INITIAL SYMPTOMS
Meningitis: fever, headache, stiff neck; Meningococcemia: fever, petechiae, hypotension, DIC, and multiple organ failure; [CCDM] Meningitis (>50% of cases); Meningococcemia (up to 40% of cases); [CDC Travel, p. 294]
COMMENTS
FINDINGS:
Asymptomatic carriage in the nasopharynx is the most common form of infection. Upper respiratory symptoms are common prior to the onset of invasive disease. These may be caused by viral infections which then promote meningococcal acquisition. The petechial rash is present in 28 to 77% of cases with invasive disease, but it may be difficult to see in patients with dark skin. In the early stages, the disease may mimic influenza. The rash is distinctive in its early onset (within 2 hours of fever), distribution (appears on ankles, wrists, and armpits), and character (petechial with discrete lesions 1-2 mm in diameter on the trunk and lower extremities). The rash usually spares the palms and soles. It may appear as papules initially, but quickly progresses to petechiae and purpura. Ecchymoses are common at points of pressure from clothing such as underwear and stockings. Rubella-like and vesicular rashes have been described in some patients. Patients may have pharyngitis. Pneumonia occurs with meningococcemia or meningitis in 8-15% of cases.
FULMINANT DISEASE:
Patients with fulminant disease develop widespread ecchymoses and purpura. In these patients the WBC count may be either high or low, and thrombocytopenia and intravascular coagulation are common. Disseminated intravascular coagulation (DIC) and multi-organ failure occur in meningococcal sepsis. Signs of DIC include enlarging petechiae, oozing at IV sites, and gingival and gastric bleeding. Other complications are pneumonia, peritonitis, arthritis, osteomyelitis, iritis, endophthalmitis, otitis, epiglottitis, urethritis, endocarditis, myocarditis, pericarditis, pulmonary edema, brain abscesses, and cranial nerve palsies. Congestive heart failure caused by myocarditis is common in fatal cases. [CCDM, p. 404-9; Guerrant, p. 177-9; ID, p. 58-60, 1653; PPID, p. 2593-8; Cohen, p. 1563-4; ABX Guide; Harrison ID, p. 492-4; Merck Manual , p. 1665-7]
OTHER SYNDROMES:
Very young children with meningitis may present with fever, abdominal pain, and vomiting. [Cohen, 3rd Ed, p. 1685] Chronic meningococcal infection is very rare. Symptoms include recurrent fever, skin eruptions (maculopapular, nodular, pustular, and petechial), and migratory arthritis. [PPID, p. 810] Skin manifestations (pruritic papules and urticarial eruptions) occur in 50% of cases of chronic meningococcemia. [Guerrant, p. 179] Chronic meningococcemia is suspected in patients with repeated bouts of petechial rash, fever, joint pain, and splenomegaly. It may progress to acute meningococcemia. [Harrison ID, p. 471] Fulminant meningococcal supraglottitis with sore throat and dysphagia is a rare presentation. Meningococcal pneumonia (cough, chest pain, and infiltrates) has been reported in military recruits and is more common in older adults. [PPID, p. 2597]
EPIDEMIOLOGY:
Meningococci in serogroups A, B, and C cause most outbreaks. The highest incidence of diseases occurs in children and young adults with a 5% to 10% mortality rate despite optimal treatment. An epidemic occurs about every 8-12 years in the meningitis belt in sub-Saharan Africa in the dry season between January and June. [Guerrant, p. 176-7]
PREVENTION:
"In rare instances, when proper precautions were not used, N. meningitidis has been transmitted from patient to personnel, through contact with the respiratory secretions of patients with meningococcemia or meningococcal meningitis, or through handling laboratory specimens. . . . Postexposure prophylaxis is advised for persons who have had intensive, unprotected contact (i.e., without wearing a mask) with infected patients (e.g., mouth-to-mouth resuscitation, endotracheal intubation, endotracheal tube management, or close examination of the oropharynx of patients)." [Guidelines for Infection Control in Health Care Personnel. CDC. 1998] Vaccination is recommended for travelers to the sub-Saharan "meningitis belt" during the dry season. There are 4 vaccines licensed in the USA, including two serogroup B meningococcal vaccines. [CDC Travel, p. 295-6] "A 2-dose vaccine series is recommended for HCP with known asplenia or persistent complement component deficiencies, because these conditions increase the risk for meningococcal disease." Vaccine indicated for "clinical and research microbiologists who might routinely be exposed to isolates of Neisseria meningitidis." [ACIP, 2011]
REFERENCES FOR CASES/YEAR
1. (US) Published in MMWR 2011 = 759; Estimated 1400 to 2800 cases per year prior to 2000; Cases have declined since then; [http://www.cdc.gov/vaccines/pubs/pinkbook/mening.html]
2. (Global) 80-85% Group A; 2009 epidemic with 88,199 cases and 5352 deaths, the largest numbers since the 1996 epidemic; [Fact sheets from WHO 2013] 500,000 cases estimated to occur annually with about a 10% case fatality rate; [Harrison ID, p. 467]