Pediatric Meningococcal Infections Workup

  • Author: Saul N Faust, MA, MBBS, PhD, MRCPCH; Chief Editor: Russell W Steele, MD   more...
 
Updated: May 2, 2011
 

Laboratory Studies

  • In patients with meningococcal infections, the WBC count and C-reactive protein level may be elevated at presentation or may increase during the subsequent 24 hours.
    • These values are not reliable markers of infection.
    • In a study of 128 consecutive children with meningococcal sepsis who were admitted to a pediatric intensive care unit, only 14% had a WBC count of more than 20 X 109/L, and 71% had a WBC count of less than 15 X 109/L.
    • A low WBC count is a poor prognostic finding and should raise concerns about disease rapid progression.
  • Coagulation is often disturbed in septicemia because of the consumption and loss of clotting factors.
  • Biochemical disturbance is common in children who have shock with or without impaired renal function. The following abnormalities are common:
    • Hypokalemia despite acidosis
    • Hypocalcemia
    • Hypomagnesemia
    • Metabolic acidosis
  • Rapid latex antigen tests may assist with diagnosis. The latex agglutination test has 50-100% sensitivity and high specificity, but it has a high rate of false-negative results.
  • Rapid diagnosis with polymerase chain reaction (PCR) using blood or cerebral spinal fluid (CSF) is being evaluated (91% sensitivity and specificity). A study that used PCR detection of N meningitidis to quantify bacterial load reported that patients with a higher bacterial load were more likely to die or have permanent disease sequelae and were more likely to have a longer hospital stay.[12]
  • Blood, throat, CSF, and skin aspirate cultures may help with diagnosis, but findings may be negative after outpatient administration of antibiotics. CSF cultures are positive in fewer than 50% of patients after the use of antibiotics.
  • A convalescent serologic test may be useful.
Next

Procedures

  • In the presence of a purpuric or petechial rash, lumbar puncture may be hazardous and may add few data to aid in the diagnosis. In a patient with a depressed level of consciousness, shock, or any of the features listed below, lumbar puncture can be delayed, and treatment can immediately begin.
  • The following are contraindications to lumber puncture (unless increased intracranial pressure [ICP] is ruled out):
    • Prolonged or focal seizures
    • Focal neurological signs
    • Widespread purpuric or petechial rash
    • Glasgow Coma Scale score of less than 13
    • Pupillary dilatation or asymmetry
    • Impaired oculocephalic reflexes (ie, doll's eye reflexes)
    • Abnormal posture or movement, decerebrate or decorticate movement or cycling
    • Coagulation disorder
    • Papilledema
    • Hypertension
    • Signs of impending brain herniation (inappropriately low pulse, increased BP, irregular respiration)
  • Although lumbar puncture is generally required to confirm the diagnosis of meningitis, some brainstem herniation (coning) seems to be temporally related to lumbar puncture. If safe to perform, lumbar puncture is useful to establish the presence of meningitis and to identify the causative organism and its antibiotic sensitivity to antibiotics.
    • CSF findings are characteristic in 90% of cases.
    • Findings may include the following:
      • Neutrophil level - 100-60,000 cells/μ L
      • Protein level - 100-1,000 mg/dL
      • CSF glucose - Less than 60% of plasma glucose
    • Results of CSF Gram staining are positive in 40-60% of acute bacterial meningitis cases, even after initial antibiotic treatment. However, results may be negative if antibiotics have been given on an outpatient basis.
    • Although lumbar puncture findings remain the criterion standard for diagnosis, the current practice is to avoid the procedure in any child with the contraindications listed above.
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Contributor Information and Disclosures
Author

Saul N Faust, MA, MBBS, PhD, MRCPCH  Senior Lecturer in Pediatric Immunology and Infectious Diseases, University of Southampton; Director, Wellcome Trust Clinical Research Facility, Southampton University Hospitals NHS Trust, UK

Saul N Faust, MA, MBBS, PhD, MRCPCH is a member of the following medical societies: British Paediatric Allergy, Immunology and Infectious Group, European Society for Paediatric Infectious Diseases, International Society for Infectious Diseases, and Royal College of Paediatrics and Child Health

Disclosure: Xoma Consulting fee Consulting; GSK Honoraria Consulting; Wyeth travel and registration fee to conference investigator in study being presented at meeting; Sanofi Pasteur Consulting fee Consulting; Pfizer Consulting fee Consulting

Coauthor(s)

Katrina Cathie, BM(Hons), MRCPCH  Academic Clinical Fellow, Southampton University, UK

Katrina Cathie, BM(Hons), MRCPCH is a member of the following medical societies: Royal College of Paediatrics and Child Health

Disclosure: Nothing to disclose.

Michael Levin, PhD, FRCP, FRCPCH  Head, Professor, Imperial College School of Medicine at St Mary's Hospital, Department of Pediatrics, London, England

Disclosure: Nothing to disclose.

Specialty Editor Board

David Jaimovich, MD  Chief Medical Officer, Joint Commission International and Joint Commission Resources

David Jaimovich, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

Joseph Domachowske, MD  Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University

Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Sanofi Pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

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Child with severe meningococcal disease and purpura fulminans.
Flowchart shows guidelines for the emergency management of meningococcal disease in children. These guidelines may be reprinted for use in clinical areas and are available at Meningitis.org.
Flowchart shows guidelines for the emergency management of meningococcal disease in adult patients. These guidelines may be reprinted for use in clinical areas and are available from Meningitis.org.
Chart for family practice recognition and management of meningococcal disease (courtesy of Meningitis.org).
Family practice booklet describing management of meningococcal disease in the community (courtesy of Meningitis.org).
 
 
 
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