The diagnosis was meningococcal septicaemia. In the top image it is clear that the organisms are diplococci. A punch biopsy of the skin showed leucocytoclastic vasculitis, microthrombi and Gram-negative cocci. There was dermal haemorrhage. Blood cultures and antigen tests for meningococcus were negative but PCR was positive for meningococcus group C.

To see more images of neutrophils containing meningococci, including a Gram stain, see a case published by Professor Bain and Dr James Uprichard, Consultant Haematologist, St George’s Hospital, London: Uprichard J and Bain BJ (2008) A young woman with sudden onset of a severe coagulation abnormality. Am J Hematol, 83, 672.

The blood film can be very important in the rapid confirmation of suspected meningococcal septicaemia.

Thank you Barbara Bain for sharing these cases with us!