eMedicine Specialties > Dermatology > Bacterial Infections

Meningococcemia: Follow-up

Author: Elizabeth L Tanzi, MD, Co-Director, Laser Surgery, Washington Institute of Dermatologic Laser Surgery
Coauthor(s): Nanette Silverberg, MD, Assistant Clinical Professor, Department of Dermatology, Columbia University School of Medicine; Director of Pediatric Dermatology, Department of Dermatology, St Luke's Roosevelt Hospital Center, Maimonides Medical Center and Beth Israel Medical Center
Contributor Information and Disclosures

Updated: Sep 11, 2009

Follow-up

Deterrence/Prevention

  • Vaccines have been developed that consist of purified capsular polysaccharide.
    • The currently available quadrivalent vaccine contains polysaccharide from serogroups A, C, Y, and W-135. This vaccine is recommended for military personnel and patients younger than 2 years with terminal complement deficiencies or anatomic or functional asplenia. Since the start of vaccination against serogroup C, the prevalence of this disease has decreased.
    • The development of an effective serogroup B vaccine is ongoing. A vaccine that combines meningococcal serogroups B and C is under development.15
    • Routine vaccination of civilians with the quadrivalent meningococcal vaccine is not recommended because of its relative ineffectiveness in children younger than 2 years and its relatively short duration of action (approximately 3 y).
  • Antimicrobial chemoprophylaxis is recommended for close contacts of patients with meningococcal disease and is the primary means of prevention in the United States.
    • Close contacts include household members, day care center classmates, and anyone exposed to the patient's respiratory secretions.
    • Institute antimicrobial chemoprophylaxis as soon as possible because the rate of secondary disease is highest in the first few days after the onset of disease in the index case.
    • Current adult recommendations include rifampin at 600 mg orally twice daily for 2 days.
    • In addition to rifampin, other antimicrobial agents are effective in reducing nasopharyngeal colonization with N meningitidis.
      • Ciprofloxacin and ofloxacin are effective single-dose oral substitutes.
      • Ceftriaxone is available for parenteral single-dose use in children and adults.
      • These medications achieve adequate concentrations in upper respiratory tract secretions and are reasonable alternatives to the multidose rifampin regimen for chemoprophylaxis.

Complications

  • Complications of meningococcemia may occur at the time of acute disease or during the recovery phase.
  • Meningococcal arthritis occurs with acute bacteremia in up to 10% of adult cases.
  • Up to 5% of patients develop a nonpurulent pericarditis with substernal chest pain and dyspnea approximately 1 week after the onset of illness. Involvement of the pericardium in meningococcal disease is a well-recognized but rare complication. It has been described with N meningitidis serotypes C, B, W135, and Y.16
  • Neurologic complications (including peripheral neuropathy) have also been documented.
  • Long-term complications in patients who survive fulminant meningococcemia are related to permanent musculoskeletal sequelae.
  • Amputation may be required for extensive tissue necrosis of the limbs.

Prognosis

  • Several investigators have identified unfavorable prognostic features in patients with meningococcemia using clinical and laboratory parameters at the time of hospitalization.
  • A mortality rate of 40-80% is associated with the acute onset of petechiae less than 12 hours before admission, shock, coma, high fever, low peripheral leukocyte count, thrombocytopenia, high serum antigen titer, absence of meningitis, metabolic acidosis, and disseminated intravascular coagulation (DIC).
  • Cases of fulminant meningococcemia can also be associated with the complication of massive adrenal hemorrhage (Waterhouse-Friderichsen syndrome). In these cases, the mortality rate is close to 100%.

Patient Education

Miscellaneous

Special Concerns

  • Chronic meningococcemia is a rare (<200 documented cases) clinical presentation of N meningitidis most often observed in adults.
    • Rare case reports associate chronic meningococcemia with the absence of a terminal component of complement. Clinically, it can be confused with the dermatitis-arthritis syndrome associated with subacute gonococcemia. The presentation is that of recurrent attacks of fever associated with migratory arthralgias, arthritis, and leukocytosis. These attacks may recur over a period of 6-8 months. Cutaneous manifestations are variable and include rose-colored macules and papules, indurated nodules, petechiae, purpura, or large hemorrhagic areas.
    • The diagnosis of chronic meningococcemia is confirmed with identification of N meningitidis from blood cultures. The blood culture should be performed during febrile episodes to ensure a correct diagnosis. Multiple cultures are often necessary to confirm bacteremia because of the high rate of false-negative test results. Alternatively, a novel N meningitidis –specific polymerase chain reaction assay performed on skin biopsy specimens may prove to be helpful for this diagnostic challenge.17
    • Chronic meningococcemia differs histopathologically from acute meningococcemia in that no bacteria are present, thrombi do not occlude capillaries and venules, and endothelial swelling does not occur. The most common finding in a person with chronic meningococcemia is a leukocytoclastic angiitis.
    • The course of chronic meningococcemia is as variable as the cutaneous findings. Patients may recover spontaneously or progress to systemic complications such as meningitis. The prognosis for treated patients is excellent, with a cure rate of nearly 100% with appropriate antibiotic therapy. Penicillin G at 6-12 million U/d in divided doses for a minimum of 7 days is effective therapy.
 


More on Meningococcemia

Overview: Meningococcemia
Differential Diagnoses & Workup: Meningococcemia
Treatment & Medication: Meningococcemia
Follow-up: Meningococcemia
References
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References

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  2. Razminia M, Salem Y, Elbzour M, Teves D, Deshmukh H, Khosla S. Importance of early diagnosis and therapy of acute meningococcal myocarditis: a case report with review of literature. Am J Ther. May-Jun 2005;12(3):269-71. [Medline].

  3. Jarva H, Ram S, Vogel U, Blom AM, Meri S. Binding of the complement inhibitor C4bp to serogroup B Neisseria meningitidis. J Immunol. May 15 2005;174(10):6299-307. [Medline].

  4. Nkosi J, Thakrar A, Kumar K, et al. Meningococcal serotype Y myopericarditis. Diagn Microbiol Infect Dis. Feb 2009;63(2):223-7. [Medline].

  5. Endler G, Marculescu R, Starkl P, et al. Polymorphisms in the interleukin-1 gene cluster in children and young adults with systemic meningococcemia. Clin Chem. Mar 2006;52(3):511-4. [Medline].

  6. Tuncer AM, Gur I, Ertem U, et al. Once daily ceftriaxone for meningococcemia and meningococcal meningitis. Pediatr Infect Dis J. Oct 1988;7(10):711-3. [Medline].

  7. Aiuto LT, Barone SR, Cohen PS, Boxer RA. Recombinant tissue plasminogen activator restores perfusion in meningococcal purpura fulminans. Crit Care Med. Jun 1997;25(6):1079-82. [Medline].

  8. Rivard GE, David M, Farrell C, Schwarz HP. Treatment of purpura fulminans in meningococcemia with protein C concentrate. J Pediatr. Apr 1995;126(4):646-52. [Medline].

  9. [Guideline] American Academy of Pediatrics Committee on Infectious Diseases. Prevention and control of meningococcal disease: recommendations for use of meningococcal vaccines in pediatric patients. Pediatrics. Aug 2005;116(2):496-505. [Medline].

  10. [Guideline] Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices. Revised recommendations of the Advisory Committee on Immunization Practices to Vaccinate all Persons Aged 11-18 Years with Meningococcal Conjugate Vaccine. MMWR Morb Mortal Wkly Rep. Aug 10 2007;56(31):794-5. [Medline].

  11. [Guideline] Scottish Intercollegiate Guidelines Network (SIGN). Management of invasive meningococcal disease in children and young people. A national clinical guideline. National Guidelines Clearinghouse. May 2008.

  12. Herrera R, Hobar PC, Ginsburg CM. Surgical intervention for the complications of meningococcal-induced purpura fulminans. Pediatr Infect Dis J. Aug 1994;13(8):734-7. [Medline].

  13. Besner GE, Klamar JE. Integra Artificial Skin as a useful adjunct in the treatment of purpura fulminans. J Burn Care Rehabil. Jul-Aug 1998;19(4):324-9. [Medline].

  14. Faibis S, Widmer R, Sapir S, Peretz B, Shapira J. Meningococcal septicaemia and dental complications: a literature review and two case reports. Int J Paediatr Dent. May 2005;15(3):213-9. [Medline].

  15. Aaberge IS, Oster P, Helland OS, et al. Combined administration of meningococcal serogroup B outer membrane vesicle vaccine and conjugated serogroup C vaccine indicated for prevention of meningococcal disease is safe and immunogenic. Clin Diagn Lab Immunol. May 2005;12(5):599-605. [Medline].

  16. Zeidan A, Tariq S, Faltas B, Urban M, McGrody K. A case of primary meningococcal pericarditis caused by Neisseria meningitidis serotype Y with rapid evolution into cardiac tamponade. J Gen Intern Med. Sep 2008;23(9):1532-5. [Medline].

  17. Parmentier L, Garzoni C, Antille C, Kaiser L, Ninet B, Borradori L. Value of a novel Neisseria meningitidis--specific polymerase chain reaction assay in skin biopsy specimens as a diagnostic tool in chronic meningococcemia. Arch Dermatol. Jun 2008;144(6):770-3. [Medline].

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  25. Periappuram M, Taylor MR, Keane CT. Rapid detection of meningococci from petechiae in acute meningococcal infection. J Infect. Nov 1995;31(3):201-3. [Medline].

  26. Ploysangam T, Sheth AP. Chronic meningococcemia in childhood: case report and review of the literature. Pediatr Dermatol. Nov-Dec 1996;13(6):483-7. [Medline].

  27. Salzman MB, Rubin LG. Meningococcemia. Infect Dis Clin North Am. Dec 1996;10(4):709-25. [Medline].

  28. Schaller RT Jr, Schaller JF. Surgical management of life-threatening and disfiguring sequelae of fulminant meningococcemia. Am J Surg. May 1986;151(5):553-6. [Medline].

  29. van Deuren M, van Dijke BJ, Koopman RJ, et al. Rapid diagnosis of acute meningococcal infections by needle aspiration or biopsy of skin lesions. BMJ. May 8 1993;306(6887):1229-32. [Medline].

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Further Reading

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Keywords

meningococcemia, meningococcal sepsis, meningococcal disease, meningococcal infection, meningitis, bacteremia, meningococcemia, acute meningococcal septicemia, adrenal hemorrhage, Waterhouse-Friderichsen syndrome, meningococcal septicemia

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Contributor Information and Disclosures

Author

Elizabeth L Tanzi, MD, Co-Director, Laser Surgery, Washington Institute of Dermatologic Laser Surgery
Elizabeth L Tanzi, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, and American Society for Laser Medicine and Surgery
Disclosure: Nothing to disclose.

Coauthor(s)

Nanette Silverberg, MD, Assistant Clinical Professor, Department of Dermatology, Columbia University School of Medicine; Director of Pediatric Dermatology, Department of Dermatology, St Luke's Roosevelt Hospital Center, Maimonides Medical Center and Beth Israel Medical Center
Nanette Silverberg, MD is a member of the following medical societies: American Academy of Dermatology, American Academy of Pediatrics, American Association of University Women, American Medical Association, American Medical Women's Association, Dermatology Foundation, International Society of Pediatric Dermatology, Phi Beta Kappa, Sigma Xi, Society for Pediatric Dermatology, and Women's Dermatologic Society
Disclosure: Nothing to disclose.

Medical Editor

Gregory J Raugi, MD, PhD, Professor, Department of Internal Medicine, Division of Dermatology, University of Washington at Seattle; Chief, Dermatology Section, Primary and Specialty Care Service, Veterans Administration Medical Center of Seattle
Gregory J Raugi, MD, PhD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Lester F Libow, MD, Dermatopathologist, South Texas Dermatopathology Laboratory
Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Texas Medical Association
Disclosure: Nothing to disclose.

CME Editor

Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology
Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds None; Genentech Consulting fee Consulting; Centocor Consulting fee Consulting; Centocor Grant/research funds None; Covance Consulting fee Consulting; Shire  Consulting

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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