Dermatologic Manifestations of Meningococcemia Treatment & Management

  • Author: Elizabeth L Tanzi, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Aug 16, 2011
 

Medical Care

  • The most important measure in treating meningococcemia is early detection and rapid administration of antibiotics. Penicillin G is the antibiotic of choice for susceptible isolates. A third-generation cephalosporin (eg, cefotaxime, ceftriaxone) can be used initially in septic patients while the diagnosis is being confirmed or in countries such as the United Kingdom or Spain, where penicillin-resistant strains of N meningitidis have been isolated.[6]
  • Intensive supportive care is required for patients with fulminant meningococcemia. Components of treatment include antibiotic therapy, ventilatory support, inotropic support, and intravenous fluids. Central venous access facilitates the administration of massive amounts of volume expanders and inotropic medications needed for adequate tissue perfusion. If disseminated intravascular coagulation (DIC) is present, fresh frozen plasma may be indicated. Treatment is individualized depending on the severity of hemodynamic compromise of the patient.
  • Many experimental and alternate therapies have been tried with varying success.[7] Currently under study are treatments to inhibit inflammatory mediators (eg, monoclonal antibodies to endotoxin, tumor necrosis factor, interleukin 1, interleukin 6, and interferon-gamma). Anecdotal reports show removal of inflammatory mediators by dialysis may offer some benefit. Fibrinolytic treatment using recombinant tissue plasminogen activator or the administration of highly purified protein C concentrate may prove to be helpful adjuncts to conventional therapy to improve tissue perfusion in the presence of DIC.[8]
  • Several clinical guideline summaries related to meningococcal disease are available, as follows:
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Surgical Care

Patients who survive the initial acute phase of fulminant meningococcemia are at increased risk for serious complications as a result of poor tissue perfusion.[12]

  • Early in the course of tissue injury, conservative therapy is recommended until a distinct line of demarcation is apparent between viable and nonviable tissue.
  • Once the patient is stable, debridement of all necrotic tissue is essential and may necessitate extensive removal of skin, subcutaneous tissue, and muscle.
  • Large defects may be covered using microvascular free flaps or skin grafts.
  • The use of artificial skin can spare the patient immediate use of autograft sites, which frequently are limited.[13]
  • Avoid amputation whenever useful function of a limb can be salvaged.
  • Poor tissue perfusion may also lead to dental complications that require extensive extraction of severely affected teeth.[14]
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Consultations

  • Infectious disease specialist - To assist in management and provide guidance in antimicrobial therapy
  • Preventive medicine specialist - To evaluate the community risk associated with an index case and initiate reporting to local and regional health authorities if indicated
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Contributor Information and Disclosures
Author

Elizabeth L Tanzi, MD  Co-Director, Laser Surgery, Washington Institute of Dermatologic Laser Surgery; Assistant Professor, Department of Dermatology, Johns Hopkins University School of Medicine

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 College of Physicians and Surgeons; Director of Pediatric Dermatology, Department of Dermatology, St Luke's Roosevelt Hospital Center, Maimonides Medical Center and Beth Israel Medical Center

Nanette Silverberg 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.

Specialty Editor Board

Gregory J Raugi, MD, PhD  Professor, Department of Internal Medicine, Division of Dermatology, University of Washington at Seattle School of Medicine; 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.

Michael J Wells, MD  Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

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.

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.

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 Investigator; Genentech Grant/research funds investigator; Centocor Consulting fee Consulting; Abbott Grant/research funds investigator; Abbott Consulting fee Consulting; Novartis investigator; Pfizer Grant/research funds investigator; Celgene Consulting fee DMC Chair; NIAMS and NHLBI Grant/research funds investigator

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

References

  1. Horino T, Kato T, Sato F, et al. Meningococcemia without meningitis in Japan. Intern Med. 2008;47(17):1543-7. [Medline].

  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].

  18. Centers for Disease Control and Prevention. Prevention and control of meningococcal disease. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. Jun 30 2000;49:1-10. [Medline].

  19. Darmstadt GL. Acute infectious purpura fulminans: pathogenesis and medical management. Pediatr Dermatol. May-Jun 1998;15(3):169-83. [Medline].

  20. Figueroa JE, Densen P. Infectious diseases associated with complement deficiencies. Clin Microbiol Rev. Jul 1991;4(3):359-95. [Medline].

  21. Hazelzet JA. Diagnosing meningococcemia as a cause of sepsis. Pediatr Crit Care Med. May 2005;6(3 Suppl):S50-4. [Medline].

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  24. Lynn WA, Cohen J. Adjunctive therapy for septic shock: a review of experimental approaches. Clin Infect Dis. Jan 1995;20(1):143-58. [Medline].

  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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