Disseminated intravascular coagulation (DIC), probable
   • Rapidly spreading stellate purpura in fulminant meningococcemia is highly suggestive of consumption coagulopathy.
7. Acute respiratory failure, probable
   • Respiratory rate 40/min and cyanosis. Assess oxygen saturation and arterial blood gases immediately.
8. Possible acute adrenal insufficiency due to bilateral adrenal hemorrhage
   • Consider Waterhouse-Friderichsen syndrome in fulminant meningococcemia with refractory shock and purpura.

2. Preliminary diagnosis and justification

Preliminary clinical diagnosis

Clinical justification

• Sudden onset with high fever, chills, headache, vomiting.
• Clear meningeal signs: neck rigidity, Kernig and Brudzinski signs.
• Hemorrhagic stellate purpura is highly characteristic of meningococcemia.
• Severe hypotension, tachycardia, cyanosis, altered consciousness, and tachypnea demonstrate septic shock and multiorgan hypoperfusion.
• Meningococcal disease commonly presents as meningitis and/or septicemia, and empiric treatment should include ceftriaxone or cefotaxime according to CDC clinical guidance.

3. Examination plan

Immediate bedside assessment, performed simultaneously with resuscitation

• ABCDE assessment.
• Continuous ECG, pulse oximetry, noninvasive or invasive blood pressure monitoring, respiratory rate, temperature.
• Glasgow Coma Scale, pupils, focal neurologic signs.
• Urine output through urinary catheter. Target at least 0.5 mL/kg/hour.
• Two large-bore peripheral IV lines. Obtain central and arterial access if needed, but do not delay antibiotics or vasopressors.

Microbiological investigations

• Two sets of blood cultures from different sites.
• Blood PCR for N. meningitidis, if available.
• Culture/PCR from purpuric skin lesion aspirate or biopsy, if feasible.
• Nasopharyngeal swab is not required to establish acute diagnosis and must not delay treatment.

Blood tests

• Complete blood count with differential and platelet count.
• Coagulation studies: PT/INR, aPTT, fibrinogen, D-dimer.
• Blood group and cross-match.
• Serum glucose, electrolytes, urea, creatinine, calcium, magnesium, phosphate.
• Liver function tests, bilirubin.
• Arterial blood gas with lactate.
• Serum lactate serially to assess shock response.
• C-reactive protein and/or procalcitonin.
• Blood smear if another hematologic process is considered.
• Pregnancy test in a woman of child-bearing potential, if it does not delay life-saving treatment.

Imaging and neurologic tests

• Portable chest radiograph after stabilization or post-intubation.
• Bedside ultrasound/echocardiography for volume status, cardiac function, and alternative shock causes if available.
• CT brain only after initial stabilization and before lumbar puncture because she is unconscious. CT must not delay antibiotic therapy.
• Lumbar puncture is currently contraindicated/deferred because of coma, severe shock, probable DIC/coagulopathy, and possible raised intracranial pressure. When safe, perform CSF opening pressure, cell count/differential, glucose with simultaneous serum glucose, protein, Gram stain, culture, and PCR.

4. Treatment plan

A. Immediate organization

• Transfer to ICU or resuscitation area.
• Droplet precautions immediately.
• Notify infection control and public-health authorities urgently because suspected meningococcal disease requires contact tracing and chemoprophylaxis.
• Do not delay treatment for confirmatory testing.

B. Airway and breathing

• Give high-flow oxygen.
• Because she is unconscious, cyanotic, and tachypneic, prepare for rapid-sequence endotracheal intubation and mechanical ventilation.
• Use lung-protective ventilation if ventilated.
• Obtain arterial blood gases and monitor oxygenation and ventilation.

C. Antimicrobial therapy

• Ceftriaxone 2 g IV every 12 hours, or
• Cefotaxime 2 g IV every 4-6 hours.

• Ceftriaxone 2 g IV every 12 hours plus
• Vancomycin IV, weight- and renal function-adjusted.

D. Septic-shock resuscitation

1. Crystalloid fluid
   • Give balanced crystalloid, initially about 30 mL/kg IV, rapidly, with repeated reassessment of lung findings, perfusion, bedside ultrasound, lactate, and blood pressure.
   • Avoid fluid overload, particularly if respiratory failure or pulmonary edema develops.
2. Vasopressor
   • Start norepinephrine early if hypotension persists during or after initial fluid resuscitation.
   • Titrate to maintain MAP at least 65 mmHg and adequate urine output/peripheral perfusion.
   • Add vasopressin or epinephrine if shock remains refractory, following ICU protocol.
3. Refractory shock / suspected adrenal hemorrhage
   • Give hydrocortisone 50 mg IV every 6 hours or 200 mg/day continuous infusion if shock remains vasopressor-dependent, particularly if Waterhouse-Friderichsen syndrome is suspected.
4. Serially monitor lactate, capillary refill, skin temperature, mental state, urine output, and blood pressure.

E. Management of probable DIC and purpura

• Check platelet count, fibrinogen, PT/INR, aPTT, and D-dimer repeatedly.
• Treat the underlying infection and shock first.
• Give blood components only for active bleeding, severe coagulopathy, or an invasive procedure:
  • Platelets if severe thrombocytopenia with bleeding or procedure requirement.
  • Fresh frozen plasma for bleeding with prolonged coagulation times.
  • Cryoprecipitate/fibrinogen concentrate if fibrinogen is critically low with bleeding.
• Avoid intramuscular injections and unnecessary invasive procedures.

F. Neurologic and supportive measures

• Elevate head of bed about 30 degrees, keep neck neutral.
• Avoid hypoxia, hypotension, hypercapnia, hyperthermia, hypo- or hyperglycemia.
• Treat seizures promptly with benzodiazepine followed by an antiseizure medication if needed.
• Assess for raised intracranial pressure. Hypertonic saline or mannitol may be considered only if there are clinical signs of impending herniation and under ICU guidance.
• Paracetamol for fever after resuscitation has started.
• Correct hypoglycemia, electrolyte abnormalities, and acid-base disorders.
• Start stress-ulcer and venous thromboembolism prophylaxis only when bleeding risk and DIC status permit.

G. Infection-control action for contacts

• Keep droplet precautions until the patient has received effective antimicrobial therapy for at least 24 hours.
• Identify household members, intimate contacts, and healthcare workers with unprotected exposure to respiratory secretions.
• Arrange prompt chemoprophylaxis for close contacts, ideally within 24 hours. CDC lists rifampin, ceftriaxone, and ciprofloxacin as standard options, with local resistance guidance affecting choice. CDC contact prophylaxis guidance