What are the symptoms and treatment of meningocococcemia?

Meningococcemia: Symptoms and Treatment

Meningococcemia is a life-threatening medical emergency characterized by fever, petechial or purpuric rash, and signs of sepsis, requiring immediate antibiotic treatment and intensive supportive care to reduce mortality.

Clinical Presentation

Early Symptoms

• Initial presentation includes non-specific symptoms such as fever, lethargy, irritability, nausea, and poor feeding, which can be difficult to distinguish from self-limiting viral illnesses 1
• Early symptoms may include leg pain, cold extremities, and abnormal skin color 1
• Arthralgias, myalgias, and abdominal pain may be present as prodromal symptoms 2

Classic Symptoms

• Fever is present in most cases 1
• Petechial or purpuric rash is strongly suggestive of meningococcal septicemia and requires urgent treatment 1
• Signs of shock including hypotension, poor capillary refill time, and tachycardia 1, 2
• Severe prostration and rapid clinical deterioration 2

Important Clinical Distinction

• Meningococcal disease can present as:
  • Meningitis (fever, vomiting, headache, neck stiffness, photophobia) 1
  • Septicemia (fever, petechial or purpuric rash, shock) 1
  • Mixed picture of both meningitis and septicemia 1
• Only 63% of patients with meningococcal meningitis have a rash, while 92% of those with a rash in the context of meningitis have meningococcal disease 1

Complications

• Disseminated intravascular coagulation (DIC) 2, 3
• Multiple organ failure 3
• Myocarditis with ECG abnormalities 2
• Peripheral gangrene requiring surgical intervention 2
• Splenic infarction and pulmonary thromboembolism 4

Diagnosis

Immediate Actions

• Blood cultures should be taken as soon as possible and within 1 hour of hospital arrival 1
• In suspected meningitis without shock, lumbar puncture (LP) should be performed within 1 hour if safe to do so 1
• In patients with sepsis or rapidly evolving rash, antibiotics should be given immediately after blood cultures are taken 1

Diagnostic Tests

• Blood cultures are essential for diagnosis 1, 3
• Cerebrospinal fluid (CSF) analysis if meningitis is suspected 3
• Skin biopsy cultures may be helpful 3
• Gram stain may show gram-negative diplococci 2

Contraindications to Immediate LP

• Focal neurological signs 1
• Presence of papilledema 1
• Continuous or uncontrolled seizures 1
• Glasgow Coma Scale (GCS) ≤ 12 1

Treatment

Immediate Management

• Administer parenteral antibiotics as soon as meningococcal disease is suspected 1
• For adults, ceftriaxone is the recommended antibiotic (1-2 grams given once daily or in equally divided doses twice a day) 5
• In patients with sepsis, fluid resuscitation should begin immediately with an initial bolus of 500 ml of crystalloid 1
• For children with meningococcal disease, the recommended total daily dose is 100 mg/kg/day (not to exceed 4 grams daily) for meningitis 5

Intensive Care Management

• Monitor for therapeutic endpoints in septic shock including:
  • Capillary refill time less than 2 seconds 1
  • Normal blood pressure (in adults > 65 mmHg mean BP) 1
  • Urine output >0.5 ml/kg/hour 1
  • Lactate < 2 mmol/L 1
• Patients with progressive disease should be transferred to intensive care 1
• Ventilatory support may be necessary for patients with fluid-resistant shock 1
• Vasopressors may be required if shock does not respond to initial fluid challenges 1

Adjunctive Therapy

• Corticosteroids (dexamethasone 0.15 mg/kg every six hours) are recommended for confirmed meningococcal meningitis but not for meningococcal septicemia 1
• Treatment duration is typically 7 days for meningococcemia 5

Prevention of Secondary Transmission

• Chemoprophylaxis should be offered to close contacts who had prolonged contact in a household setting within 7 days before onset of illness 1
• Close contacts include household members, dormitory roommates, boyfriends/girlfriends, and those whose mouth or nose has come into close contact with the patient's respiratory secretions 1
• Effective prophylactic antibiotics include ciprofloxacin, rifampin, and ceftriaxone 1
• Meningococcal vaccination should be offered before discharge from hospital 1

Follow-up Care

• All patients should be assessed for potential long-term sequelae before discharge 1
• Hearing tests should be performed if hearing may have been affected 1
• Monitor for neurological complications, including cognitive deficits and learning impairment 1
• Watch for potential post-traumatic stress disorder in both patients and their families 1
• Follow-up care is important as many issues may only become apparent after discharge 1

Pitfalls and Caveats

• The classic triad of neck stiffness, fever, and altered consciousness is present in less than 50% of bacterial meningitis cases 1
• Kernig's and Brudzinski's signs are not reliable for diagnosis and should not be relied upon 1
• Meningococcal disease can progress rapidly, with most deaths occurring within the first 24 hours 2
• Elderly patients may present atypically with altered mental status rather than fever or neck stiffness 1
• Antibiotic treatment should not be delayed for neuroimaging or LP in suspected cases 1