A 30-year-old man presents with fever, severe headache, and neck stiffness. LP shows WBC 2,200 cells/mm³ (90% neutrophils), protein 180 mg/dL, glucose 28 mg/dL (serum glucose 90 mg/dL). Gram stain shows gram-negative diplococci. Which finding is MOST likely on examination and indicates POOR prognosis?

• A Petechiae and purpuric rash with haemodynamic instability ✓
• B Kernig's sign positive
• C Papilloedema on fundoscopy
• D Photophobia and phonophobia

Explanation

Gram-negative diplococci indicates Neisseria meningitidis. Meningococcaemia with purpuric/petechial rash and haemodynamic instability (septic shock) indicates disseminated intravascular coagulation and Waterhouse-Friderichsen syndrome, carrying very high mortality (>50%). Kernig's sign is a meningeal sign present in most bacterial meningitis but does not specifically predict poor prognosis. Papilloedema is a contraindication to LP but not prognostically worse per se. Photophobia is a non-specific meningeal irritation sign.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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