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[EMERGENCIES]


Meningococcemia: Heading Off a Killer

Warren B. Howe, MD

Emergencies Series
Editor: Warren B. Howe, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 24 - NO. 2 - FEBRUARY 96


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In Brief: Meningococcemia is a dangerous disease requiring early and aggressive treatment to prevent a potentially lethal outcome. It often occurs in relatively closed groups, including sports camps and athletic teams. A high index of suspicion must be maintained when evaluating acute febrile illness, particularly in people younger than 20. Treatment includes antibiotics and intensive care support. Prophylaxis in the intimately exposed population, and education about signs and symptoms of the disease for more peripheral contacts are critical for successfully limiting any outbreak.

The youngster looked ill. He was attending a summer sports camp and woke the trainer at 5:00 am to report feeling hot and having nausea and abdominal pain. The trainer alertly notified the camp physician, who saw the 10-year-old boy shortly thereafter and noted an ill-appearing patient with a temperature of 103°F, diffuse abdominal tenderness, and a 1.5-cm tender, ecchymotic lesion on his left lateral malleolus. He did not have signs of meningitis.

By the time the patient was transferred to the hospital, he had developed a number of petechial lesions on his limbs and trunk. Antibiotic treatment for septicemia was instituted, and the boy made an excellent recovery. Blood cultures later grew Neisseria meningitidis.

Almost simultaneously with the patient's hospital admission, a friend of the patient—with whom the patient had attended a swim meet 2 days before departing to camp—was admitted to the same hospital with similar symptoms. This second 10-year-old boy was also successfully treated for meningococcemia. As is usually the case in outbreaks of invasive meningococcal disease, the camp administration and the parents of children attending the camp were considerably dismayed about the implications of this infection. The camp physician spent more effort in arranging prophylaxis for those exposed and educating the entire population involved about the disease than was spent in treating the index case.

No further cases occurred. The successful outcome, achieved without significantly interrupting the camp's activities, was satisfying for all concerned.

Epidemiology

Outbreaks of meningococcal disease occur sporadically and may, as in this case report, involve athletes and sports situations. This is a dangerous disease that demands early and aggressive treatment, vigorous measures to control spread, and reassurance for the larger population that may feel threatened by the outbreak.

Neisseria meningitidis is a gram-negative diplococcus whose reservoir is the human nasopharynx. Serogroup A is associated with large-scale epidemics, particularly in developing countries, while serogroups B and, increasingly, C are currently associated with localized outbreaks in North America. Jackson et al (1) have documented 21 outbreaks of serogroup C disease in the United States between 1981 and 1993, with dramatically increasing frequency since 1990. The emergence of new, increasingly virulent strains has also been associated with outbreaks (1,2).

The organism can be cultured in 5% to 15% of healthy people and spreads when people inhale droplets of contaminated upper-respiratory secretions. During outbreaks, this percentage rises significantly in the affected population, although only a small number of those carrying the organism will develop clinical meningococcal disease. The incubation period is 1 to 10 days, usually 4 days or less.

Most cases of invasive meningococcal disease occur in patients younger than 20, and the risk of contagion seems to vary with the closeness and persistence of contact; it is highest in household members. Outbreaks have been reported in populations in other relatively closed settings, such as military camps, day care centers, and colleges. However, many patients cannot recall exposure to symptomatic individuals.

Signs and Symptoms

Few, if any, symptoms attend nasopharyngeal infection by meningococci. In the early stages of invasive disease, meningococcemia usually presents as an acute febrile illness with malaise, nausea, myalgia or arthralgia, significant fever, and chills. Instead of the rapid resolution of symptoms usually associated with self-limited infections, the patient with meningococcemia usually becomes progressively and impressively sicker with toxemia and prostration.

Rash occurs in most patients, and because it can develop very quickly, should be searched for repeatedly. It is initially macular, erythematous, and located mainly on the extremities; petechiae and purpura subsequently develop. Other symptoms depend on where the meningococci localize after hematogenous spread.

Meningitis, with symptoms such as a stiff neck, severe headache, back pain, and mental status changes, is the most common localized manifestation. Meningococcal pneumonia, endocarditis, myocarditis, pericarditis, pleurisy, peritonitis, and arthritis may also occur. Approximately 10% of patients with meningococcemia develop Waterhouse-Friderichsen syndrome, characterized by a fulminant septicemia with shock, widespread purpura (purpura fulminans), congestive heart failure, and progressive, usually irreversible, collapse.

Laboratory abnormalities typically include significant leukocytosis with left shift, but leukopenia may occur in overwhelming disease. Coagulopathy may be demonstrable. If meningeal infection has occurred, purulent spinal fluid is encountered with elevated cerebrospinal fluid protein and decreased glucose. Cultures of blood and cerebrospinal fluid will usually be positive for meningococci; serogroup and serotype identification can aid epidemiologic investigation (1).

Prompt Treatment

The key to effective intervention is a high index of suspicion at the early stage, particularly during periods of increased respiratory disease in the community, since meningococcemia also seems to peak at such times. Once meningococcemia is suspected, antibacterial treatment must be instituted promptly, because early treatment seems to improve prognosis (3). Urgent hospitalization for intensive care and support is mandatory.

Blood cultures can be obtained as the intravenous (IV) line is being placed. For adults, IV penicillin G, 2 million units every 2 hours around the clock, is appropriate. The dose for children is 250,000 units/kg/day administered every 2 hours in divided doses.

If penicillin-resistant meningococci are suspected, alternatives include IV ceftriaxone sodium (adults 4 g/day, children 100 mg/kg/day; doses every 12 hours) or chloramphenicol (adults and children 100 mg/kg/day, maximum 4 g/day; doses every 6 hours). Ceftriaxone is preferred as initial therapy in children, because septicemia with Haemophilus influenzae can produce a clinical picture similar to that of meningococcemia. Chloramphenicol is especially useful in patients who have a history of anaphylactic reaction to penicillin; its use is otherwise limited by potential hematologic toxicity.

Avoiding an Epidemic

Preventing the spread of the disease and treating new cases early are critical. This is an urgently reportable disease in all states. Once the diagnosis is made, the early symptoms of meningococcemia should be widely publicized, and people in the potentially exposed population should be urged to seek immediate medical evaluation if they contract a febrile illness.

Patients who have meningococcemia should be isolated during the first 24 to 36 hours of antibacterial therapy. Household members are at greatest risk for contagion, followed by contacts within the relatively closed populations mentioned earlier. People in close contact with the patient should receive chemoprophylaxis aimed at eradicating meningococci from the nasopharynx. More peripheral contacts are not routinely treated, although I have adopted the philosophy of treating any peripheral contact who requests prophylaxis.

Currently recommended medications for prophylaxis include the drug of choice, rifampin, and also minocycline, ceftriaxone, ciprofloxacin, and—when the organism is known to be sensitive to it—sulfadiazine (table 1). Remember that rifampin stains body fluids orange, including tears, so permanent staining of soft contact lenses can result. Because meningococci can often be recovered from the nasopharynx of treated meningococcemia patients, they must also receive chemoprophylaxis before being discharged from the hospital (5).

______________________________________________________________________________
Table 1. Meningococcal Disease Chemoprophylaxis for Children and 
Adults
______________________________________________________________________________
Drug           Dosage                              Dosage     
               Adult, Child      Dosage            Child           
               13 Yr or Older    Child 1-12 Yr     Under 1 Yr      Comments
______________________________________________________________________________
Rifampin       600 mg orally     10 mg/kg          5 mg/kg orally  Preferred 
               every 12 hr,      (max 600 mg)      every 12 hr,    drug
               4 doses           orally every 12   4 doses 
                                 hr, 4 doses
Sulfadiazine   1,000 mg          500 mg orally     500 mg orally   Only if index
               orally every      every 12 hr,      every 24 hr,    organism
               12 hr, 4 doses    4 doses           2 doses         sensitive
                                                                   to this drug
Ciprofloxacin  Age 18 yr         NA                NA              Not recommended
               or older: 750                                       for  under age
               mg as  single                                       18 yr
               oral dose (4)
Minocycline    200 mg orally     Age  8 yr or      NA              Avoid in
               followed by       older: 4 mg/kg                    pregnancy
               6 100-mg oral     orally followed                   and  under 
               doses every       by 6 2-mg/kg                      age 8 yr
               12 hr             oral doses every
                                 12 hr
Ceftriaxone    250 mg,           125 mg,           125 mg,         Intramuscular
sodium         single dose       single dose       single dose
NA=Not applicable
______________________________________________________________________________

Meningococcal vaccine effective against serogroups A, C, Y, and W-135 (but not serogroup B) is available. It is used routinely in the military, and is recommended for travel to endemic areas. Patients who may have impaired resistance—such as those who have no spleen or are deficient in terminal-component complement—should be offered immunization. Universal immunization is not practiced, but the vaccine is recommended by some authorities as a supplement to chemoprophylaxis for controlling outbreaks involving a vaccine-sensitive organism (1).

Raising Awareness

By educating themselves about common manifestations of the disease, physicians can raise their index of suspicion for meningococcal disease in patients affected by febrile illness, which can result in early diagnosis. Then quick action can be taken to treat the afflicted person and help prevent the spread of the disease.

Suggested Reading

  • Samore MII, Karchmer, AW: Infections due to Neisseria, in Dale DC, Federman DD (eds): Scientific American Medicine. New York City, Scientific American, Inc, 1994, secn 7, III, pp 1-9

References

  1. Jackson LA, Schuchat A, Reeves MW, et al: Serogroup C meningococcal outbreaks in the United States: an emerging threat. JAMA 1995;273(5):383-389
  2. Whalen CM, Hockin JC, Ryan A, et al: The changing epidemiology of invasive meningococcal disease in Canada, 1985 through 1992: emergence of a virulent clone of Neisseria meningitidis. JAMA 1995;273(5): 390-394
  3. Strang JR, Pugh EJ: Meningococcal infections: reducing the case fatality rate by giving penicillin before admission to hospital. BMJ 1992;305(6846):141-143
  4. Dworzack DL, Sanders CC, Horowitz EA, et al: Evaluation of single-dose ciprofloxacin in the eradication of Neisseria meningitidis from nasopharyngeal carriers. Antimicrob Agents Chemother 1988;32(11): 1740-1741
  5. Abramson JS, Spika JS: Persistence of Neisseria meningitidis in the upper respiratory tract after intravenous antibiotic therapy for systemic meningococcal disease. J Infect Dis 1985;151(2):370-371

Dr Howe is the team physician at Western Washington University in Bellingham, Washington, and a member of the editorial board of The Physician and Sportsmedicine. Address letters to Warren B. Howe, MD, 4222 Northridge Way, Bellingham, WA 98226; e-mail to [email protected]


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