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      Drugs & Diseases > Infectious Diseases

      Meningococcemia Clinical Presentation

      Updated: Aug 05, 2022
      • Author: Mahmud H Javid, MBBS; Chief Editor: John L Brusch, MD, FACP  more...
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      Presentation

      History

      Individuals with meningococcal disease may present with a nonspecific prodrome of cough, headache, and sore throat. After a few days of upper respiratory symptoms, the temperature rises abruptly, often after a chill. Malaise, weakness, myalgias, headache, nausea, vomiting, and arthralgias are common presenting symptoms. The skin rash of meningococcemia may advance from a few ill-defined lesions to a widespread petechial eruption within a few hours. In fulminant meningococcemia, a hemorrhagic eruption, hypotension, and cardiac depression, as well as rapid enlargement of petechiae and purpuric lesions, may be apparent within hours of the initial presentation. 

      Purpura in a young adult with fulminant meningococ Purpura in a young adult with fulminant meningococcemia.
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      Meningitis

      Meningitis is associated with the following [2] :

      • Headache
      • Fever
      • Vomiting
      • Photophobia
      • Lethargy
      • Neck stiffness
      • Rash - In more than 50% of cases
      • Seizures - In 20% of patients at presentation and in an additional 10% of patients within 72 hours
      • Early nonspecific symptoms - especially in infants

      In adults, bacterial meningitis has a characteristic clinical pattern, although the progression of symptoms varies somewhat. Symptoms of meningitis may accompany the petechiae of meningococcemia and may produce the predominant features on presentation.

      Bacterial meningitis is a febrile illness of short duration; the major symptoms include headache and a stiff neck. Lethargy or drowsiness are common. Confusion, agitated delirium, and stupor are rarer; however, coma is an ominous prognostic sign.

      The clinical pattern of bacterial meningitis often is atypical in young children because headache and nuchal rigidity frequently are absent. Irritability, especially upon movement, is a common presenting manifestation of meningitis in a young child. Convulsions may signal the onset of meningitis at this age. Progression of the illness results in the development of lassitude and a more constant fever, often accompanied by abdominal discomfort. Projectile vomiting may occur.

      Septicemia

      Septicemia may be confused with influenza, particularly when myalgia is prominent. Meningococcal septicemia is characterized by the following [3] :

      • Fever
      • Rash: An early short-lived maculopapular rash may precede the classic erythematous one that may evolve into petechiae and purpura. This may be mistaken for a viral exanthema. [74]
      • Vomiting
      • Headache
      • Myalgia that may be diffuse and severe
      • Abdominal pain
      • Tachycardia/tachypnea
      • Hypotension
      • Cool extremities
      • Initially normal level of consciousness
      • Early symptoms indistinguishable from those associated with viral illness, including leg pain

      Symptoms of meningitis and septicemia may occur together and may complicate the distinction between an acute decreased level of consciousness due to hypotension and that caused by elevated ICP.

      Chronic meningococcemia

      Chronic meningococcemia is an intermittent bacteremic illness that lasts from at least 1 week to as long as several months. The fever tends to be intermittent, with afebrile periods ranging from 2-10 days, during which the patient seems completely healthy. As the disease progresses, the febrile periods become more common, and the fever may become continuous. [75]  It may present with joint symptoms. [76]  Cutaneous manifestations are variable and can consist of rose-colored macules and papules, indurated nodules, petechiae, purpura, or large hemorrhagic areas. Chronic meningococcemia may mimic the dermatitis-arthritis syndrome of subacute gonococcemia. 

      Patients may recover spontaneously or progress to systemic complications such as meningitis. The prognosis for treated patients is excellent, with a cure rate of nearly 100% with appropriate antibiotic therapy. Penicillin G at 6-12 million U/day in divided doses for a minimum of 7 days is effective therapy.

       

      Next:

      Physical Examination

      Patients are severely ill. Tachycardia and mild hypotension are present. Patients with acute meningococcemia usually present with moderate fever (average, 39.5°C). High fever (average, 40.6°C) is present in fulminant meningococcemia.

      Rapidly developing signs and symptoms of congestive heart failure, hypotension, pulmonary edema, and respiratory failure may be present and mark the progression to fulminant meningococcemia. Laboratory or imaging evidence of end-organ damage such as pericarditis often appear concurrently.

      Dermatologic manifestations

      Petechiae develop in 50-80% of patients with meningococcal disease and involve the axillae, flanks, wrists, and ankles, although they can progress to any part of the body. Lesions commonly begin on the trunk and legs in areas where pressure is applied.

      Dorsum of the hand showing petechiae. Courtesy of Dorsum of the hand showing petechiae. Courtesy of Professor Chien Liu.
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      Petechiae on lower extremities. Courtesy of Profes Petechiae on lower extremities. Courtesy of Professor Chien Liu.
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      Scattered petechiae in a patient with acute mening Scattered petechiae in a patient with acute meningococcemia.
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      The legs of a 22-year-old woman in septic shock wi The legs of a 22-year-old woman in septic shock with a rapidly evolving purpuric rash. Photo by D. Scott Smith, MD, taken at Stanford University Hospital.
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      Petechiae often are located in the center of lighter-colored macules. They are discrete lesions 1-2mm in diameter. Confluence of lesions results in hemorrhagic patches, often with central necrosis. In some cases, a transient maculopapular rash develops, usually lasting for less than 48 hours. Rash may be missed early in an individual with dark skin. [77]

      Critically ill patients with sepsis may develop rapidly progressing petechiae, ecchymoses, and extensive, palpable purpura or retiform purpura, accompanied by DIC and vascular collapse.

      Skin lesions tend to occur in crops on any part of the body, occasionally presenting on the conjunctivae and the mucous membranes (see the first image below). The face usually is spared, and involvement of the palms and the soles is less common (see the second image below).

      Conjunctival petechiae. Courtesy of Professor Chie Conjunctival petechiae. Courtesy of Professor Chien Liu.
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      Petechiae on the palm. Courtesy of Professor Chien Petechiae on the palm. Courtesy of Professor Chien Liu.
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      Fulminant meningococcemia

      Fulminant meningococcemia is associated with a purpuric eruption, as shown in the image below. Lesions generally are characterized by maplike purpuric or necrotic areas.

      Hemorrhages may appear on the buccal mucosa and the conjunctivae. Less frequently, fulminant meningococcemia presents as purpura fulminans. In rare cases, no skin lesions develop. Symmetrical, peripheral gangrene has been described in this form. Amputation may be required in severe cases of necrosis.

      Child with severe meningococcal disease and purpur Child with severe meningococcal disease and purpura fulminans.
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      Signs of meningitis

      The characteristic physical examination findings of meningitis include pain and resistance to neck flexion. Other signs of meningeal irritation also can be elicited. Children with meningitis may have none of these findings.

      The Kernig sign is positive when the leg cannot be extended more than 135° on the thigh when flexed 90° at the hip. The Brudzinski sign is positive when neck flexion causes involuntary flexion of the thighs and the legs.

      Focal neurologic signs are uncommon presenting findings of bacterial meningitis. However, nuchal rigidity may not be elicited in patients who are comatose and who may have signs of focal or diffuse neurologic deficits.

      Papilledema is not a presenting feature of bacterial meningitis and suggests the presence of an accompanying process.

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