PEDIATRICS

MENINGOCOCCEMIA
Outline
★ ETIOLOGY
★ EPIDEMIOLOGY
★ PATHOGENESIS
★ CLINICAL MANIFESTATION
★ PROGNOSIS & COMPLICATIONS
★ DIAGNOSIS
★ MANAGEMENT
★ PREVENTION
 Meningococcemia
● Meningococcal septicemia
● A rare infectious disease characterized by upper respiratory tract
infection, fever, skin rash and lesions, eye and ear problems, and shock
which may be life-threatening without appropriate medical care
● Defined as dissemination of meningococci into the bloodstream
ETIOLOGY

Neisseria meningitidis
● Gram negative
● Fastidious
● Encapsulated
● Oxidase positive
● Aerobic diplococcus

● A commensal of the human

nasopharynx
● Divided into 12 serogroups
● Serotypes A, B , C, W, X and Y are the
most common causes of invasive
disease
EPIDEMIOLOGY
● Children < 2 years old are frequently affected
■ peak rate among infants <1 year
● Another peak attack period occurs in adolescents aged 15 18 years
● Transmission: aerosol droplets or contact with respiratory secretions
■ humans are the only reservoir
● Incubation period: 1-10 days (usually <4 days)
● Period of communicability until 24hrs after initiation of antimicrobial therapy
● Fatality rate is 10%

Serotype A: common cause of epidemics

Serotype B: common cause of sporadic disease
Serotype Y: may cause primary pneumonia
 RISK FACTORS/GROUPS
❏ Age
❏ Male gender
❏ Respiratory viral infections
❏ Smoking and marijuana use
❏ Crowded living conditions
❏ Low socioeconomic status
Persons
● with terminal complement
deficiencies
● with anatomic or functional
asplenia
● with immunosuppression
● Industrial or laboratory
personnel routinely exposed to
organism
● Residents or travelers to
hyper-endemic or epidemic
areas
PATHOGENESIS
PATHOGENESIS
PATHOGENESIS
PATHOGENESIS
Colonization and penetration of nasopharyngeal
mucosal membranes by bacteria
↓
Invasion into the bloodstream
↓
Survival in blood and transportation via circulation
↓
Activation of host inflammatory pathways
↓
⬆Pro-inflammatory cytokines ⬇ Anti-inflammatory cytokines
(TNF-∝, IL-1ß, IL-6 and IL-8) ↓ (IL-1RA, IL-2 and IL-12b)

Activation of coagulation

Bacteremia Meningitis Sepsis Septic Shock Purpura Fulminans

PATHOPHYSIOLOGY: Meningococcal Septicemia
MICROVASCULAR INJURY

Increased Vascular Permeability Dramatic fluid loss and severe hypovolemia

Capillary Leak Syndrome Pulmonary edema and respiratory failure

Initial vasoconstriction results to pallor and Profound

cold extremities Myocardial
Pathologic Vasoconstriction Dysfunction
and Vasodilation following resuscitation
May result to warm shock→ intense
vasodilation with bounding pulses and warm
extremities

Procoagulant state and

Dysfunctional Antithrombotic
Disseminated Intravascular
Mechanisms
Coagulation
CLINICAL MANIFESTATIONS
Meningococcal meningitis and Meningococcemia
● Two most common presentations of invasive disease of meningococcal
infection
● Depending on Host Response an infected individual may have bacteremia
without sepsis, meningococcal septicemia with or without meningitis,
pneumonia, chronic meningococcemia, and occult bacteremia
● Abrupt onset with rapid progression
Acute Meningococcal Septicemia
- Early course→ indistinguishable Progressing Disease
from other causes ❏ Cold hands and feet
❏ Prolonged CRT
- Non-specific symptoms ❏ Non blanching or petechial rash
❏ Fever develops in >80% of cases
❏ Irritability
❏ Lethargy
❏ Respiratory symptoms
❏ Refusal to drink
❏ Vomiting
❏ Limb pain, myalgia or
refusal to walk (7%)
 Fulminant Meningococcal Septicemia
- Rapid progression from
nonspecific symptoms to septic
shock

❏ Prominent petechiae and

purpura or Purpura fulminans
❏ Poor peripheral perfusion
❏ Tachycardia
❏ Tachypnea
❏ Hypotension
❏ Confusion or Coma
MENINGOCOCCAL RASH
 Meningococcal Meningitis
- Presents in highest
portion of cases (30-50%)

- Nonspecific symptoms
❏ Fever
❏ Headache

- More specific
❏ Photophobia
❏ Nuchal Rigidity
❏ Bulging of Fontanel
❏ Brudzinski’s and
Kernig’s signs
 Occult Meningococcal Bacteremia
❏ Fever with or without associated symptoms
❏ Resolution may occur without antibiotics
❏ May lead into meningitis in 60% of cases
 Chronic Meningococcemia
- Rarely occurs

❏ Fever
❏ Non-toxic look
❏ Arthralgia
❏ Headache
❏ Splenomegaly
❏ Maculopapular
rash or petechial
rash

- Duration of illness:
6 to 8 weeks
 PROGNOSTIC FACTORS
- Most deaths occur within 48hrs of hospitalization in patients with meningococcemia

Poor Prognostic Factors Poorer Prognostic Factors

● Hypothermia or hyperpyrexia ● Presence of petechiae <12 hours

● Hypotension or shock or seizures before admission
● Purpura fulminans ● Absence of meningitis
● Leukopenia ● Low or normal ESR
● Thrombocytopenia
● Acidosis
● High levels of endotoxin and TNF α
 COMPLICATIONS

● Adrenal hemorrhage ● Focal skin infarction

● Endophthalmitis ● Distal tissue necrosis
● Arthritis ● Avascular necrosis of epiphyses and
● Endocarditis epiphyseal-metaphyseal defects
● Pericarditis ● Deafness
● Myocarditis ● Cerebral arterial or venous thrombosis
● Pneumonia with resultant cerebral infarction
● lung abscess
● Peritonitis
● Renal infarcts
 DIAGNOSIS
● Initial diagnosis must be
made on clinical assessment
● Confirmed diagnosis is made
by isolation of N.
meningitidis from sterile
body fluid
- Blood
- CSF
- Synovial fluid
- Pleural fluid
- Pericardial fluid
● Gram stain
Laboratory findings:
● Leukocytopenia or leukocytosis
● Anemia, thrombocytopenia
● Proteinuria, and hematuria
● Elevated ESR and CRP
● Decreased serum electrolytes ,
metabolic acidosis
● Decreased serum prothrombin
and fibrinogen and prolonged
coagulation times
 MANAGEMENT
Empirical antimicrobial therapy
● Penicillin G
● 3rd generation cephalosporin
○ Ceftriaxone 2g IV every 12hrs

● IV vancomycin in regions with high resistance to B-lactam drugs

 MANAGEMENT
Drug of choice for meningococcemia
(Treatment duration: 5-7 days)
MANAGEMENT
MANAGEMENT
 MANAGEMENT

Nelson 21st ed
 MANAGEMENT
Supportive Care
● Assessment of airway
● Supplemental Oxygen → Treat hypoxia
● Volume support and inotropic support → Maintain cardiac output due to
hypovolemia
■ endotracheal intubation and ventilation should be initiated in a patient who
remains in compensated shock after 40 mL/kg of fluid resuscitation to improve
oxygenation and reduce work of breathing.

● Assessment and correction of glucose, serum electrolytes , clotting factors

and anemia
 PREVENTION
PRIMARY PREVENTION: Vaccination

Classified as polysaccharide or conjugate

preparations

POLYSACCHARIDE
● Bivalent for serogroups A and C disease
(MPSV2)
● Quadrivalent for serogroups A, C, Y and W 135
(MPSV4)

-A quadrivalent conjugate vaccine for serogroups A,

C, Y, and W 135 (MCV4) has recently been
introduced
 PREVENTION
High Risk Groups
Persons
● with terminal complement
deficiencies
● with anatomic or functional
asplenia
● with immunosuppression
● Industrial or laboratory
personnel routinely exposed
to organism
● Residents or travelers to
hyper-endemic or epidemic
areas
● Local recommendations: 2 doses of
MCV4 → individuals at least 9 months of
age known to be high risk
Adverse reactions
● Local site reactions→ pain and redness
● Fever
● Headache
● Malaise
Contraindication
● Anaphylactic rxn to vaccine component
● Px with moderate or severe acute illness
 PREVENTION
PRIMARY PREVENTION: Vaccination

Single dose of meningococcal vaccine for all children aged 2 years who
1 are known to be high risk

2 During outbreaks, infants and toddlers as young as 3 months to 2 years

may be given 2 doses, 3 months apart

3 Revaccination is considered every 3-5 years after the first dose for those
who remain at risk
 PREVENTION
SECONDARY PREVENTION

● Close Contact
○ individuals who have
been exposed directly
to a patient’s oral
secretions
○ household, kissing,
and close family
contacts of cases, as
well as childcare and
recent preschool
contacts
REFERENCES
Nelson’s Textbook on Pediatrics, 21st edition
Navarro, Fundamentals of Pediatrics
DOH Antibiotic Guidelines, 2018
CDC, Meningococcus
NCBI StatPearls, Meningococcemia