Meningitis
Myalgias may be an important differential sign, and occasionally the pain is quite
intense. These are generally more painful than myalgias seen in viral influenza. Disease
progression is usually quite rapid with transition from health to severe disease in a
matter of hours.
Because of the trend for endemic meningococcal infection to occur during the late
winter when concurrent influenza virus is in the community, many cases of
meningococcal disease are mistaken initially for severe "flu." It is also not uncommon
for other cases to have been reported in the region or for the patient to have been a
contact of a previously diagnosed case.
The clinical expression of this infection ranges widely, and, thus, a high index of
suspicion and a careful search for clues of disease are required to make a diagnosis,
particularly in the absence of an epidemic. (See "Epidemiology of Neisseria
meningitidis infection".)
The difficulty in identifying meningococcal disease is due, in part, to the fact that
clinicians in the community see so few cases in their lifetime and that the classic clinical
features of meningococcal disease (eg, hemorrhagic rash, meningismus, and impaired
consciousness) appear late in the illness. The critical need for diagnosis as early as
possible, because of the narrow time window between progression from initial
symptoms to death, prompted a systematic study of the occurrence of symptoms before
admission to the hospital in children and adolescents (aged 16 years) with
meningococcal disease [6].
Data were obtained from questionnaires answered by patients and primary care
physician records of the clinical symptoms and signs of infection before admission to
the hospital in 448 children (103 fatal and 345 nonfatal). The following findings were
noted:
The median time between onset of symptoms and admission to the hospital was 22
hours:
The first specific clinical symptoms were signs of sepsis in all age groups:
The first classic symptom of meningococcal disease was rash, which sometimes
evolved from nonspecific to petechial to hemorrhagic over several hours (in 42 to 70
percent of cases).
Median time of onset of specific meningitis symptoms (eg, neck stiffness,
photophobia, bulging fontanelle) was approximately 12 to 15 hours after onset of
illness. Late signs of meningitis (eg, unconsciousness, delirium, or seizures) occurred at
a median of 15 hours in infants under 1 year of age and 24 hours in older children.
Most children (72 percent) had one of the three sepsis symptoms (eg, leg pain,
abnormal skin color, or cold hands and feet) at a median time of 8 hours after the onset
of illness, 11 hours sooner than the median time of hospital admission (19 hours).
The authors suggested that both clinicians and parents should be educated regarding the
frequency and importance of the early signs of sepsis (eg, leg pain, cold hands and feet,
and abnormal skin color) as potential warning signs of meningococcal disease. The
study was limited by retrospective data collection, recall bias, and the absence of similar
data collection for children with other illnesses to compare frequency of symptoms.
Leg pain
Physical examination The vital signs often show a low blood pressure with an
elevated pulse rate. The patient should be examined for postural hypotension as a sign
of early vascular instability. Diaphoresis is common. Patients will frequently respond to
intravenous infusions with transient rises in blood pressure and an improved sense of
wellbeing. This can be misleading and result in a delay in initiating definitive
antimicrobial and supportive therapy.
The pathogenesis of this problem in patients with meningococcal sepsis may be related
in part to high levels of circulating microparticles that originate from platelets or
granulocytes and have procoagulant activity. In one report, those with the most severe
manifestations had microparticles which, when added to normal plasma in vitro,
generated a substantial amount of thrombin [11]. Clinical evidence of DIC becomes
apparent with extension of subcutaneous hemorrhages, gastric or gingival bleeding, or
oozing at the sites of venipuncture or intravenous infusions.
A number of studies have shown that patients with DIC and purpura fulminans,
especially children, have low levels of protein C [12-14] (see "Protein C deficiency").
Protein C appears to play a role in anticoagulation but also in modifying inflammation
[13]. One study examined vascular endothelial integrity, endothelial protein C receptor,
and plasma thrombomodulin in children with meningococcal sepsis and found intact
endothelial cells in both thrombosed and unaffected vessels in skin biopsy specimens
but decreased expression of endothelial thrombomodulin and protein C receptor [15].
Plasma thrombomodulin was higher in patients with meningococcal sepsis compared
with healthy controls. The authors concluded that protein C activation in endothelial
cells might be disordered in patients with severe meningococcal sepsis. Protein C
replacement is being investigated as a possible therapeutic agent. (See "Treatment and
prevention of meningococcal infection".)
More than 50 percent of patients who die of meningococcal disease have myocarditis of
varying degrees of severity detected on postmortem examination [21,26]. In one series
of 12 children with meningococcemia, those with evidence of myocardial dysfunction
on serial echocardiograms had a higher incidence of fatal outcomes (three of seven
children versus zero of five) [27].
The crude and age-adjusted mortality rates were 0.10 deaths per 100,000 population
per year
The majority of deaths occurred among persons <25 years of age (58 percent)
Mortality was highest in infants (crude mortality rate 0.95 per 100,000 population)
Age-adjusted mortality rates were significantly higher among African Americans (0.13
per 100,000 population) compared with other racial or ethnic groups
Mortality rates increased from 1990 to 1997 and decreased from 1998 to 2002
(primarily due to declining mortality in children <5 years and infants)
While the ability of the meningococcus to cause pneumonia has been appreciated for
many years [52-55], it is difficult to establish the diagnosis from a sputum culture since
nasopharyngeal carriage of the organism is common. Unlike the situation with the
pneumococcus, the incidence of bacteremia in meningococcal pneumonia appears to be
quite low [53], which means that blood cultures probably do not assist in making the
diagnosis. In a group of 68 Air Force recruits with group Y meningococcal pneumonia,
transtracheal aspiration and culture were used to confirm the etiology [53].
More than 50 percent of patients in this large series had a history of cough, chest pain,
chills, and previous upper respiratory infection [53]. Almost all of the patients had rales
and fever; an accompanying pharyngitis occurred in over 80 percent. Forty percent of
patients had involvement of more than one lobe on chest radiography; the right lower
and middle lobes were the most frequently affected. No deaths occurred in this study.
SUMMARY
Myalgias may be an important differential sign, and occasionally the pain is quite
intense. These are generally more painful than myalgias seen in viral influenza. Disease
progression is usually quite rapid with transition from health to severe disease in a
matter of hours. (See 'Clinical manifestations' above.)
The clinical expression of this infection ranges widely, and, thus, a high index of
suspicion and a careful search for clues of disease are required to make a diagnosis,
particularly in the absence of an epidemic. (See 'Clinical manifestations' above.)
Although initial clinical features of patients with meningococcal disease are similar to
many common, self-limiting viral illnesses seen in primary care, signs of early sepsis
should differentiate the patient who merits clinical monitoring. (See 'Worrisome signs'
above.)
The vital signs often show a low blood pressure with an elevated pulse rate. An
intensive search for petechiae and ecchymoses should be undertaken. The physical
examination should also include provocative tests for meningeal irritability, such as the
Kernig and Brudzinski signs. However, the absence of signs of meningitis does not
exclude the diagnosis of systemic meningococcal infection. (See 'Physical examination'
above.)