Meningococcemia Clinical Presentation

Updated: Aug 28, 2018
  • Author: Mahmud H Javid, MBBS; Chief Editor: John L Brusch, MD, FACP  more...
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Presentation

History

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.)

Purpura in a young adult with fulminant meningococ Purpura in a young adult with fulminant meningococcemia.

Meningitis

Meningitis is associated with the following [1] :

  • Headache
  • Fever
  • Vomiting
  • Photophobia
  • Lethargy
  • Neck stiffness
  • 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

Septicemia may be confused with influenza, particularly when myalgia is prominent. Meningococcal septicemia is characterized by the following [3] :

  • Fever
  • 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. [54]
  • Vomiting
  • Headache
  • Myalgia that may be diffuse and severe
  • Abdominal pain
  • Tachycardia/tachypnea
  • Hypotension
  • Cool extremities
  • 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

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. [55]

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.

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Physical Examination

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.

Dermatologic manifestations

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.)

Dorsum of the hand showing petechiae. Courtesy of Dorsum of the hand showing petechiae. Courtesy of Professor Chien Liu.
Petechiae on lower extremities. Courtesy of Profes Petechiae on lower extremities. Courtesy of Professor Chien Liu.
Scattered petechiae in a patient with acute mening Scattered petechiae in a patient with acute meningococcemia.
The legs of a 22-year-old woman in septic shock wi The legs of a 22-year-old woman in septic shock with a rapidly evolving purpuric rash. Photo by D. Scott Smith, MD, taken at Stanford University Hospital.

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. [56]

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).

Conjunctival petechiae. Courtesy of Professor Chie Conjunctival petechiae. Courtesy of Professor Chien Liu.
Petechiae on the palm. Courtesy of Professor Chien Petechiae on the palm. Courtesy of Professor Chien Liu.

Fulminant meningococcemia

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.

Child with severe meningococcal disease and purpur Child with severe meningococcal disease and purpura fulminans.

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.

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