A 51-year-old woman, with a history of unilateral adnexectomy for endometriosis, who after 24 hours of evolution presented with fever of up to 40oC and odynophagia, which partially subsided with non-steroidal anti-inflammatory drugs (NSAIDs). Subsequently, vomiting and several diarrhoeal stools appeared, with persistence of the febrile syndrome, so she went to the health centre. After medical assessment, antipyretic treatment and home observation were prescribed. Hours later, his general condition worsened, with hypotension, and he also reported headache and dorsalgia, so the Emergency Department was notified and he was transferred to hospital. Physical examination revealed a fair general state, tachypnoea at rest and tachycardia, and blood pressure could not be detected, nor was it possible to palpate the peripheral radial pulses. There was no nuchal rigidity or neurological focality. Laboratory tests and blood gas analysis revealed marked leukocytopenia (2,440/ml) and metabolic acidosis (pH 7.21; HCO3 14 mmol/l; EB -11.1 mmol/l). The patient was admitted to the Intensive Care Unit (ICU), where, despite treatment with corticosteroids and intravenous antibiotic therapy, she worsened and died 2 hours later, after cardiopulmonary resuscitation manoeuvres. Due to the torpid evolution and the uncertain origin of the shock, death was not certified.
Autopsy findings
Significant findings on external examination included a generalised skin rash, more pronounced on the head and on the anterior face of the upper third of the thorax, and petechiae on the tarsal conjunctivae of both lower eyelids.

In the internal examination, macroscopically it is observed:
- Moderate pulmonary congestion with significant pulmonary oedema of alveolar and interstitial characteristics with bronchial foam.
- Right pleural effusion. Mild pericardial effusion.
- Exudative fluid in retromammary subcutaneous tissue on both sides, purulent appearance.
- Liver with steatotic appearance with haemorrhagic stippling.
- Both adrenal glands with congestive-hemorrhagic marrow.

- The brain had a generalised congestive and oedematous appearance, with a casual finding of a cyst in the left parietal lobe.

Samples of the brain, lung, liver, liver, spleen, adrenal glands, heart, peripheral blood, vitreous humour, pericardial fluid, intestinal contents, bronchial smear, pleural effusion and swab impregnated with subcutaneous exudate from the right pectoral muscle were submitted for toxicological, microbiological and histopathological studies.
The results of the microbiological study carried out using antigenic techniques, culture and real-time polymerase chain reaction (PCR) detected the presence of N. meningitidis serogroup C in peripheral blood, serum and, in small quantities, at the encephalic level. Epidemiological characterisation of the strain and the study of antibiotic resistance by minimum inhibitory concentration (MIC) were carried out.
Histopathological findings in the brain included congestion and oedema, as well as the existence of a transitional-psammomatous meningioma. Both adrenals showed severe haemorrhage; the liver showed signs suggestive of shock in the initial phase, and at the renal level there were alterations compatible with DIC. In addition, splenomegaly and some neutrophilic myocarditis were diagnosed.
The toxicology study showed only positive results for dipyrone or metamizole.
Based on the findings described above, the causes of death were established as multi-organ failure due to fulminant meningococcal septicaemia (N. meningitidis serogroup C) and Waterhouse-Friderichsen syndrome.