A 63-year-old female patient was admitted to the Hospital for Tropical Diseases, Ho Chi Minh City, Viet Nam with a four day history of fever and meningism. Abdominal pain and diarrhoea occurred on the second day, and widespread skin purpura developed on the fourth day. Although retired she had continued to prepare and sell fresh pork in the market. On admission the Glasgow Coma Scale was 13/15, there was marked neck stiffness, and widespread skin and conjunctival haemorrhages. Her index finger on the left hand and six of her toes were necrotic (Figs 1 and 2).
The CSF was cloudy with a marked increase in the protein (446 mg/dL) and white cell count (350 × 103/mL, 65% neutrophils, 35% lymphocytes). The glucose in the CSF was less than 1.0 mmol/L compared with a plasma concentration of 5.0 mmol/L. CSF lactate was markedly elevated (9.2 mmol/L). Direct examination of the CSF
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