Intended for healthcare professionals

Endgames Case report

Black and blue . . . and unconscious

BMJ 2009; 339 doi: (Published 22 July 2009) Cite this as: BMJ 2009;339:b2864
  1. Marieke van Onna, resident in internal medicine,
  2. Thomas van Bemmel, internist,
  3. Erik van Wensen, neurologist,
  4. Cees Schaar, internist-haematologist,
  5. Hein Slis, radiologist,
  6. Peter E Spronk, internist-intensivist
  1. 1Department of Intensive Care Medicine, Gelre Hospitals, 7334 DZ Apeldoorn, Netherlands
  1. Correspondence to: P E Spronk p.spronk{at}

    Case history

    A comatose 29 year old male was brought to the emergency department of our hospital. The patient was an international truck driver, and he and his co-driver had slept the night before in their truck at a car park near the motorway. The next morning, the co-driver found the patient in a comatose state in the sleep cabin of their truck. The attending neurologist observed a Glasgow coma score of four (E1-M2-V1) with fixed dilated pupils and no cornea and ocular cephalic brainstem reflexes. Furthermore, the patient had multiple petechiae on the left side of the throat and symmetrical bruises on the anterior medial side of both upper legs. Otherwise, physical investigation was unremarkable.


    • 1 What initial investigations are appropriate?

    • 2 What is the most likely diagnosis?


    Short answers

    • 1 The initial investigations should include brain computed tomography and a limited panel of laboratory tests.

    • 2 The most likely causes of coma in young patients with petechiae are meningococcal septicaemia and intracerebral haemorrhage caused by …

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