Diagnostic Considerations

The differential diagnosis of acute meningococcemia encompasses multiple entities, including other infectious processes. Although only 2-11% of children with petechiae and fever have invasive meningococcal disease, antibiotic therapy should be started in children and most adults without awaiting confirmatory evidence. Distinguishing meningococcal disease from other causes in these cases is difficult, and the fatality rate is high. Other causes may include the following:

Bacterial infections - Pneumococcal septicemia, group A streptococcal septicemia, other gram-positive or gram-negative sepsis, and syphilis
Viral infections - Epstein-Barr virus infection, enterovirus infection, measles, rubella, herpes simplex virus infection, cytomegalovirus infection, hemorrhagic viral fevers (eg, dengue)
Other infections - Mycoplasma infection (usually maculopapular), Rocky Mountain spotted fever, epidemic typhus, ehrlichiosis, leptospirosis, and Candida infection
Platelet disorders - Immune thrombocytopenia, leukemia, other causes of bone marrow failure, Bernard-Soulier disease, and Glanzmann disease
Clotting disorders - Hemophilia, von Willebrand disease, vitamin K deficiency, and congenital or acquired protein C or S deficiency
Autoantibody-mediated causes - After varicella, rubella, group A hemolytic, Streptococcus, coumarin drugs, cholestasis, renal dialysis, nephrotic syndrome, and bone marrow transplantation
Vasculitis - Henoch-Schönlein purpura, polyarteritis, antiphospholipid syndrome, other vasculitides, and Kawasaki disease,
Trauma - Injury and violent coughing or emesis
Connective tissue disease - Osteogenesis imperfecta, Marfan syndrome, and vitamin C deficiency
Miscellaneous - Cushing syndrome, hemolytic uremic syndrome, drug ingestion, erythema nodosum, erythema multiforme, and spider and snake bites
Enteroviruses
Infective endocarditis
Influenza
Leptospirosis
Malaria
Antiphospholipid antibody syndrome
Bernard-Soulier syndrome
Bone marrow transplantation
Cholestasis
Enterococcal infection
Hemophilia A, B, and C
Kawasaki disease
Marfan syndrome
Nephrotic syndrome
Polyarteritis nodosa
Bacterial sepsis - Gonococcemia, Haemophilus influenzae, and Streptococcus pneumoniae infection
Anaphylactoid purpura
Arboviral infections
Capnocytophaga canimorsus infection
Marburg virus infection
Acute febrile neutrophilic dermatosis (Sweet syndrome)
H influenzae meningitis - The H influenzae type B vaccine caused the decline of meningitis related to this bacteria; half of all childhood cases of bacterial meningitis are caused by N meningitidis. Most other cases are due to S pneumoniae.
Staphylococcal endocarditis with meningitis ^[78]

Workup

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Media Gallery

Dorsum of the hand showing petechiae. Courtesy of Professor Chien Liu.
Petechiae on the palm. Courtesy of Professor Chien Liu.
Petechiae on lower extremities. Courtesy of Professor Chien Liu.
Conjunctival petechiae. Courtesy of Professor Chien Liu.
Gram-negative intracellular diplococci. Courtesy Professor Chien Liu.
Scattered petechiae in a patient with acute meningococcemia.
Purpura in a young adult with fulminant meningococcemia.
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.
A 9-month-old baby in septic shock with purpuric Neisseria meningitis skin lesions. Photo by D. Scott Smith, MD, taken at Stanford University Hospital.
The leg of a 9-month-old infant in septic shock with a rapidly evolving purpuric rash. Photo by D. Scott Smith, MD, taken at Stanford University Hospital.
Neisseria meningitis purpuric lesions on the ear and cheek of a 9-month-old infant who is in septic shock. Photo by D. Scott Smith, MD, taken at Stanford University Hospital.
Lesions caused by Neisseria meningitis bacteremia on the palm of the hand of a 9-month-old infant. Photo by D. Scott Smith, MD, taken at Stanford University Hospital.
Areas with frequent epidemics of meningococcal disease. This is known as the meningitis belt of Africa; visitors to these locales may benefit from meningitis vaccine. Image courtesy of CDC.
Child with severe meningococcal disease and purpura fulminans.
Flow chart 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.
Flow chart 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).

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Table 1. Guidelines on Meningococcal B Vaccination by the Advisory Committee on Immunization Practices ^{[100, 101]}

Patient population	Conditions	Vaccine Regimen
Persons aged 10 years or older at increased risk for serogroup B meningococcal disease	In high-risk persons and during serogroup B meningococcal disease outbreaks	3 doses of MenB-FHbp at 0, 1-2, and 6 months to provide earlier protection and maximize short-term immunogenicity. If the second dose of MenB-FHbp is administered at an interval of 6 months or greater, a third dose need not be given.
Adolescents and young adults aged 16-23 years	Healthy adolescents and young adults	2 doses of MenB-FHbp at 0 and 6 months. If the second dose of MenB-FHbp is given less than 6 months after the first dose, give a third dose at least 4 months after the second dose.
Pregnant or lactating individuals		Defer vaccination unless the person is at increased risk for serogroup B meningococcal disease and their healthcare provider determines benefits outweigh potential risks.

Table 2. Recommendations for Meningococcal Vaccine According to Type of Patient

Type of patient	Vaccine type	Regimen
11-18 years old	Quadrivalent ACWY vaccines	One dose at age 11-12 years and booster at 16 years
19–21 years old	Quadrivalent ACWY vaccines +/- serogroup B vaccines	Freshman in college dormitories should receive serogroup B vaccines

Table 2. Guidelines on Meningococcal B Vaccination by the Advisory Committee on Immunization Practices

Patient population	Conditions	Vaccine Regimen
Persons aged 10 years or older at increased risk for serogroup B meningococcal disease	In high-risk persons and during serogroup B meningococcal disease outbreaks	3 doses of MenB-FHbp at 0, 1-2, and 6 months to provide earlier protection and maximize short-term immunogenicity. If the second dose of MenB-FHbp is administered at an interval of 6 months or greater, a third dose need not be given.
Adolescents and young adults aged 16-23 years	Healthy adolescents and young adults	2 doses of MenB-FHbp at 0 and 6 months. If the second dose of MenB-FHbp is given less than 6 months after the first dose, give a third dose at least 4 months after the second dose.
Pregnant or lactating individuals		Defer vaccination unless the person is at increased risk for serogroup B meningococcal disease and their healthcare provider determines benefits outweigh potential risks.

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Author

Mahmud H Javid, MBBS Consultant in Infectious Diseases, Quaid-e-Azam International Hospital, Pakistan

Mahmud H Javid, MBBS is a member of the following medical societies: Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Coauthor(s)

Shadab Hussain Ahmed, MD, FACP, FIDSA, AAHIVS Professor of Clinical Medicine, Renaissance School of Medicine at Stony Brook University Medical Center; Adjunct Clinical Associate Professor, Department of Medicine, New York College of Osteopathic Medicine of New York Institute of Technology; Chief, Division of Infectious Diseases, Department of Medicine, Nassau University Medical Center

Shadab Hussain Ahmed, MD, FACP, FIDSA, AAHIVS is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

John L Brusch, MD, FACP Corresponding Faculty Member, Harvard Medical School

John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Acknowledgements

Katrina Cathie, BM (Hons), MRCPCH, Fellow in Paediatric Clinical Research, Southampton NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, UKKatrina Cathie, BM(Hons), MRCPCH is a member of the following medical societies: Royal College of Paediatrics and Child Health