Meningococcemia Clinical Presentation
- Author: Mahmud H Javid, MBBS; Chief Editor: John L Brusch, MD, FACP more...
The clinical pattern of meningococcemia varies. Persons with meningococcal disease may present with a nonspecific prodrome of cough, headache, and sore throat. After a few days of upper respiratory symptoms, the temperature rises abruptly, often after a chill. Malaise, weakness, myalgias, headache, nausea, vomiting, and arthralgias are common presenting symptoms.
A skin rash, which is essential for recognizing meningococcemia, is the characteristic manifestation. The skin rash may advance from a few ill-defined lesions to a widespread petechial eruption within a few hours. Meningococcemia’s potential rapidity of progression cannot be stressed enough.
In fulminant meningococcemia, a hemorrhagic eruption, hypotension, and cardiac depression, as well as rapid enlargement of petechiae and purpuric lesions, may be apparent within hours of the initial presentation. (See the image below.)
Meningitis is associated with the following :
Rash - In more than 50% of cases
Seizures - In 20% of patients at presentation and in an additional 10% of patients within 72 hours
Early nonspecific symptoms - Especially in infants
In adults, bacterial meningitis has a characteristic clinical pattern, although the progression of symptoms varies somewhat. Symptoms of meningitis may accompany the petechiae of meningococcemia and may produce the predominant features on presentation.
Bacterial meningitis is a febrile illness of short duration; the major symptoms include headache and a stiff neck. Lethargy or drowsiness is common. Confusion, agitated delirium, and stupor are rarer; however, coma is an ominous prognostic sign.
The clinical pattern of bacterial meningitis is often atypical in young children because headache and nuchal rigidity are frequently absent. Irritability, especially upon movement, is a common presenting manifestation of meningitis in a young child. Convulsions may signal the onset of meningitis at this age. Progression of the illness results in the development of lassitude and a more constant fever, often accompanied by abdominal discomfort. Projectile vomiting may occur.
Septicemia may be confused with influenza, particularly when myalgia is prominent. Meningococcal septicemia is characterized by the following :
Rash: An early short-lived maculopapular rash may precede the classic erythematous one that may evolve into petechiae and purpura. This may be mistaken for a viral exanthema. 
Myalgia that may be diffuse and severe
Initially normal level of consciousness
Early symptoms indistinguishable from those associated with viral illness, including leg pain
Symptoms of meningitis and septicemia may occur together and may complicate the distinction between an acute depression in level of consciousness due to hypotension and that due to elevated ICP.
Chronic meningococcemia is an intermittent bacteremic illness that lasts from at least 1 week to as long as several months. The fever tends to be intermittent, with afebrile periods ranging from 2-10 days, during which the patient seems completely healthy. As the disease progresses, the febrile periods become more common, and the fever may become continuous.
Eventually, a skin eruption or some other manifestation of meningococcal disease appears during a febrile episode. Cutaneous manifestations are variable and can consist of rose-colored macules and papules, indurated nodules, petechiae, purpura, or large hemorrhagic areas.
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 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/day in divided doses for a minimum of 7 days is effective therapy.
Patients with meningococcal disease appear severely ill. Tachycardia and mild hypotension are present. Patients with acute meningococcemia usually present with moderate fever (average, 39.5°C) and no signs of shock. High fever (average, 40.6°C) is present in fulminant meningococcemia.
Congestive heart failure, gallops, and pulmonary edema may be present in meningococcal disease. Other evidence of end-organ damage may also rapidly appear.
Patients with fulminant meningococcemia rapidly deteriorate clinically, with hypotension and respiratory failure.
Pericarditis can occur during the acute disease or in the recovery period and is associated with serogroup C disease.
Petechiae develop in 50%-80% of patients with meningococcal disease and involve the axillae, flanks, wrists, and ankles, although they can progress to any part of the body. Lesions commonly begin on the trunk and legs in areas where pressure is applied. (See the images below.)
Petechiae are often located in the center of lighter-colored macules. They are discrete lesions 1-2mm in diameter. Confluence of lesions results in hemorrhagic patches, often with central necrosis. In some cases, a transient maculopapular rash develops, usually lasting for less than 48 hours. Rash may be missed early in an individual with dark skin.
Critically ill patients with sepsis may develop rapidly progressing petechiae, ecchymoses, and extensive, palpable purpura or retiform purpura, accompanied by DIC and vascular collapse.
Skin lesions tend to occur in crops on any part of the body, occasionally presenting on the conjunctivae and the mucous membranes (see the first image below). The face is usually spared, and involvement of the palms and the soles is less common (see the second image below).
Fulminant meningococcemia is associated with a purpuric eruption, as shown in the image below. Lesions are generally characterized by maplike purpuric or necrotic areas.
Hemorrhages may appear on the buccal mucosa and the conjunctivae. Less frequently, fulminant meningococcemia presents as purpura fulminans (see the image below). In rare cases, no skin lesions develop. Symmetrical, peripheral gangrene has been described in this form. Amputation may be required in severe cases of necrosis.
Additional signs of fulminant meningococcemia
Signs of meningitis are typically absent. However, cyanosis, hypotension, and profound shock eventually appear.
Patients with fulminant meningococcemia usually present with a high fever (average temperature, 40.6°C). The blood pressure is lowered, and pulmonary insufficiency develops within a few hours.
Many patients with fulminant meningococcemia die despite appropriate antibiotic therapy and intensive care. Patients with fatal forms of fulminant meningococcemia are likely to die within 24-48 hours of presentation.
Signs of meningococcal septicemia
Fever, rash, tachycardia, hypotension, cool extremities, and an initially normal level of consciousness indicate meningococcal septicemia.
Confusion, cold extremities, poor capillary refill, and increasing tachycardia may herald a precipitous decrease in blood pressure.
An increasing respiratory rate suggests pulmonary edema or shock. Generalized edema develops as a result of capillary leak syndrome, and myocardial depression further impairs tissue perfusion.
Signs of meningitis
The characteristic physical examination findings of meningitis include pain and resistance to neck flexion. Other signs of meningeal irritation can also be elicited. Children with meningitis may have none of these findings.
The Kernig sign is positive when the leg cannot be extended more than 135° on the thigh when flexed 90° at the hip. The Brudzinski sign is positive when neck flexion causes involuntary flexion of the thighs and the legs.
Focal neurologic signs are uncommon presenting findings of bacterial meningitis. However, nuchal rigidity may not be elicited in patients who are comatose and who may have signs of focal or diffuse neurologic deficits.
Papilledema is not a presenting feature of bacterial meningitis and suggests the presence of an accompanying process.
A common presenting sign of meningococcal meningitis is petechiae. Most patients with meningitis are febrile, although the height of fever varies.
[Guideline] Prevention and control of meningococcal disease: recommendations for use of meningococcal vaccines in pediatric patients. Pediatrics. 2005 Aug. 116(2):496-505. [Medline].
[Guideline] Prevention and control of meningococcal disease. MMWR Recomm Rep. 2013 Mar 22. 62:1-22. [Medline].
[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:
Horino T, Kato T, Sato F, Sakamoto M, Nakazawa Y, Yoshida M, et al. Meningococcemia without meningitis in Japan. Intern Med. 2008. 47(17):1543-7. [Medline].
Coureuil M, Join-Lambert O, Lécuyer H, Bourdoulous S, Marullo S, Nassif X. Pathogenesis of meningococcemia. Cold Spring Harb Perspect Med. 2013 Jun 1. 3 (6):[Medline].
Brandtzaeg P, van Deuren M. Classification and pathogenesis of meningococcal infections. Methods Mol Biol. 2012. 799:21-35. [Medline].
Livorsi DJ, Stenehjem E, Stephens DS. Virulence factors of gram-negative bacteria in sepsis with a focus on Neisseria meningitidis. Contrib Microbiol. 2011. 17:31-47. [Medline].
Plant L, Sundqvist J, Zughaier S, Lovkvist L, Stephens DS, Jonsson AB. Lipooligosaccharide structure contributes to multiple steps in the virulence of Neisseria meningitidis. Infect Immun. 2006 Feb. 74(2):1360-7. [Medline]. [Full Text].
Sanders MS, van Well GT, Ouburg S, Morré SA, van Furth AM. Toll-like receptor 9 polymorphisms are associated with severity variables in a cohort of meningococcal meningitis survivors. BMC Infect Dis. 2012 May 11. 12:112. [Medline].
Faust SN, Levin M, Harrison OB, Goldin RD, Lockhart MS, Kondaveeti S, et al. Dysfunction of endothelial protein C activation in severe meningococcal sepsis. N Engl J Med. 2001 Aug 9. 345(6):408-16. [Medline].
Pathan N, Hemingway CA, Alizadeh AA, Stephens AC, Boldrick JC, Oragui EE, et al. Role of interleukin 6 in myocardial dysfunction of meningococcal septic shock. Lancet. 2004 Jan 17. 363(9404):203-9. [Medline].
Pathan N, Williams EJ, Oragui EE, Stephens AC, Levin M. Changes in the interleukin-6/soluble interleukin-6 receptor axis in meningococcal septic shock. Crit Care Med. 2005 Aug. 33(8):1839-44. [Medline].
MacLennan J, Kafatos G, Neal K, Andrews N, Cameron JC, Roberts R, et al. Social behavior and meningococcal carriage in British teenagers. Emerg Infect Dis. 2006 Jun. 12(6):950-7. [Medline]. [Full Text].
Faber J, Henninger N, Finn A, Zenz W, Zepp F, Knuf M. A toll-like receptor 4 variant is associated with fatal outcome in children with invasive meningococcal disease. Acta Paediatr. 2009 Mar. 98(3):548-52. [Medline].
Jansen AG, Sanders EA, VAN DER Ende A, VAN Loon AM, Hoes AW, Hak E. Invasive pneumococcal and meningococcal disease: association with influenza virus and respiratory syncytial virus activity?. Epidemiol Infect. 2008 Nov. 136(11):1448-54. [Medline]. [Full Text].
Fijen CA, Kuijper EJ, te Bulte MT, Daha MR, Dankert J. Assessment of complement deficiency in patients with meningococcal disease in The Netherlands. Clin Infect Dis. 1999 Jan. 28 (1):98-105. [Medline].
Harrison LH. Epidemiological profile of meningococcal disease in the United States. Clin Infect Dis. 2010 Mar 1. 50 Suppl 2:S37-44. [Medline].
[Guideline] 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 (RR-2):1-28. [Medline].
Ortega-Sanchez IR, Meltzer MI, Shepard C, Zell E, Messonnier ML, Bilukha O, et al. Economics of an adolescent meningococcal conjugate vaccination catch-up campaign in the United States. Clin Infect Dis. 2008 Jan 1. 46(1):1-13. [Medline].
Cathie K, Levin M, Faust SN. Drug use in acute meningococcal disease. Arch Dis Child Educ Pract Ed. 2008 Oct. 93(5):151-8. [Medline].
Tappero JW, Reporter R, Wenger JD, Ward BA, Reeves MW, Missbach TS, et al. Meningococcal disease in Los Angeles County, California, and among men in the county jails. N Engl J Med. 1996 Sep 19. 335(12):833-40. [Medline].
Brundage JF, Ryan MA, Feighner BH, Erdtmann FJ. Meningococcal disease among United States military service members in relation to routine uses of vaccines with different serogroup-specific components, 1964-1998. Clin Infect Dis. 2002 Dec 1. 35(11):1376-81. [Medline].
Simon MS, Weiss D, Gulick RM. Invasive meningococcal disease in men who have sex with men. Ann Intern Med. 2013 Aug 20. 159 (4):300-1. [Medline].
Miller L, Arakaki L, Ramautar A, Bodach S, Braunstein SL, Kennedy J, et al. Elevated risk for invasive meningococcal disease among persons with HIV. Ann Intern Med. 2014 Jan 7. 160 (1):30-7. [Medline].
Sejvar JJ, Johnson D, Popovic T, Miller JM, Downes F, Somsel P, et al. Assessing the risk of laboratory-acquired meningococcal disease. J Clin Microbiol. 2005 Sep. 43 (9):4811-4. [Medline].
Rosenstein NE, Perkins BA, Stephens DS, Lefkowitz L, Cartter ML, Danila R, et al. The changing epidemiology of meningococcal disease in the United States, 1992-1996. J Infect Dis. 1999 Dec. 180 (6):1894-901. [Medline].
Centers for Disease Control and Prevention (CDC). Notice to Healthcare Providers: Recognizing and Reporting Serogroup B Meningococcal Disease Associated with Outbreaks at Princeton University and the University of California at Santa Barbara. Available at http://emergency.cdc.gov/han/han00357.asp. November 27, 2013;
Wilder-Smith A. W135 meningococcal carriage in association with the Hajj pilgrimage 2001: the Singapore experience. Int J Antimicrob Agents. 2003 Feb. 21(2):112-5. [Medline].
Wilder-Smith A, Barkham TM, Earnest A, Paton NI. Acquisition of W135 meningococcal carriage in Hajj pilgrims and transmission to household contacts: prospective study. BMJ. 2002 Aug 17. 325(7360):365-6. [Medline]. [Full Text].
Wilder-Smith A, Chow A, Goh KT. Emergence and disappearance of W135 meningococcal disease. Epidemiol Infect. 2010 Jul. 138(7):976-8. [Medline].
Hart CA, Cuevas LE. Meningococcal disease in Africa. Ann Trop Med Parasitol. 1997 Oct. 91 (7):777-85. [Medline].
Health Protection Agency. Invasive meningococcal infections, England and Wales, laboratory reports: weeks 51-52/2007. [Full Text].
Christensen H, May M, Bowen L, Hickman M, Trotter CL. Meningococcal carriage by age: a systematic review and meta-analysis. Lancet Infect Dis. 2010 Dec. 10(12):853-61. [Medline].
Kaplan SL, Schutze GE, Leake JA, Barson WJ, Halasa NB, Byington CL, et al. Multicenter surveillance of invasive meningococcal infections in children. Pediatrics. 2006 Oct. 118(4):e979-84. [Medline].
Darton T, Guiver M, Naylor S, Jack DL, Kaczmarski EB, Borrow R, et al. Severity of meningococcal disease associated with genomic bacterial load. Clin Infect Dis. 2009 Mar 1. 48(5):587-94. [Medline].
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. 2008 Sep. 23(9):1532-5. [Medline]. [Full Text].
Vienne P, Ducos-Galand M, Guiyoule A, Pires R, Giorgini D, Taha MK, et al. The role of particular strains of Neisseria meningitidis in meningococcal arthritis, pericarditis, and pneumonia. Clin Infect Dis. 2003 Dec 15. 37(12):1639-42. [Medline].
Wong JS, Balakrishnan V. Neisseria meningitidis endogenous endophthalmitis: case report and literature review. J Pediatr Ophthalmol Strabismus. 1999 May-Jun. 36(3):145-52. [Medline].
Borg J, Christie D, Coen PG, Booy R, Viner RM. Outcomes of meningococcal disease in adolescence: prospective, matched-cohort study. Pediatrics. 2009 Mar. 123(3):e502-9. [Medline].
Buysse CM, Raat H, Hazelzet JA, Hulst JM, Cransberg K, Hop WC, et al. Long-term health status in childhood survivors of meningococcal septic shock. Arch Pediatr Adolesc Med. 2008 Nov. 162(11):1036-41. [Medline].
Buysse CM, Oranje AP, Zuidema E, Hazelzet JA, Hop WC, Diepstraten AF, et al. Long-term skin scarring and orthopaedic sequelae in survivors of meningococcal septic shock. Arch Dis Child. 2009 May. 94(5):381-6. [Medline].
Stephens DS, Greenwood B, Brandtzaeg P. Epidemic meningitis, meningococcaemia, and Neisseria meningitidis. Lancet. 2007 Jun 30. 369(9580):2196-210. [Medline].
Feldman HA. Meningococcal infections. Adv Intern Med. 1972. 18:117-40. [Medline].
Feldman HA. Meningococcal infections. Adv Intern Med. 1972. 18:117-40. [Medline].
Durand ML, Calderwood SB, Weber DJ, Miller SI, Southwick FS, Caviness VS Jr, et al. Acute bacterial meningitis in adults. A review of 493 episodes. N Engl J Med. 1993 Jan 7. 328 (1):21-8. [Medline].
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. 2008 Jun. 144(6):770-3. [Medline].
Periappuram M, Taylor MR, Keane CT. Rapid detection of meningococci from petechiae in acute meningococcal infection. J Infect. 1995 Nov. 31(3):201-3. [Medline].
Arend SM, Lavrijsen AP, Kuijken I, van der Plas RN, Kuijper EJ. Prospective controlled study of the diagnostic value of skin biopsy in patients with presumed meningococcal disease. Eur J Clin Microbiol Infect Dis. 2006 Oct. 25(10):643-9. [Medline].
Dolan Thomas J, Hatcher CP, Satterfield DA, Theodore MJ, Bach MC, Linscott KB, et al. sodC-based real-time PCR for detection of Neisseria meningitidis. PLoS One. 2011 May 5. 6(5):e19361. [Medline]. [Full Text].
Guarner J, Greer PW, Whitney A, Shieh WJ, Fischer M, White EH, et al. Pathogenesis and diagnosis of human meningococcal disease using immunohistochemical and PCR assays. Am J Clin Pathol. 2004 Nov. 122(5):754-64. [Medline].
Fernandez-Rodriguez A, Alcala B, Alvarez-Lafuente R. Real-time polymerase chain reaction detection of Neisseria meningitidis in formalin-fixed tissues from sudden deaths. Diagn Microbiol Infect Dis. 2008 Apr. 60(4):339-46. [Medline].
Bryant PA, Li HY, Zaia A, Griffith J, Hogg G, Curtis N, et al. Prospective study of a real-time PCR that is highly sensitive, specific, and clinically useful for diagnosis of meningococcal disease in children. J Clin Microbiol. 2004 Jul. 42(7):2919-25. [Medline]. [Full Text].
de Filippis I, do Nascimento CR, Clementino MB, Sereno AB, Rebelo C, Souza NN, 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].
Lin HW, Yin JH, Lo JP, Wang YH, Lee SY, Lu JJ. Use of universal polymerase chain reaction assay and endonuclease digestion for rapid detection of Neisseria meningitides. J Microbiol Immunol Infect. 2004 Dec. 37(6):371-4. [Medline].
Health Protection Agency. Guidance for the public health management of meningococcal disease in the UK. [Full Text].
Sprung CL, Annane D, Keh D, Moreno R, Singer M, Freivogel K, et al. Hydrocortisone therapy for patients with septic shock. N Engl J Med. 2008 Jan 10. 358(2):111-24. [Medline].
Jaeschke R, Angus DC. Living with uncertainty in the intensive care unit: should patients with sepsis be treated with steroids?. JAMA. 2009 Jun 10. 301(22):2388-90. [Medline].
Tuncer AM, Gur I, Ertem U, et al. Once daily ceftriaxone for meningococcemia and meningococcal meningitis. Pediatr Infect Dis J. 1988 Oct. 7(10):711-3. [Medline].
Hart CA, Cuevas LE. Meningococcal disease in Africa. Ann Trop Med Parasitol. 1997 Oct. 91(7):777-85. [Medline].
Food and Drug Administration. Ceftriaxone (marketed as Rocephin) information. 2008:[Full Text].
Roche. Important clarification of prescribing information. Contraindications. http://www.rocheusa.com. Available at http://www.gene.com/gene/products/information/rocephin. Accessed: June 28, 2012.
Medicines and healthcare products regulatory agency. Ceftriaxone; incompatibility with calcium containing solutions. 2008:[Full Text].
Food and Drug Administration. Ceftriaxone (marketed as Rocephin) Information. http://www.fda.gov. Available at http://www.fda.gov/Cder/drug/infopage/ceftriaxone/default.htm. Accessed: April 2009.
Brouwer MC, McIntyre P, de Gans J, Prasad K, van de Beek D. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2010 Sep 8. CD004405. [Medline].
Herrera R, Hobar PC, Ginsburg CM. Surgical intervention for the complications of meningococcal-induced purpura fulminans. Pediatr Infect Dis J. 1994 Aug. 13(8):734-7. [Medline].
Besner GE, Klamar JE. Integra Artificial Skin as a useful adjunct in the treatment of purpura fulminans. J Burn Care Rehabil. 1998 Jul-Aug. 19(4):324-9. [Medline].
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. 2005 May. 15(3):213-9. [Medline].
Aaberge IS, Oster P, Helland OS, Kristoffersen AC, Ypma E, Høiby EA, 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. 2005 May. 12(5):599-605. [Medline]. [Full Text].
Bethell D, Pollard AJ. Meningococcal vaccines. Expert Rev Vaccines. 2002 Jun. 1(1):75-84. [Medline].
Pollard AJ. Global epidemiology of meningococcal disease and vaccine efficacy. Pediatr Infect Dis J. 2004 Dec. 23(12 Suppl):S274-9. [Medline].
U.S. Food and Drug Administration. First vaccine approved by FDA to prevent serogroup B Meningococcal disease. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm420998.htm. October 29, 2014;
[Guideline] American Academy of Pediatrics Committee on Infectious Diseases. Updated recommendations on the use of meningococcal vaccines. Pediatrics. 2014 Aug. 134 (2):400-3. [Medline].
Tucker ME. New meningococcal vaccine recommended for high-risk infants. Medscape Medical News. Jan 24, 2013. Available at http://www.medscape.com/viewarticle/778124. Accessed: Feb 5, 2013.
Infant Meningococcal Vaccination: Advisory Committee on Immunization Practices (ACIP) Recommendations and Rationale. MMWR Morb Mortal Wkly Rep. 2013 Jan 25. 62:52-4. [Medline].
Brown T. ACIP OKs Meningitis Vaccine (Menveo) for High-Risk Infants. Medscape Medical News. Available at http://www.medscape.com/viewarticle/813066. Accessed: October 28, 2013.
Harrison LH, Shutt KA, Arnold KE, Stern EJ, Pondo T, Kiehlbauch JA, et al. Meningococcal carriage among Georgia and Maryland high school students. J Infect Dis. 2015 Jun 1. 211 (11):1761-8. [Medline].
Update: Guillain-Barre syndrome among recipients of Menactra meningococcal conjugate vaccine--United States, June 2005-September 2006. MMWR Morb Mortal Wkly Rep. 2006 Oct 20. 55(41):1120-4. [Medline].
[Guideline] 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].
Fraser A, Gafter-Gvili A, Paul M, Leibovici L. Prophylactic use of antibiotics for prevention of meningococcal infections: systematic review and meta-analysis of randomised trials. Eur J Clin Microbiol Infect Dis. 2005 Mar. 24(3):172-81. [Medline].
Jarva H, Ram S, Vogel U, Blom AM, Meri S. Binding of the complement inhibitor C4bp to serogroup B Neisseria meningitidis. J Immunol. 2005 May 15. 174(10):6299-307. [Medline].
Nkosi J, Thakrar A, Kumar K, Ahmadie R, Fang T, Lytwyn M, et al. Meningococcal serotype Y myopericarditis. Diagn Microbiol Infect Dis. 2009 Feb. 63(2):223-7. [Medline].
Aiuto LT, Barone SR, Cohen PS, Boxer RA. Recombinant tissue plasminogen activator restores perfusion in meningococcal purpura fulminans. Crit Care Med. 1997 Jun. 25(6):1079-82. [Medline].
Derkx B, Wittes J, McCloskey R. Randomized, placebo-controlled trial of HA-1A, a human monoclonal antibody to endotoxin, in children with meningococcal septic shock. European Pediatric Meningococcal Septic Shock Trial Study Group. Clin Infect Dis. 1999 Apr. 28(4):770-7. [Medline].
Rivard GE, David M, Farrell C, Schwarz HP. Treatment of purpura fulminans in meningococcemia with protein C concentrate. J Pediatr. 1995 Apr. 126(4):646-52. [Medline].
de Kleijn ED, de Groot R, Hack CE, Mulder PG, Engl W, Moritz B, et al. Activation of protein C following infusion of protein C concentrate in children with severe meningococcal sepsis and purpura fulminans: a randomized, double-blinded, placebo-controlled, dose-finding study. Crit Care Med. 2003 Jun. 31(6):1839-47. [Medline].
Nadel S, Goldstein B, Williams MD, Dalton H, Peters M, Macias WL, et al. Drotrecogin alfa (activated) in children with severe sepsis: a multicentre phase III randomised controlled trial. Lancet. 2007 Mar 10. 369(9564):836-43. [Medline].
Levin M, Quint PA, Goldstein B, Barton P, Bradley JS, Shemie SD, et al. Recombinant bactericidal/permeability-increasing protein (rBPI21) as adjunctive treatment for children with severe meningococcal sepsis: a randomised trial. rBPI21 Meningococcal Sepsis Study Group. Lancet. 2000 Sep 16. 356(9234):961-7. [Medline].
Day KM, Haub N, Betts H, Inwald DP. Hyperglycemia is associated with morbidity in critically ill children with meningococcal sepsis. Pediatr Crit Care Med. 2008 Nov. 9(6):636-40. [Medline].
Licensure of a meningococcal conjugate vaccine for children aged 2 through 10 years and updated booster dose guidance for adolescents and other persons at increased risk for meningococcal disease--Advisory Committee on Immunization Practices (ACIP), 2011. MMWR Morb Mortal Wkly Rep. 2011 Aug 5. 60(30):1018-9. [Medline].
Licensure of a meningococcal conjugate vaccine (Menveo) and guidance for use - Advisory Committee on Immunization Practices (ACIP), 2010. MMWR Morb Mortal Wkly Rep. 2010 Mar 12. 59(9):273. [Medline].
Haemophilus influenzae type b (Hib) and meningococcal serogroup C (MenC) vaccines for children - Factsheet. Available at http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_106052. Accessed: 8/7/2011.
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].
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. 2006 Mar. 52(3):511-4. [Medline].
FDA News Release. FDA approves the first vaccine to prevent meningococcal disease in infants and toddlers. April 22, 2011. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm252392.htm. Accessed: April 27, 2011.
Miller L, Arakaki L, Ramautar A, et al. Elevated risk for invasive meningococcal disease among persons with HIV. Ann Intern Med. 2013 Oct 29. [Medline].
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. 2005 May-Jun. 12(3):269-71. [Medline].
[Guideline] Recommendation of the Advisory Committee on Immunization Practices (ACIP) for use of quadrivalent meningococcal conjugate vaccine (MenACWY-D) among children aged 9 through 23 months at increased risk for invasive meningococcal disease. MMWR Morb Mortal Wkly Rep. 2011 Oct 14. 60(40):1391-2. [Medline].
Waknine Y. Meningococcal Disease Risk 10-Fold Higher in People With HIV. Medscape Medical News. Oct 30 2013. [Full Text].