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Meningococcal Infections: Differential Diagnoses & Workup

Author: D Scott Smith, MD, MSc, DTM&H, Adjunct Assistant Professor, Department of Microbiology and Immunology, Stanford University; Chief of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, Kaiser Redwood City Hospital
Coauthor(s): Thomas A Hoffman, MD, Professor, Department of Internal Medicine, Division of Infectious Diseases, Jackson Memorial Hospital, University of Miami; Joanna L Chan, MD, Resident Physician, Department of Dermatology, University of Texas Southwestern Medical Center
Contributor Information and Disclosures

Updated: Mar 12, 2009

Differential Diagnoses

Dengue Fever
Malaria
Ebola Virus
Rocky Mountain Spotted Fever
Enteroviruses
Syphilis
Gonococcal Infections
Thrombotic Thrombocytopenic Purpura
Henoch-Schoenlein Purpura
Infective Endocarditis
Leptospirosis

Other Problems to Be Considered

Anaphylactoid purpura
Arboviral infections
Capnocytophaga canimorsus (dysgonic fermenter-2 [DF-2]) infection
Marburg virus infection
Acute febrile neutrophilic dermatosis (Sweet syndrome)

  • Cutaneous differential diagnoses of acute meningococcemia include multiple entities, including other infectious processes such as leptospirosis, Rocky Mountain spotted fever, or acute viral syndrome. Other differential diagnoses of acute meningococcemia include acute hypersensitivity vasculitides, septic vasculitis due to acute bacteremia or endocarditis, toxic shock syndrome, or purpura fulminans.
  • Chronic meningococcemia may resemble chronic gonococcemia, Henoch-Schönlein purpura, rat-bite fever, Sweet syndrome, erythema multiforme, and subacute bacterial endocarditis.
  • Importantly, glucocorticoids administered for the rash and arthritis of rheumatic diseases would substantially worsen the course of meningococcemia.

Workup

Laboratory Studies

  • Collect blood cultures (2 sets, with at least 10 mL per bottle) in any febrile patient with a petechial rash.
  • CBC count, platelet count, BUN study, creatinine clearance evaluation, and a series of coagulation studies can be used to evaluate a consumptive coagulopathy. DIC is a laboratory diagnosis, but no single laboratory test is diagnostic. Instead, DIC is recognized clinically by a pattern of changes in numerous coagulation tests. Typically, these changes include lowered platelet count, prolonged prothrombin time, prolonged partial thromboplastin time, lowered fibrinogen levels, and the presence of fibrin-split products in the circulation. Not all of these changes are found in all patients. Fibrinogen, an acute-phase reactant, may be elevated in patients with DIC.
  • Gram stain of the peripheral blood buffy coat may reveal gram-negative diplococci in fulminant meningococcemia.
  • Needle aspirates or skin biopsy specimens from patients with meningococcal sepsis tested using Gram stain yield a 72% sensitivity based on one study and was reportedly 80% using scraped material from petechial lesions in another retrospective study.4 A prospective controlled study combining Gram stain and culture of skin biopsy specimens reported a sensitivity of 56%.5
  • A study of adults with fulminant meningococcemia found that 4 variables at the time of admission portend a fatal outcome (odds ratio, 2; CI, 1.5-2.7).
    • Plasma fibrinogen level of 1.5 g/L or less (sole adverse prognostic variable)
    • Factor V concentration of 0.2 or less
    • Platelet count lower than 80 X 109/L
    • Cerebrospinal fluid (CSF) leukocyte count of 20 X 106/L or less

Imaging Studies

  • Brain imaging studies before a lumbar puncture (LP) are unnecessary unless the patient is obtunded, has focal neurologic signs, has experienced a seizure within the previous week, or presents with papilledema.

Other Tests

  • A polymerase chain reaction (PCR) test has been developed for detection of N meningitidis DNA in clinical specimens.6,7,8,9,10 PCR can be used to detect small amounts of meningococcal DNA in CSF. It is thought to be a more sensitive test for meningococcal meningitis than culture methods. Because of the cost and expertise necessary to operate a PCR assay, this diagnostic test is used only in large-scale outbreaks when numerous specimens can be analyzed. Several studies have confirmed the usefulness of this method in an epidemic setting. A recent small case series reported the utility of PCR assay using skin biopsy specimens to assist in diagnosis when routine microbiologic tests fail to isolate the bacteria.10

Procedures

  • Perform LP for CSF evaluation.
    • Immediately stain and culture spinal fluid.
    • Gram stain of the CSF should be immediately performed and examined microscopically. Organisms can be observed in the CSF in approximately half of patients who present with meningococcal meningitis.
    • Send the CSF for WBC count, WBC differential, total protein content, and glucose studies. Send additional tests as indicated for ruling out other diagnoses.
    • Bacterial meningitis produces various inflammatory changes in the CSF. The CSF becomes turbid with more than 1000 WBC/µL, and the cells are predominantly polymorphonuclear. The intracranial pressure (ICP) may be elevated. The total protein content is increased, and the glucose level, which is normally 60% of the simultaneous blood glucose level, becomes lowered (hypoglycorrhachia).

Histologic Findings

  • Leukocytoclastic vasculitis, thrombosis, and organisms are often demonstrated in biopsy specimens collected from patients with acute meningococcemia.
  • Perivascular lymphocytic infiltrate with few neutrophils characterize chronic meningococcemia, although leukocytoclastic vasculitis may be seen in biopsies of petechial lesions.

More on Meningococcal Infections

Overview: Meningococcal Infections
Differential Diagnoses & Workup: Meningococcal Infections
Treatment & Medication: Meningococcal Infections
Follow-up: Meningococcal Infections
Multimedia: Meningococcal Infections
References
Further Reading
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References

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Further Reading

Thompson MJ, Ninis N, Perera R, Mayon-White R, Phillips C, Bailey L, et al. Clinical recognition of meningococcal disease in children and adolescents. Lancet. Feb 4 2006;367(9508):397-403. [Medline].

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Keywords

meningococcal infections, epidemic cerebrospinal fever, Waterhouse-Friderichsen syndrome, meningitis, meningococci, fulminant meningococcemia, acute meningococcemia, meningococcemia, meningococcal meningitis, bacterial meningitis, meningococcal disease, Neisseria meningitidis, N meningitidis, chronic meningococcemia

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Contributor Information and Disclosures

Author

D Scott Smith, MD, MSc, DTM&H, Adjunct Assistant Professor, Department of Microbiology and Immunology, Stanford University; Chief of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, Kaiser Redwood City Hospital
D Scott Smith, MD, MSc, DTM&H is a member of the following medical societies: American Medical Association, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, and International Society of Travel Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Thomas A Hoffman, MD, Professor, Department of Internal Medicine, Division of Infectious Diseases, Jackson Memorial Hospital, University of Miami
Thomas A Hoffman, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Joanna L Chan, MD, Resident Physician, Department of Dermatology, University of Texas Southwestern Medical Center
Joanna L Chan, MD is a member of the following medical societies: American Academy of Dermatology and American Society for Dermatologic Surgery
Disclosure: Nothing to disclose.

Medical Editor

Joseph Richard Masci, MD, Chief of Infectious Diseases, Associate Director, Associate Professor, Department of Internal Medicine, Division of Infectious Diseases, Elmhurst Hospital Center, Mount Sinai School of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Aaron Glatt, MD, Professor of Clinical Medicine, New York Medical College; President and CEO, Former Chief Medical Officer, Departments of Medicine and Infectious Diseases, New Island Hospital
Aaron Glatt, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physician Executives, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Infectious Diseases Society of America, International AIDS Society, and Society for Healthcare Epidemiology of America
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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