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Meningococcemia


Background

Nan’s life was tragically cut short by a severe infection with Meningococcemia,  an acute (sudden onset) infection of the bloodstream and subsequent vasculitis (inflammation of the blood vessels) caused by the bacteria Neisseria meningitidis.

Meningococcemia is a rare infectious disease characterized by upper respiratory tract infection, fever, skin rash and lesions, eye and ear problems, and possibly a sudden state of extreme physical depression (shock) which may be life-threatening without appropriate medical care. There are two forms of meningococcemia. Fulminant meningococcemia develops very rapidly and is more severe than chronic meningococcemia, which has a waxing and waning course.

Neisseria meningitidis is the second most common cause of community-acquired adult bacterial meningitis in the United States.. Since routine vaccination of infants with the Haemophilus influenzae type b capsular conjugate vaccine was introduced, N. meningitidis has become the leading cause of bacterial meningitis in children and young adults in the United States, with an overall mortality rate of 13 percent. The clinical manifestations of meningococcal disease can be quite varied, ranging from transient fever and bacteremia to fulminant disease with death ensuing within hours of the onset of clinical symptoms.

Because of the trend for endemic meningococcal infection to occur during the late winter when concurrent influenza virus is in the community, many cases of meningococcal disease are mistaken initially for severe “flu.” It is also not uncommon for other cases to have been reported in the region or for the patient to have been a contact of a previously diagnosed case. Alternatively, preceding symptoms of pharyngitis, which in meningococcal meningitis is nonsuppurative, can lead to a preliminary misdiagnosis of streptococcal pharyngitis. However, patients with meningococcal meningitis either present with, or soon develop, a degree of illness that is much too severe to warrant these diagnoses. The patient will frequently tell the physician that this is the sickest they have ever felt; many express the feeling that they are going to die. With infants, the parents are frequently more worried than the early symptoms may warrant.

Symptoms

Symptoms may be very few at first, and can include:

  • Fever
  • Petechial (spotty red or purple) rash
  • Irritability
  • Appears Anxious

Later symptoms and signs can include:

  • Appears acutely ill
  • Changing level of consciousness
  • Shock
  • Large areas of hemorrhage and/or thrombosis under the skin

Quickly (within hours), the blood vessel damage increases and large bleeding areas on the skin (purpura) are seen. The same changes are taking place in the affected person’s internal organs. The blood pressure is often low and there may be signs of bleeding from other organs (like coughing up blood, nose bleeds, blood in the urine). The organism not only damages the blood vessels by causing them to leak, but also causes clotting inside the vessels. If this clotting occurs in the larger arteries, it results in major tissue damage. Essentially, large areas of skin, muscle, and internal organs die from lack of blood and oxygen. Even if the disease is quickly diagnosed and treated, the patient has a high risk of dying.

Treatment

Immediate treatment of a suspected case of meningococcemia begins with antibiotics that work against the organism. Possible choices include penicillin G, ceftriaxone (Rocephin), cefotaxime (Claforan), or trimethoprim/sulfamethoxazole (Bactrim, Septra). If the patient is diagnosed in a doctor’s office, antibiotics should be given immediately if possible, even before transfer to the hospital and even if cultures cannot be obtained before treatment. It is most likely that the speed of initial treatment will affect the ultimate outcome.

Prognosis

As many as 15-20% of patients with meningococcemia will die as a result of the acute infection. A significant percentage of the survivors will have tissue damage that requires surgical treatment. This treatment may consist of skin grafts, or even partial or full amputations of an arm or leg. Certain people with immune system defects (particularly those with defects in the complement system) may have recurrent episodes of meningococcemia. These patients, however, seem to have a less serious outcome.

Prevention

Although a vaccine is available for meningococcus, it is still difficult at this time to produce a vaccine for the type B organism, the most common one in the United States. Because of this and the short time that the vaccine seems to offer protection, the product has not been routinely used in the United States. It can be used for travelers going to areas where meningococcal disease is more common or is epidemic. Recently, the vaccine has been suggested for use in incoming college freshman, particularly those living in dormitories. These students appear to have a somewhat higher risk of meningococcal infections.

It is, however, recommended that all people take certain antibiotics if they have had contact (like at home or in a daycare) with a person who has meningococcal infection. The most common antibiotics given are rifampin (Rifadin) or ciprofloxacin (Cipro). These medicines are usually taken by mouth twice a day for two days. This treatment will decrease the risk of infection in these people who have been exposed. However, the overall risk to people who have been exposed, even without antibiotic use, is probably no more than 1-2%.