Meningococcal Septicaemia

Clinical Presentation

Differential Diagnosis

Management

Remember not all children with meningococcal disease arrive with a rash and shock but can rapidly progress to such and when suspected must be treated fast and aggressively. Caused by Neisseria Meningitidis, meningococcal disease is an important cause of morbidity and mortality in children- highest incidence is in the <5 age group, but disease can occur at any age. Early recognition, aggressive resuscitation, specialist advice and transfer to PICU reduces mortality from 50% to as low as 5%. 

Clinical Presentation

Meningococcal disease usually presents in one of 3 ways 

Meningitis: 

• Present with features of meningitis such as headache, fever, vomiting and neck stiffness indistinguishable from other forms of meningitis. 
• There may be no rash present and diagnosis is usually made on CSF culture later. 

Septicaemia: 

• The classic features are a fever and non-blanching rash in an unwell child. 
• A child may present with features of an URTI and then rapidly progress to rash and septicaemia. 

Although the rash is typically petechial in nature it may present initially with a maculo-papular rash similar to a viral exanthema. The rash typically begins in the buttocks, back of legs and conjunctiva. Some rashes evolve quickly, so serial inspections might be of value. 

Combination of Meningitis and Septicaemia: 

• These children present with a rash as well as features of meningitis. 

Remember 

Features may be atypical or non-specific, especially early on in the disease and in the young infant. Maintains a high index of suspicion as unrecognized disease can progress rapidly to shock and death. The initial diagnosis is CLINICAL. Management should not be delayed whilst awaiting results of laboratory investigations. 

Differential Diagnosis

The clinical differential diagnosis of bleeding diathesis and fever with or without neurological signs 

Includes: 

1. Severe sepsis – caused by Gram-negative or Gram-positive bacteria 
2. Fulminant hepatitis 
3. Leukaemia and other malignancies. 
4. Fulminant malaria 
5. Severe tick bite fever 
6. Viral haemorrhagic fevers (notably Crimean Congo Haemorrhagic Fever for South Africa) 
7. Other Travel Related Haemorrhagic fevers 

Management 

1. Resuscitate airway, breathing and circulation 
2. Isolate for 1^st 2 days of treatment. 
3. Do not do an LP in suspected meningococcemia even if clinical meningitis present. 
4. Ceftriaxone 50mg/kg 12H IV/IM X 10 days 
5. OR cefotaxime 50mg/kg/dose 6H IV X 10 days. 
6. Dexamethasone 0.15mg/kg/dose 6 hourly IV X 2-4days. 
7. If meningitis is clinically present and seizures anticipated give phenobarbitone 15-20mg/kg oral STAT then phenobarbitone 5mg/kg/dose daily oral (maximum oral dose usually 250mg). Treat convulsions as for acute convulsions. 
8. Expect and look for shock (cold peripheries, delayed capillary filling, oliguria) and acidosis. Treat shock urgently and aggressively before transfer. This will usually require vigorous treatment both for hypovolaemia (Ringers lactate or 0.9%sodium chloride infusions of 20ml/kg rapidly–may require repeat up to 2-3 times) and sometimes cardiogenic cause (may require Inotrope infusion). 
9. Watch for signs of raised intracranial pressure/cerebral oedema and treat. 

Contact chemoprophylaxis: Prophylaxisis only given to house hold contacts and medical staff WHO have performed mouth to mouth resuscitation or endotracheal intubation on the patient. Ciprofloxacin 500mg STAT is the drug of choice. Alternatives include Rifampicin or Ceftriaxone. 

Notification: Notify meningococcal infection by phone as soon as possible and check within 24 hours that prophylaxis has been given to contacts.