Meningococcal Meningitis Clinical Presentation
- Author: Francisco de Assis Aquino Gondim, MD, MSc, PhD, FAAN; Chief Editor: Niranjan N Singh, MD, DM more...
Meningococcal meningitis is characterized by acute onset of intense headache, fever, nausea, vomiting, photophobia, and stiff neck. Elderly patients are prone to have an altered mental state and a prolonged course with fever.
Lethargy or drowsiness in patients frequently is reported. Stupor or coma is less common. If coma is present, the prognosis is poor.
Patients also may complain of skin rash, which usually points to disease progression.
The clinical pattern of bacterial meningitis is quite different in young children. Bacterial meningitis in these patients usually presents as a subacute infection that progresses over several days.
Projectile vomiting may occur in children.
Seizures occur in 40% of children with meningitis, typically during the first few days. The majority of seizures have a focal onset.
In infants, the illness may have an insidious onset; stiff neck may be absent. In children, even when the combination of convulsive status epilepticus and fever is present, the classic signs and symptoms of acute bacterial meningitis may not be present.
The Waterhouse-Friderichsen syndrome may develop in 10-20% of children with meningococcal infection. This syndrome is characterized by large petechial hemorrhages in the skin and mucous membranes, fever, septic shock, and DIC.
Neurologic signs of meningococcal meningitis include nuchal rigidity (eg, Kernig sign, Brudzinski sign), lethargy, delirium, coma, and convulsions.
Irritability is a common presenting feature in children.
However, in a 2008 published cohort study from Netherlands (the Meningitis Cohort Study), conducted in adult patients with meningococcal meningitis, only 70% of the patients had the classic triad of fever, neck stiffness, and change in mental status. If the presence of rash was added, 89% of the patients had 2 of the 4 features.
Patients older than 30 years were noted to have petechiae (62%) less frequently than younger patients (81%).
A more severe, but less common form of meningococcal disease, is meningococcal septicemia, which is characterized by rapid circulatory collapse and a hemorrhagic rash.
A petechial or purpuric rash usually is found on the trunk, legs, mucous membranes, and conjunctivae. Occasionally, it is on the palms and soles. The rash may progress to purpura fulminans, when it usually is associated with multiorgan failure (ie, Waterhouse-Friderichsen syndrome). The petechial rash may be difficult to recognize in dark-skinned patients.
Brown T. First Serogroup B Meningococcal Vaccine Approved by FDA. Medscape Medical News. Available at http://www.medscape.com/viewarticle/834103. Accessed: November 10, 2014.
FDA. First vaccine approved by FDA to prevent serogroup B Meningococcal disease. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm420998.htm. Accessed: November 10, 2014.
Chin RF, Neville BG, Scott RC. Meningitis is a common cause of convulsive status epilepticus with fever. Arch Dis Child. 2005 Jan. 90(1):66-9. [Medline].
Stephens DS. Neisseria meningitidis. Infect Control. 1985 Jan. 6(1):37-40. [Medline].
Jackson LA, Schuchat A, Reeves MW, Wenger JD. Serogroup C meningococcal outbreaks in the United States. An emerging threat. JAMA. 1995 Feb 1. 273(5):383-9. [Medline].
Ahlawat S, Kumar R, Roy P, et al. Meningococcal meningitis outbreak control strategies. J Commun Dis. 2000 Dec. 32(4):264-74. [Medline].
Kutz JW, Simon LM, Chennupati SK, et al. Clinical predictors for hearing loss in children with bacterial meningitis. Arch Otolaryngol Head Neck Surg. 2006 Sep. 132(9):941-5. [Medline].
Andersen J, Backer V, Voldsgaard P, et al. Acute meningococcal meningitis: analysis of features of the disease according to the age of 255 patients. Copenhagen Meningitis Study Group. J Infect. 1997 May. 34(3):227-35. [Medline].
Heckenberg SG, de Gans J, Brouwer MC, Weisfelt M, Piet JR, Spanjaard L, et al. Clinical features, outcome, and meningococcal genotype in 258 adults with meningococcal meningitis: a prospective cohort study. Medicine (Baltimore). 2008. 87:185-92. [Medline].
Cuevas LE, Hart CA. Chemoprophylaxis of bacterial meningitis. J Antimicrob Chemother. 1993 Feb. 31 Suppl B:79-91. [Medline].
Helmick CG, Bernard KW, D'Angelo LJ. Rocky Mountain spotted fever: clinical, laboratory, and epidemiological features of 262 cases. J Infect Dis. 1984 Oct. 150(4):480-8. [Medline].
Kotilainen P, Jalava J, Meurman O, et al. Diagnosis of meningococcal meningitis by broad-range bacterial PCR with cerebrospinal fluid. J Clin Microbiol. 1998 Aug. 36(8):2205-9. [Medline].
Pardo F, Juncal R, Rajo C, Perez del Molino ML. [Usefulness of polymerase chain reaction (PCR) in the diagnosis of meningococcal meningitis]. Enferm Infecc Microbiol Clin. 1999 Feb. 17(2):74-7. [Medline].
Ni H, Knight AI, Cartwright K, et al. Polymerase chain reaction for diagnosis of meningococcal meningitis. Lancet. 1992 Dec 12. 340(8833):1432-4. [Medline].
de Filippis I, do Nascimento CR, Clementino MB, et al. Rapid detection of Neisseria meningitidis in cerebrospinal fluid by one-step polymerase chain reaction of the nspA gene. Diagn Microbiol Infect Dis. 2005 Feb. 51(2):85-90. [Medline].
Talan DA, Guterman JJ, Overturf GD, et al. Analysis of emergency department management of suspected bacterial meningitis. Ann Emerg Med. 1989 Aug. 18(8):856-62. [Medline].
Shao PL, Chang LY, Hsieh SM, Chang SC, Pan SC, Lu CY, et al. Safety and immunogenicity of a tetravalent polysaccharide vaccine against meningococcal disease. J Formos Med Assoc. 2009 Jul. 108(7):539-47. [Medline].
FDA News Release: First vaccine approved by FDA to prevent serogroup B Meningococcal disease. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm420998.htm. Accessed: October 29, 2014.
[Guideline] CDC. Updated recommendations for use of meningococcal conjugate vaccines --- Advisory Committee on Immunization Practices (ACIP), 2010. MMWR Morb Mortal Wkly Rep. 2011 Jan 28. 60(3):72-6. [Medline]. [Full Text].
Cohn AC, MacNeil JR, Clark TA, Ortega-Sanchez IR, Briere EZ, Meissner HC, et al. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2013 Mar 22. 62:1-28. [Medline]. [Full Text].
Novartis Vaccines. FDA expands age indication for Menveo®, first and only quadrivalent meningococcal vaccine for infants as young as 2 months of age. Available at http://www.novartisvaccines.com/newsroom/media-releases/2013/US_Menveo_Infant_FDA_Approval_Press_Release_US.pdf. Accessed: August 7, 2013.
Bhatt KM, Bhatt SM, Mirza NB. Meningococcal meningitis. East Afr Med J. 1996 Jan. 73(1):35-9. [Medline].
Schwartz B, Al-Tobaiqi A, Al-Ruwais A, et al. Comparative efficacy of ceftriaxone and rifampicin in eradicating pharyngeal carriage of group A Neisseria meningitidis. Lancet. 1988 Jun 4. 1(8597):1239-42. [Medline].
Brooks M. FDA OKs Use of Meningitis Vaccine in Infants, Toddlers. Medscape Medical News. Aug 2 2013. Available at http://www.medscape.com/viewarticle/808914. Accessed: August 13 2013.
Hart CA, Cuevas LE, Marzouk O, et al. Management of bacterial meningitis. J Antimicrob Chemother. 1993 Jul. 32 Suppl A:49-59. [Medline].
FDA News Release. FDA approves a second vaccine to prevent serogroup B meningococcal disease. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm431370.htm. Accessed: January 23, 2015.