When a 19-year-old student was rushed to hospital after falling critically ill, deteriorating at an astonishing rate, doctors scrambled to unravel the mystery and save his life. The only clue as to how his condition developed was a meal of leftover rice, chicken, and lo mein just 20 hours before admission to the hospital. 

What the doctors were soon to discover was this nearly fatal case of infection was a tragic symphony of unfortunate conditions, leaving him fighting for his life for almost a month. 

This case report, published in the New England Journal of Medicine in March 2021, was featured in a recent video by Youtuber and Clinical Adjunct Professor at the University of Illinois ChubbyEmu. 

 

Admission 

The student ate some leftover food – like all students do – that he and a friend had got from a restaurant the night before. Soon after, he began vomiting a red-brown fluid and faced severe abdominal pain. This developed into chills, chest pain, and shortness of breath. He began to struggle to move his neck, muscles became stiff, and his vision blurred.

Five hours before hospital admission, purplish discoloration occurred beneath his skin, looking like bruises that had no reason to be there. Concerned, his friend drove him to the hospital, while the patient sat in the car in extreme pain and almost unable to move his head. 

Once at the emergency room, the patient had high blood pressure and a pulse of 147 beats per minute, and he was breathing rapidly at around 1.5 times the normal rate.

Despite the heavy breathing and hard work of his heart, he developed hypoxemia (lack of oxygen in the blood) and was given an oxygen mask, which did little to help. General antibiotics were given in a first attempt at stemming a possible bacterial infection, but the student continued to deteriorate and his blood pressure plummeted. 

At this point, more purple rashes had spread over his limbs and he remained in a state of hypotension; his organs begin shutting down.

Around 2 hours after admission, he was flown by helicopter to a pediatric intensive care unit where they had the resources to deal with such a critical condition. 

 

Worsening condition 

 

As the patient arrived in the intensive care unit, his blood pressure was extremely low, his pulse a rapid 166 beats per minute, and his body temperature beyond a fever-like temperature of 40.8 °C (105.4 ° F). The patient was sedated, but pupil tests showed his brain was functioning.

The rashes across his arms and legs were now dark and widespread. A catheter placed to allow urine collection showed he wasn't producing urine, a sign of kidney failure.  

Doctors had differing diagnoses – the patient was young and showed no risk factors for sepsis, but symptoms suggested a systemic inflammatory response and his blood was not clotting as it should, demonstrated by the bruise-like discolorations over his body. 

The team discovered the man has thrombocytopenia (a lack of platelets in the blood that allow clotting). However, when this usually happens, destroyed platelets are expelled from the body in some manner, often through urine. The man produced no urine, so it is likely the thrombocytes remained inside the body.  

In light of the results, the patient is diagnosed with infectious purpura fulminans, a potentially fatal condition where the blood forms thromboses (blood clots) throughout the body that clog small and medium-sized blood vessels. Large vessels dilate to increase blood flow, blood pressure drops, and organs begin failing as oxygen can’t reach them, while outer extremities like the fingers and toes begin to necrotize and become gangrenous.

 

Microbial attack 

 

Confirming doctors’ suspicions, microbiological analysis of the patient’s blood pointed to the presence of Neisseria meningitidis bacteria, meaning the patient had meningococcemia (infection of the blood with meningococcus bacteria).

The infection had caused widespread blood clotting, causing multiple organ failure and shock. By this point, the patient had failure of the kidneys, lungs, and heart, just 24 hours after eating the leftovers. 

The doctors could now attack the infection with specific antibiotics known to fight meningococcal bacteria, but much of the damage was already done. With necrosed tissue and gangrene through his legs and hands, both of his legs below the knee and parts of all of his fingers had to be amputated. The patient remained in hospital under intensive care for 26 days before being discharged to another unit. 

So, how did N. meningitidis get into the man’s body, and why did someone with no history of blood disorders suddenly have a clotting emergency?

Much of this remains a mystery. The leftover food was also eaten by his roommate, who immediately threw it up before returning the leftovers to be eaten by the student. Neisseria is not a foodborne pathogen, it is spread through consistent contact with an infected person and their saliva through kissing, sneezing or other means. It is therefore possible, although extremely unlikely, that it was spread through saliva contact after the roommate contaminated the leftovers and returned it so long as the leftovers were eaten cold and not returned to the fridge, although it is more likely persistent contact with someone colonized with Neisseria transmitted the bacteria. What is more likely is that the timing of the infection directly coinciding with the leftovers is purely a coincidence.

The difference between the roommate and the student, however, was that the roommate was up-to-date on the meningitis vaccination boosters that college students usually receive, whereas the unfortunate patient had not received the two boosters. It is likely this distinction that allowed one to escape with vomiting and a troubled night's rest, while the other was left fighting for his life, although there is no way of knowing whether the roommate was the source of infection.

As for the thrombocytopenia, that is left unanswered, but it is another unfortunate factor that added together to become a life-threatening emergency.  

Check out ChubbyEmu's video below.