Question 22

With regards to meningococcal sepsis:
a) List four risk factors for meningococcal sepsis. (2 marks)
b) Outline the clinical features that increase the suspicion of meningococcal
sepsis as the diagnosis. (3 marks)
c) Outline the specific management of meningococcal sepsis. (3 marks)
d) List four complications of this disease. (2 marks)

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College Answer

Syllabus topic/section:
2.1.3 Sepsis and infections – L1.
2.1.8 Neurological Intensive Care – L1.
Aim:
To allow the candidate to demonstrate competency in a life-threatening infective disease.
Discussion:
Many candidates performed below the standard required for this core level of clinical practice. Risk factors were not well known. Examples would have included contact with incident case, immunodeficiency, and age-related factors.
There was a lack of detail in part b, candidate's answers were not specific to meningococcal sepsis and lacked a structured and organised description of the clinical features. Most candidates did not mention or mentioned an incorrect dose of antibiotics and included investigations as well as management which gained no marks and investigations is part of assessment These candidates would have benefited from using the glossary of terms as a guide to what is required.
The complications mentioned were non-specific and marks were awarded for complications “specific to this disease” (meningococcal sepsis) rather than generic complications of sepsis. E.g. sensory neural hearing loss, cognitive disabilities.

Discussion

a) Risk factors:

  • Immune compromise (eg. splenectomy, chemotherapy, complement deficiency, HIV)
  • Close contact with nasopharyngeal secretions from a case 
  • Crowded living conditions, eg. institutionalisation or incarceration
  • Smoking
  • Young age (under 12 months) or old age (over 65)
  • Travel to the "meningitis belt" in sub-Saharan Africa 

b) Clinical features:

  • Abrupt onset of high fever
  • Myalgias, arthralgias, headache, decreased level of consciousness
  • Petechial or purpuric rash
  • Hypotension and shock
  • Characteristic severe myocardial depression
  • Blood or CSF cultures positive for N.meningitidis
  • PCR of peripheral blood (apparently, it is useful for diagnosis of meningococcal disease)

c) Specific management:

d) Complications:

Or did they mean, longer term? The comments are ambiguous.

  • Physical
    • Amputations (8% of children, 3% adolescents/adults)
    • Skin scars  (55% of children, 18% adolescents, 2% adults)
    • Chronic renal failure
    • Adrenal insufficiency
  • Neurological
    • Hearing loss (8%) or tinnitus
    • Blindness
    • Cranial nerve palsies
    • Persistent cognitive dysfunction
  • Psychological
    • Anxiety, PTSD
    • Learning difficulties
    • Emotional and behavioural difficulties

These are from the abstract of this excellent systematic review submitted by a reader (thank you dinusha@did.not.leave.an email.com), and the article contains a whole table for long term sequelae, which is too large to include here but which has merit as a reference. The percentage values are for adults (in children and infants the complication rates are higher).

References

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.

Pathan, N., S. N. Faust, and M. Levin."Pathophysiology of meningococcal meningitis and septicaemia."  Archives of disease in childhood 88.7 (2003): 601-607.

Rouphael, Nadine G., and David S. Stephens. "Neisseria meningitidis: biology, microbiology, and epidemiology." Neisseria meningitidis. Humana Press, 2012. 1-20.

Pollard, A. J., et al. "Emergency management of meningococcal disease."Archives of disease in childhood 80.3 (1999): 290-296.

Van Deuren, Marcel, Petter Brandtzaeg, and Jos WM van der Meer. "Update on meningococcal disease with emphasis on pathogenesis and clinical management." Clinical microbiology reviews 13.1 (2000): 144-166.

Nassif, Xavier. "Interaction mechanisms of encapsulated meningococci with eucaryotic cells: what does this tell us about the crossing of the blood–brain barrier by Neisseria meningitidis?." Current opinion in microbiology 2.1 (1999): 71-77.

Yunis, A. A. "Chloramphenicol toxicity: 25 years of research." The American journal of medicine 87.3N (1989): 44N-48N.

Bruce, Michael G., et al. "Risk factors for meningococcal disease in college students." Jama 286.6 (2001): 688-693.

Sarah, Kerstin J. Olbrich Dirk Müller, Schumacher Ekkehard Beck, and Kinga Meszaros Florian Koerber. "Systematic Review of Invasive Meningococcal Disease: Sequelae and Quality of Life Impact on Patients and Their Caregivers." (2018).