Meningococcal Septicemia in a Young Adult- A Case Report

Mahaarachchi N.C.1, Thalgahagoda S.S.L.K1, De Silva S.N.A1, Samaranayaka P.M.J1, Suriyaarachchi S.A.T.K.1, Fernando T.R.P1

1Department of Microbiology, Base Hospital, Wathupitiwala

 

Abstract

 

Neisseria meningitidis are Gram-negative diplococci capable of causing a range of infections with high morbidity and mortality. Here, we present a case of meningococcal septicemia with associated purpuric rash in a young adult. Septicemia with purpuric rash is associated with 14-50 % mortality. In this case, early prompt identification and management of meningococcal disease with high suspicion have led to the full recovery of the patient without any sequelae despite the high mortality rate.

 

INTRODUCTION

 

Neisseria meningitidis are Gram-negative diplococci capable of causing a range of infections with high morbidity and mortality. Meningococci are obligate human pathogens. Invasive meningococcal disease is usually present as septicemia or meningitis. Septicemia with purpuric rash is associated with 14-50 % mortality(1). Here, we present a case of meningococcal septicemia in an immunocompetent young adult.

Case Summary

 

A 32-year-old female, a diagnosed patient with epilepsy who was on regular antiepileptics presented with a fever for 2 days, 1 episode of seizure, and a generalized body rash. She was transferred from a local hospital. She didn’t have headaches, photophobia, or phonophobia. There was associated myalgia with one episode of vomiting. The rash was bluish-purple ecchymotic patches around B/L lower limbs and then spread to the whole body. She didn’t have a recent travel history or a contact history with a possible source. Her GCS was 15/15 on admission with low blood pressure of 80/50 MmHg. Her pulse rate was 110 min. SPO2 was 100% on air. Kernig's sign was negative.  Her initial CRP was 229, WBC 19,000 with neutrophil predominance. The platelet count was 133,000 with elevated S.Cr 2.09mg/dl. Her blood culture became positive after 24 hours of incubation. The initial Gram stain revealed Gram-negative diplococci. Lumbar puncture was not performed due to low platelet count.  The initial NCCT brain was normal.

 

On the following day, there was a growth on blood and chocolate agar with no growth on Mackonkey agar. There were grayish, round, convex glistening colonies on blood agar. The oxidase test was positive. The isolate was sensitive to penicillin, Cefotaxime, and Ciprofloxacin.

 

The isolate was sent to the Medical Research Institute, Sri Lanka for Confirmation. Upon further identification, the meningococcal PCR (a real-time quantitative PCR) was positive. The patient was started on IV cefotaxime 2g 6 hourly with the Gram stain results of the blood culture. There were continuous fever spikes with a rising CRP of 503. The patient was transferred to ICU at a tertiary care hospital by clinical team. Notification and contact tracing were done and antibiotic prophylaxis to close contacts was given. IV Cefotaxime was later changed to IV ceftriaxone 2g bd dose and continued for 14 days duration. The patient fully recovered with the antibiotics and supportive management and was later discharged.

Discussion

 

Worldwide, Meningococcal disease has a varying incidence from very rare to more than 1000 cases per 100,000 population every year(2). Meningococcal sepsis is not commonly reported in Sri Lanka. Data for meningococcal disease is limited to a few case reports and case series in Sri Lanka. According to a previous case series of 11 cases, there is a possibility of endemicity of disease in the country(3). These previously reported cases occurred in high-density areas of the Colombo district and with associations of the prisons. However, in this patient the source is unknown. The case is most likely a sporadic one.

The meningococci are naturally carried in the human nasopharynx in around 10-15% of the normal population(1). The carriers are usually asymptomatic, but they risk developing local inflammation and invasion of the mucosal surface accessing the bloodstream and progression to disease. The invasive disease is usually occurred in capsulate strains and serogroups A, B, C, W135, X, and Y account for the majority of invasive diseases. These serogroups are known as epidemic strains. The spread occurred by respiratory droplets and throat secretions, mostly in closed contacts in enclosed environments.

The bacteria are capable of causing a wide range of infections such as fulminant septicemia, septicemia with rash, meningitis, chronic meningococcal septicemia, arthritis, pericarditis, and pneumonia. Among them, acute septicemia with rash is the most common disease manifestation. The disease is usually seen in infants. Skin lesions are present in 28% to 77% of patients with invasive meningococcal disease on admission(2). In this case, we couldn’t exclude the possibility of associated meningococcal meningitis.

Bacteriologic isolation, antigen, or DNA identification by polymerase chain reaction in in usually sterile body fluid or tissues is needed for the definitive diagnosis of invasive meningococcal disease of N. meningitidis(2). Here, in this case, we were able to isolate the organism in blood and confirm the identification of the isolate by PCR.

As Invasive meningococcal disease is a medical emergency, early parenteral antibiotic treatment with ceftriaxone, cefotaxime should be the primary goal of therapy(2). Here, we have treated the patient with ceftriaxone for the recommended duration which led to the patient's recovery.

Further, early diagnosis and prompt treatment are important to prevent morbidity and mortality. Vaccination is the mainstay of prevention of disease and effective vaccines are available. However, in Sri Lanka vaccinations are given only for international travelers at risk of developing the infection. The vaccination of high-risk individuals following exposure to disease is still not carried out in Sri Lanka.

 

Conclusion

 

In this case, early prompt identification and management of meningococcal disease with high suspicion have led to the recovery of the patient despite the high mortality rate. Also, it has prevented the occurrence of further cases. This highlights the importance of the availability and utilization of diagnostic facilities and taking blood cultures before antibiotics.

References

 

  1. MEDICAL MICROBIOLOGY EIGHTEENTH EDITION. 2012.
  2. Bennett JE., Dolin Raphael, Blaser MJ. Mandell, Douglas, and Bennett’s principles and practice of infectious diseases (vol. 2). Elsevier; 2020. 125 p.
  3. Galappaththi J, Hapuarachchi T, Francis V, Dassanayake M, Karunanayake L, Chandrasiri S, et al. Case series of meningococcal sepsis; are we seeing the real picture. Sri Lankan Journal of Infectious Diseases. 2021 Oct 28;11(2):94.