Saskatchewan Northern Health Authorities, Saskatchewan Correspondence and reprints: Dr James Irvine, Population Health Unit, Athabasca Health Authority, Keewatin Yatthé Health Region and Mamawetan Churchill River Health Region, Box 6000, LaRonge, Saskatch

A 51-year-old Aboriginal woman from northern Saskatchewan presented to a local family medical clinic in early October 2006 with a three-day history of left knee pain. Her vital signs included a blood pressure of 114/70 mmHg, a heart rate of 100 beats/min and a respiratory rate of 20 breaths/min. Her temperature was not documented. On examination, her knee was warm and painful, and an effusion was noted. Approximately six weeks prior, she had fallen on her right knee while walking. This injury was complicated by hemarthrosis and effusion, requiring needle drainage on two occasions. In addition, she had a history of pain, swelling and erythema involving her shoulder joint. Her past history was significant for alcohol abuse and unstable social and housing conditions. The laboratory results showed the followingwhite blood cell (WBC) count 9.8×10 9 /L (normal 0.2×10 9 /L to 10×10 9 /L); granulocyte count 8.8×10 9 /L (normal 2×10 9 /L to 7.8×10 9 /L); hemoglobin (Hb) level 102 g/L (normal 120 g/L to 180 g/L) and platelet count 68×10 9 /L (normal 150×10 9 /L to 450×10 9 /L). A presumptive diagnosis of inflammatory arthritis was made, and she was given indomethacin 50 mg three times a day for her symptoms. Two days later, the patient became progressively more confused, disoriented and unresponsive to questions. She was brought by ambulance to the local emergency department where her temperature was 38.8°C, pulse 98 beats/min, blood pressure 140/83 mmHg and respiratory rate 32 breaths/min. Her Glasgow coma scale score was 6. She was unresponsive to verbal commands but responsive to painful stimuli. Bruising was noted on both legs, and a large area of erythema was noted around the left knee. Her respiratory examination was unremarkable. Laboratory results showed the following -WBC count 3. 135 U/L) and creatine kinase isoenzyme -MB level 28 U/L (normal 0 U/L to 16 U/L). An evolving neurological condition was thought to be the primary diagnosis. Initial management included intravenous fluid (200 mL/h), cefotaxime 2 g administered intravenously, and blood cultures. She was transferred by air to the Royal University Hospital in Saskatoon, Saskatchewan. During the 1 h flight to Saskatoon, the area of erythema on her left leg tripled in size, and 3 L of intravenous fluids and dopamine were required to stabilize her blood pressure. On arrival, she was noted to be diffusely rigid with no response to painful stimuli. Her temperature was 39°C. She had rigors, peripheral mottling, absence of peripheral pulses, bronchial breath sounds over the right middle lobe, and erythema and target-like lesions over her left knee. Laboratory evaluation on admission showed the following -WBC count 3.