Meningococcaemia: Lecture notes

Epidemiology:

• MENINGOCOCCAL DISEASE: ‘MENINGOCOCCAEMIA’
• Potentially pathogenic meningococci present in 2-10% asymptomatic carriers. Droplet / oropharyngeal secretion spread (viability in air only a few seconds).
• Developed-world: disease predominantly serogroups B, C, Y, W135 (in Australia 62% is B, 32% C but over 60% deaths are group C).
• Developing-world: predominantly serogroup A.
• Increased risk in smokers, recent illness, crowded conditions and multiple kissing partners + functional or actual asplenia.

Clinical syndromes include:

• ‘Early’ signs (median of 8 hrs) include leg pains, cold hands and feet, and abnormal skin colour such as pallor or mottling in 72% children.
• Or may be fulminant with rapidly spreading purpura, impaired consciousness and vascular collapse plus coagulopathy with DIC (15-20%) by median of 13-22 hrs. Note rash may be blanching macular or maculopapular in first 24 hours.
• Invasion of meninges (80-85%), purulent leptomeninges, encephalitis, or other organs affected such as heart, joints, eyes (uncommon).
• Chronic meningococcaemia (rare).
• Transient bacteraemia with no sequelae.
• Note that meningitis is not a prerequisite to diagnose meningococcaemia; plus there is only one useful early differentiating feature for influenza which is the presence of a cough, therefore if a cough is absent, do not diagnose “the ‘flu”.

Thompson M, Ninis N, Perera R et al. Clinical recognition of meningococcal disease in children and adolescents. Lancet 2006; 367:397-403. [Reference] (Editorial: Nascimento-Carvalho CM, Moreno-Carvalho O. Lancet 2006; 367:371-2 [Reference]).

Management:

• Immediate benzyl penicillin 1.2 g IV or IM prehospital for suspected meningococcaemia (rigors, fever plus rash)/ meningococcal meningitis.
• Ceftriaxone 4 g (child 100 mg/kg up to 4 g) IV daily or 2 g (50 mg/kg up to 2 g) IV 12-hrly, plus benzylpenicillin 2.4 g (child 60 mg/kg up to 2.4 g) IV 4-hrly until sensitivities known, immediately on suspicion meningococcaemia / bacterial meningitis in hospital, after blood cultures (do not await LP if sick).
• Correction hypovolaemia – may require large volumes of fluids and catecholamine vasopressors/inotropes to optimize cardiac function.
• IPPV for altered mental state, raising ICP, hypoventilation, hypoxia and pulmonary oedema.
• Treatment of DIC, immunomodulation (experimental), surgery including fasciotomy, debridement, amputation, grafting.

Chemoprophylaxis

• Close household contacts or kissing contacts, give rifampicin 600 mg orally bd for 2 days, or ceftriaxone 250 g IM once (if pregnant / liver disease), or ciprofloxacin 500 mg orally once (women on OCP).
• Vaccine – conjugate against group C, and possibly now A (both long term protection) for non-immunised contacts, or tetravalent polysaccharide against groups A, C, W135, Y; except if known outbreak of serogroup B. [For Australia see - http://www.immunise.health.gov.au]

Pollard A, Nadel S, Ninis N et al. Emergency management of meningococcal disease: eight years on. Arch Dis Child 2007;92:283-6. [Reference]

Hart C, Thomson A. Meningococcal disease and its management in children. BMJ 2006;333:685-90. [Reference]

Yung A, McDonald M. Early clues to meningococcaemia. MJA 2003; 178: 134-7. [Reference]

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