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BASICS

Meningococcemia is a blood-borne infection caused by Neisseria meningitidis.

  • Bacteremia without meningitis: acutely ill patient with skin manifestations (rashes, petechiae, ecchymosis) and hypotension.
  • Bacteremia with meningitis: sudden onset of fever, nausea, vomiting, headache, decreased concentration, myalgias.
  • Disease progresses rapidly (hours).
  • Skin findings and hypotension may be present.
  • Petechial rash: discrete 1-2 mm lesions, mostly on trunk and lower body; seen in >50% of patients at presentation.
  • Purpura fulminans: severe complication in up to 25%—acute cutaneous hemorrhage and necrosis due to vascular thrombosis and disseminated intravascular coagulopathy (DIC).

EPIDEMIOLOGY

  • Mortality rate: ~13%.
  • 11-19% survivors have serious sequelae (deafness, neurologic deficits, limb loss).
  • Seasonal peak: December/January.
  • Atypical presentations: abdominal symptoms, septic arthritis, bacteremic pneumonia.
  • Peak incidence: first year of life; 35-40% cases in children <5 years; second peak in adolescence.
  • 2021 CDC data: 210 reported cases (~0.2/100,000), most common in adolescents, young adults, infants <1 year【1】.

ETIOLOGY AND PATHOPHYSIOLOGY

  • N. meningitidis: aerobic, gram-negative diplococcus with ≥13 serotypes.
  • Produces endotoxin; virulence factors promote invasive disease.
  • Humans are the only reservoir.
  • Major serogroups in U.S.: B, C, Y, W-135.
  • Serogroup B: predominant in children <1 year.
  • Serogroup C: most common overall in U.S.
  • Serogroup Y: predominant in elderly【2】.
  • Worldwide major serogroups: A, B, C, Y, W-135.
  • W-135: major cause in sub-Saharan Africa ("meningitis belt").
  • Genetics: autosomal recessive late complement deficiency (C5-C9).

RISK FACTORS

  • Age: 3 months to 1 year.
  • Late complement deficiency (C5-C9).
  • Asplenia【1】.
  • Close living quarters (household contacts, daycare, dormitories, military barracks).
  • Exposure to active/passive tobacco smoke【1】.

GENERAL PREVENTION

  • Meningococcal ACWY Vaccines (MenACWY):
  • Infants/children: routine vaccination from 2 months for high-risk.
  • Adolescents: first dose at 11-12 years, booster at 16 years.
  • Teens/young adults (16-23 years) may receive serogroup B vaccine.
  • At-risk adults and travelers to endemic areas should be vaccinated.
  • Meningococcal B vaccines (MenB):
  • Not routine for all children, given to high-risk groups.
  • Adolescents 16-23 years (preferably 16-18) based on shared decision-making.
  • Protective antibody levels develop ~7-10 days post-immunization【2】.
  • CDC travel advisory: required for Hajji pilgrims >2 years; travelers to “meningitis belt.”

DIAGNOSIS

HISTORY

  • Sudden onset: fever, nausea, vomiting, headache, myalgias, chills, rigors, sore throat (nonsuppurative).
  • Pharyngitis may mimic strep throat.
  • Myalgias may mimic severe influenza.
  • Changes in mental status, decreased concentration, stiff neck, convulsions.
  • Assess exposures.

PHYSICAL EXAM

  • Fever, hypotension, tachycardia.
  • Neurologic: nuchal rigidity, focal neurologic signs, coma, seizures.
  • Cardiac: signs of heart failure with pulmonary edema.
  • Dermatologic: maculopapular rash, petechiae, ecchymosis, purpura.
  • Meningitis signs onset within 12-15 hours; late signs (unconsciousness, delirium) after ~15 hours in infants, ~24 hours in older children.

DIFFERENTIAL DIAGNOSIS

  • Sepsis, other bacterial meningitis organisms.
  • Acute bacterial endocarditis.
  • Rocky Mountain spotted fever.
  • Hemolytic uremic syndrome.
  • Gonococcal arthritis-dermatitis syndrome.
  • Influenza.

DIAGNOSTIC TESTS & INTERPRETATION

ALERT: Isolation of N. meningitidis from sterile site (blood or CSF) is gold standard.

  • Antibiotics may render cultures negative within 2 hours.

Initial Tests

  • Culture: blood, CSF, or other sterile site.
  • CBC with diff: leukocytosis or leukopenia, thrombocytopenia.
  • Lactic acidosis.
  • Procalcitonin: often elevated in bacterial meningitis【3】.
  • Coagulation: prolonged PT/PTT, low fibrinogen, elevated fibrin degradation products.
  • Blood cultures positive in 50-60% cases.
  • CSF:
  • Grossly cloudy.
  • Increased WBC with polymorphonuclear predominance.
  • Gram stain: gram-negative diplococci.
  • Glucose-to-blood glucose ratio <0.4; protein >45 mg/dL.
  • Antigen tests (MAT or PCR) positive for N. meningitidis.
  • CSF culture positive in 80-90%.
  • Head CT prior to LP if concern for space-occupying lesions or focal neurologic signs.

TREATMENT

MEDICATION

First Line

  • Start treatment immediately on suspicion.
  • Age-based empiric antibiotics:
  • Preterm to <1 month: ampicillin + cefotaxime or ampicillin + gentamicin.
  • 0 to 7 days: cefotaxime 50 mg/kg q12h.
  • 8 to 28 days: cefotaxime 50 mg/kg q8h.
  • Ampicillin dosing varies with birth weight and age.
  • 1 month to 50 years: cefotaxime or ceftriaxone + vancomycin.
  • Severe penicillin allergy: chloramphenicol + TMP-SMX + vancomycin.

  • 50 years or comorbidities: ampicillin + ceftriaxone + vancomycin.

  • Penicillin G effective if MIC <0.1 µg/mL; otherwise, 3rd generation cephalosporin preferred.

  • Treatment duration: 7 days.

Dexamethasone

  • Indicated in pneumococcal meningitis; not beneficial in meningococcal meningitis—discontinue once diagnosis established.
  • Dosage: IV 0.15 mg/kg q6h for 2-4 days, started 10-20 minutes before or with first antibiotic dose.
  • Children >6 weeks old receive steroids.

Chemoprophylaxis

  • Indicated for close contacts with prolonged close exposure or direct contact with oral secretions from 1 week before symptom onset to 24 hours after antibiotic start.
  • Not indicated for casual contacts unless exposed to respiratory secretions.
  • Ideal timing: <24 hours after case identification; not if >14 days post-exposure.
  • Drugs: rifampin, ciprofloxacin, ceftriaxone (ceftriaxone preferred in pregnancy).
  • Rising ciprofloxacin-resistant, β-lactamase-producing serogroup Y isolates; susceptibility testing recommended【1】.

Second Line

  • Chloramphenicol or ceftriaxone IV in meningitis cases (pediatric dosing available).
  • Ceftriaxone contraindicated in history of severe penicillin anaphylaxis.
  • Chloramphenicol risks: aplastic anemia.

ISSUES FOR REFERRAL

  • Seizures, DIC, ARDS, renal or adrenal failure, multisystem organ failure

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

  • Start antibiotics ± corticosteroids and obtain LP immediately if suspected.
  • Droplet isolation for 24 hours after antibiotic start.
  • IV fluids: replace volume; large crystalloids may be needed in septic shock.

ONGOING CARE

PATIENT EDUCATION

  • Educate family and close contacts about risk and prophylaxis.

PROGNOSIS

  • Mortality ~13%.
  • Poor prognostic factors: young age, hypotension, thrombocytopenia, altered mental status, leukopenia.

COMPLICATIONS

  • Disseminated intravascular coagulation (DIC)
  • Acute tubular necrosis
  • Neurologic: sensorineural hearing loss, cranial nerve palsy, seizures
  • Obstructive hydrocephalus
  • Subdural effusions
  • Acute adrenal hemorrhage
  • Waterhouse-Friderichsen syndrome

REFERENCES

  1. Centers for Disease Control and Prevention. Meningococcal disease: technical and clinical information. https://www.cdc.gov/meningococcal/clinical-info.html. Accessed September 28, 2023.
  2. Deghmane A-E, Taha S, Taha M-K. Global epidemiology and changing clinical presentations of invasive meningococcal disease: a narrative review. Infect Dis (Lond). 2021;54(1):1-7.
  3. Fitzgerald D, Waterer GW. Invasive pneumococcal and meningococcal disease. Infect Dis Clin North Am. 2019;33(4):1125-1141.

ICD10 Codes

  • A39.4 Meningococcemia, unspecified
  • A39.0 Meningococcal meningitis
  • A39.2 Acute meningococcemia

Clinical Pearls

  • Invasive meningococcal disease can be rapidly fatal; early antibiotic treatment is essential.
  • Treat first, then test in suspected cases.
  • Provide chemoprophylaxis to close contacts.
  • All adolescents and children in high-risk groups should receive MenACWY vaccine.
  • Meningitis B vaccines recommended for high-risk children ≥10 years.