Question 10

College Answer

•    Acute systemic meningococcal disease is usually manifest as meningitis &/or meningococcaemia. The diagnostic features include: history of sudden onset of fever/nausea/vomiting/headache/myalgias (sometimes intense), with rapid progression. Examination may reveal hypotension, tachycardia, diaphoresis, and discrete petechiae (initially 1-2 mm diameter; may coalesce). Shock is often profound with extreme vasoconstriction. Blood cultures and CSF cultures are often positive.
•    Complications include refractory shock, disseminated intravascular coagulation (including bleeding and major vessel thrombosis), cerebral oedema, and myocardial dysfunction.
•    Treatment is with immediate antibiotics. High dose penicillin (2 million units every 2 hours for adults) or chloramphenicol or 2nd or 3rd generation cephalosporins (according to sensitivities). Supportive care for shock (vasopressors and fluids) and other complications (eg. DIC, ARDS etc). Other unproven therapies may include plasmapheresis or activated protein C.

Discussion

A good NEJM review article is available which covers this territory well.

Diagnostic features of meningococcal sepsis

• Abrupt onset of high fever
• Myalgias, arthralgias, headache, decreased level of consciousness
• Petechial or purpuric rash
  • progression to purpura fulminans
• Hypotension and shock
• Blood or CSF cultures positive for N.meningitidis

Complications of meningococcal sepsis

• Septic shock
• DIC
• Acute adrenal haemorrhage (Waterhouse-Friedrichsen syndrome)
• Multiorgan system failure
• Meningitis
• Conjunctivitis
• Arthritis
• Pericarditis

Management of meningococcal sepsis

• Most strains are susceptible to penicillin
• The Sanford Guide recomends ceftriaxone 2g bd or benzylpenicillin 2.4g q4h
• Chloramophenicol is an alternative
• Supportive management consists of vasopressor support and fluid resuscitiation, with correction of DIC-associated coagulopathy
• Corticosteroids may be useful if there is meningitis
• Plasma exchange may improve survival if commenced early, but the evidence for it is not robust.

Rosenstein, Nancy E., et al. "Meningococcal disease." New England Journal of Medicine 344.18 (2001): 1378-1388.

Mautner, L. S., and W. Prokopec. "Waterhouse-Friderichsen Syndrome."Canadian Medical Association journal 69.2 (1953): 156.

Kumar, Ajay, et al. "Plasma exchange and haemodiafiltration in fulminant meningococcal sepsis." Nephrology Dialysis Transplantation 13.2 (1998): 484-487.