So , it is necessary to prevent the disease by cutting the route of transmission, proper vaccination and chemoprophylaxis of close contacts especially in rural areas. == Conclusion == This case report highlights the rarity of atypical presentation. were: pulse rate 110/minutes regular and brachial blood pressure in both arms 118/80mmHg. Examination of central NVS-CRF38 nervous system revealed that patient was drowsy with Glasgow Coma Scale (GCS) of 11 (E3V3M5). Signs of meningeal irritations were present with bilateral extensor planter reflex. Bilateral pupils were equal and reactive to light. Rest of the systemic examinations were normal. There was no history of smoking, diabetes, hypertension, trauma, seizure, vasculitis, drug intake, heart disease and previous similar illness. == [Table/Fig-1, 2]: == Dry NVS-CRF38 gangrene of both hands and feet. Laboratory tests showed Hb-14. 1gm/dl, total leucocyte count of 13200/mm3with predominant neutrophils, platelet count 140000/mm3, random blood sugar 104mg/dl, serum Na+137mEq/L, serum K+4. 4mEq/L, blood urea 50mg/dl and serum creatinine 1 . 1mg/dl. His liver function test was mildly deranged (alanine aminotransferase; SGPT 60 U/L, aspartate aminotransferase; SGOT 65U/L and alkaline phosphatase; SALP 150U/L). Erthyrocyte Sedimentation Rate (ESR) by Westergreen method was 17mm/hr. Serology for hepatitis A, B, C and ELISA for HIV were negative. Serum Antinuclear Antibody (ANA) test was negative. Blood culture showed growth of meningococci. Lumbar puncture was performed and Cerebrospinal Fluid (CSF) was suggestive of bacterial meningitis (turbid, total cell count 600/mm3with neutrophils predominant, protein 48mg/dl and sugar 15mg/dl). CSF culture was sterile. Doppler study of four limbs showed minimal/absent flow in small peripheral arteries of hands and feet. Rapid card test and smear for malaria parasite were negative. Bilateral fundus examination was normal. Chest X-ray and ultrasonography of abdomen were normal. On the basis of clinical and laboratory findings, the standard protocol for management of meningococcal meningitis was started. He was given intravenous ceftriaxone 2gm 12 hourly for one week with adequate fluid resuscitation and supportive management. Necrotic tissues of digits were P85B amputated in our surgical department. He responded well and was discharged on the 13thday of hospitalization. He was alright on OPD follow-up of three months. == Discussion == Neisseria meningitidisis a heterotrophic gram negative aerobic diplococcal bacterium. There are total 13 identified serotypes (A to L), while only 5 serotypes namely A, B, C, Y and W-135 are known to cause major invasive disease. It is estimated that about 5. 2 cases per 100000 population are affected each year worldwide, while 10% individuals die. Generally, invasive meningococcal infection presented as meningitis or septicemia or combination of both and rashes are commonly associated with disease [1]. Meningococcemia is rarely reported without rashes [2]. On reviewing literature, unusual association with meningococcal infection was found whereas no other case of meningococcal meningitis presented with early vascular involvement without development of rashes was found [3]. Though meningitis and meningococcal septicemia are common clinical presentations but it may also manifest as pneumonia, purulent pericarditis, pyogenic arthritis or osteomyelitis, endophthalmitis, conjunctivitis, primary peritonitis and urethritis. Lipopolysaccharide is an endotoxin which is a component of meningococcal cell wall [1]. The pathophysiology of meningococcemia involves direct bacterial toxicity, cytokine release, ischemia, vasculitis and oedema. Meningococcal septicemia has more aggressive course and it is associated with NVS-CRF38 high mortality [1, 4, 5]. Eventhough, death due to fulminant meningococcemia may occur within hours of the first symptoms. Rashes are developed in more than 80% cases of meningococcal disease. These rashes develop as a result of occlusion of small vessels by antigen antibody interaction in the dermis of NVS-CRF38 skin. Rash may be absent during early phase of illness or in overwhelming sepsis [1]. It is often suspected on the basis of clinical presentations and diagnosis is confirmed by blood culture. Once endothelial injury occurred, it results in platelet-release reactions, local vasoconstriction and platelet plugs formation which leads to intravascular thrombosis. Severe thrombosis in the microvasculature of the skin may present in meningococcemia which often occurred in glove-and-stocking pattern that can necessitate amputation of digits or limbs [6]. Neisseria meningitidisis the second most common cause of community acquired bacterial meningitis in adults. It remains a major health problem especially in developing countries [7]. So , it is necessary to prevent the disease.
So , it is necessary to prevent the disease by cutting the route of transmission, proper vaccination and chemoprophylaxis of close contacts especially in rural areas
