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Clinical Summary

Meningococcemia is an acute febrile illness caused by Neisseria meningitidis bacteremia characterized by its generally rapid onset, significant toxicity, and petechial rash involving the skin and mucous membranes. The petechiae progress to become palpable purpura and may coalesce to become purpura fulminans. It progresses rapidly to decompensated septic shock with hypotension and multisystem organ failure. In cases of fulminant disease, progressive shock is accompanied by disseminated intravascular coagulation and massive mucosal hemorrhages. Prodromal symptoms may include cough, coryza, headache, neck pain, and malaise. Children less than 5 years of age and college students who did not receive the meningococcal vaccine during high school are at greatest risk.

FIGURE 14.48

Meningococcemia. Diffuse petechiae and purpura in a lethal meningococcal infection. (Photo contributor: Lawrence B. Stack, MD.)

FIGURE 14.49

Meningococcemia. Diffuse petechiae in a patient with meningococcemia. (Photo contributor: Richard Strait, MD.)

FIGURE 14.50

Meningococcemia. Petechiae and purpura in an adolescent patient with meningococcemia. (Photo contributor: Kevin J. Knoop, MD, MS.)

FIGURE 14.51

Meningococcemia. Purpura are seen in this patient with meningococcemia. (Photo contributor: Lawrence B. Stack, MD.)

FIGURE 14.52

Meningococcemia. Subtle petechiae and purpura on the soles of the feet in a patient with meningococcemia. (Photo contributor: Kevin J. Knoop, MD, MS.)

FIGURE 14.53

Meningococcemia. Subtle periorbital petechiae and purpura in a patient with meningococcemia. (Photo contributor: Kevin J. Knoop, MD, MS.)

Management and Disposition

In stable patients in whom meningococcemia is in the differential diagnosis, obtain cultures of blood and spinal fluid and from the nasopharynx, along with a CBC and coagulation studies. Consider bedside screening studies (eg, blood gas to assess acid-base status), lactate, liver function tests, and other studies as clinically indicated. These patients should be admitted for intensive monitoring to institutions capable of delivering critical care services. Broad-spectrum parenteral antibiotics should be administered initially until the organism is identified and sensitivities are available as with any patient with suspected sepsis. In the unstable septic patient, support end organ perfusion and oxygenation via early goal-directed therapy. Hemodynamic monitoring and blood pressure support (fluids and vasoactive drugs) are of paramount importance. Peripheral and central venous catheters and urinary and arterial catheters are usually necessary for optimal management of these patients.

Pearls

  1. Skin scrapings of the purpuric lesion can be cultured and microscopically examined for the presence of gram-negative diplococci, although a negative result does not exclude ...

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