What is the diagnosis and treatment of meningococcemia?

Diagnosis and Treatment of Meningococcemia

Diagnosis

Meningococcemia should be suspected in any patient presenting with acute fever, hypotension, and petechial or purpuric rash, even without meningeal signs. 1, 2

Clinical Presentation

The classic triad of fever, neck stiffness, and altered mental status is present in only 41-51% of bacterial meningitis cases, and characteristic signs may be entirely absent. 1

Key clinical features to identify:

• Fever (>38°C) - present in 77-97% of cases 1
• Petechial or purpuric rash - identified in 20-52% of patients and indicative of meningococcal infection in over 90% of cases 1
• Hypotension and tachycardia - often present early, with patients maintaining blood pressure until late in disease before rapid deterioration 1, 3
• Headache - present in 58-87% of cases 1
• Altered mental status - present in 54-69% of cases 1
• Neck stiffness - present in only 65-83% of cases, with low sensitivity (31%) for CSF pleocytosis 1

Critical Diagnostic Pitfall

Early symptoms frequently mimic benign viral illness with nonspecific prodrome including arthralgias, myalgias, and abdominal pain, potentially delaying treatment with serious consequences. 2, 3 Kernig and Brudzinski signs have poor sensitivity (11% and 9% respectively) and cannot exclude bacterial meningitis. 1

Diagnostic Testing

The gold standard is bacteriologic isolation of Neisseria meningitidis from blood, CSF, synovial fluid, or pleural fluid. 4

Recommended diagnostic approach:

• Blood cultures - positive in 40-60% of meningococcal cases, though yield decreases by 20% with prior antibiotics 1
• CSF culture - positive in 60-90% of bacterial meningitis cases, with 10-20% reduction after antibiotic pretreatment 1
• CSF Gram stain - demonstrates Gram-negative diplococci with excellent specificity but variable sensitivity 1
• PCR of peripheral blood - 100% sensitivity and specificity for confirmed meningococcal disease, unaffected by prior antibiotic treatment 5
• Skin biopsy cultures - useful when petechial/purpuric rash present 4

CSF examination should be performed unless contraindications exist, as bacterial meningitis can present with nonspecific symptoms alone. 1

Treatment

Immediate empiric antibiotic therapy should be initiated within one hour of clinical suspicion, ideally before or simultaneously with diagnostic lumbar puncture. 1, 2

Empiric Antibiotic Therapy

For adults <60 years with suspected meningococcemia:

• Ceftriaxone 2g IV every 12 hours OR
• Cefotaxime 2g IV every 6 hours 1, 6
• Alternative: Chloramphenicol 25 mg/kg every 6 hours if cephalosporin allergy 1

For adults ≥60 years, add Amoxicillin 2g IV every 4 hours to cover Listeria monocytogenes. 1, 6

If penicillin-resistant pneumococci suspected (recent travel to high-resistance areas), add Vancomycin 15-20 mg/kg IV twice daily OR Rifampicin 600mg twice daily. 1, 6

Confirmed Meningococcal Disease Treatment

Once meningococcal infection confirmed:

• Continue Ceftriaxone 2g IV every 12 hours OR Cefotaxime 2g IV every 6 hours 1, 6
• Alternative: Benzylpenicillin 2.4g IV every 4 hours for susceptible organisms 1, 7
• Treatment duration: 5 days for patients who have recovered 1

For patients not treated with ceftriaxone, give single dose of Ciprofloxacin 500mg orally to eliminate nasopharyngeal carriage. 1

Adjunctive Corticosteroid Therapy

Dexamethasone 10mg IV every 6 hours should be started on admission, either shortly before or simultaneously with antibiotics. 1

• If antibiotics already commenced, dexamethasone should still be initiated up to 12 hours after first antibiotic dose 1
• Continue for 4 days if pneumococcal meningitis confirmed or probable 1
• Stop if meningococcal or other cause confirmed 1

Critical Care Management

Intensive care involvement is mandatory for patients with:

• Rapidly evolving rash 1
• GCS ≤12 (or drop >2 points) 1
• Evidence of limb ischemia 1
• Cardiovascular instability 1
• Hypoxia or respiratory compromise 1
• Frequent seizures 1

Intubation should be strongly considered for GCS <12. 1 Patients require aggressive fluid resuscitation, vasopressor support, and management according to surviving sepsis guidelines. 1, 2

Infection Control

Droplet precautions and respiratory isolation required until 24 hours of effective antibiotic therapy (ceftriaxone) or single dose of ciprofloxacin completed. 1

Healthcare worker chemoprophylaxis only indicated for close contact with respiratory secretions (e.g., intubation without mask). 1

All close contacts of confirmed cases require chemoprophylaxis regardless of immunization status. 2, 8

Common Complications Requiring Monitoring

• Disseminated intravascular coagulation (DIC) 4
• Multiple organ failure 4
• Myocarditis with ECG/echocardiographic changes 3
• Peripheral gangrene requiring surgical intervention 3
• Hearing loss - requires testing before discharge or within 4 weeks 1
• Cognitive deficits and neurological sequelae 1