Meningococcemia

 Neisseria meningitidis - is an encapsulated

gram-negative diplococcus
 Acquisition of the organism - results in
asymptomatic pharyngeal colonization or
invasive disease.
 Dissemination of meningococci into the
bloodstream defines meningococcemia and
is a medical emergency..
Pathophysiology

 Humans - are the only natural reservoir

 Transmission - by aerosols or
nasopharyngeal secretions.
 Infection is preceded by colonization of the
nasopharynx..
3 virulence factors:

 A polysaccharide capsule - enables the

organism to resist phagocytosis

 A lipo-oligosaccharide endotoxin - can be

shed in large amounts by a process called
blebbing, causing fever, shock, and other
pathophysiology

 An immunoglobulin A1 protease - cleaves

lysosomal membrane glycoprotein-1 (LAMP1),
helping the organism survive intracellularly
 An outbreak –
 characterized by the occurrence of 3 or
more cases in a 3-month period
 a primary attack rate of at least 10 cases
per 100,000 population.
 Serogroups A and C predominate in Asia and
Africa.
 Case-fatality rate - is approximately 10% for
meningococcal meningitis and 20% for
meningococcemia despite therapy with
antimicrobial agents.
History
 Nonspecific prodrome of cough, headache, and
sore throat may be present. > followed by rapid
onset of fever with chills, arthralgias, and
myalgias.

 In fulminant meningococcemia, collapse occurs

within a few hours, with rapid enlargement of
petechiae and purpuric lesions.

 If meningitis is present with meningococcemia,

then headache, neck stiffness, lethargy, and
drowsiness may be present.
 Decreased mentation and coma may be
present.

 Young children may present with sudden

onset of fever and lethargy. They may also
have vomiting and convulsions.
Physical
Examination

 Patients appear severely ill.

 Tachycardia and mild hypotension
are present.
 Fever is moderate. High fever is
present in fulminant
meningococcemia.
 Petechial rash - present in 50-80% of
patients.
 Axillae, flanks, wrists, and ankles.

 Petechiae - often located in the center

of lighter-colored macules.
 Lesions commonly begin on the trunk
and legs in areas where pressure is
applied.
 Confluence of lesions - results in
hemorrhagic patches, often with central
necrosis.
 Congestive heart failure, gallops, and
pulmonary edema may be present. Other
evidence of end-organ damage may also
rapidly appear.

 In fulminant meningococcemia, rapid

clinical worsening is observed, with
hypotension and respiratory failure.
Laboratory Studies

 Definitive diagnosis - culture of

meningococci from blood, spinal fluid,
joint fluid, or, occasionally, from skin
lesions.

 PMN leukocyte levels - usually elevated.

 Thrombocytopenia may be present.

Laboratory Studies

 In meningitis, CSF pressures are elevated,

with elevated protein levels and low glucose
levels.

 Gram-negative diplococci may be observed in

punch biopsy and needle aspiration
specimens of skin lesions.

 Polymerase chain reaction (PCR) is a rapid

method for diagnosing CSF infection.
Meningococcal Infections
Complications
1. CNS – deafness, seizures, paralysis and
impairment of intellectual function
2. Hydrocephalus – VP shunt
3. Extensive skin necrosis
4. Loss of digits or extremities
5. Intestinal hemorrhage
6. Late adrenal insufficiency
7. Waterhouse-Freiderichsen syndrome: fulminant
meningococcemia w/ DIC, massive skin and
mucosal hemorrhages and shock
Chemoprophylaxis
Rifampin (Rifadin, Rimactane)
 Semisynthetic derivative of rifamycin B that
inhibits bacterial and mycobacterial RNA
synthesis by binding to beta-subunit of DNA-
dependent RNA polymerase, thus inhibiting
binding to DNA and blocking RNA
transcription.
Chemoprophylaxis: Rifampicin
 Adult
 600 mg PO bid for 2 d

 Pediatric
 <1 month: 5 mg/kg PO q12h for 2 d
>1 month: 10 mg/kg PO q12h for 2 d
Antimicrobial Treatment
Aqueous Penicillin G
 Treat suspected meningococcal disease with
a high dose in the initial 48 h of therapy
because meningitis is a likely complication.

 Pediatric dose
 250,000 U/kg/d IV divided q4h
Chloramphenicol (Chloromycetin)
 Used in patients with penicillin allergy.

 Chloramphenicol binds to 50S bacterial-

ribosomal subunits and inhibits bacterial
growth by inhibiting protein synthesis.
 Pediatric

 50-100 mg/kg/d IV divided q6h

Prevention
 Meningococcal vaccine

 Adult
 MCV - for persons ages 11 through 55 years
 0.5 ml IM
 Pediatric
 MPSV - for children 2-10 years old and adults over 55
 0.5 ml IM