© Springer Nature Switzerland AG 2021
P. Treadwell et al. (eds.)Atlas of Adolescent Dermatologyhttps://doi.org/10.1007/978-3-030-58634-8_3

3. Meningococcal Infections

Patricia Treadwell1  
(1)
Department of Dermatology, Indiana University School of Medicine, Indianapolis, IN, USA
 
 
Patricia Treadwell
Email: ptreadwe@iupui.edu
Keywords
MeningococcemiaMeningococcal vaccinePenicillinCeftriaxone

3.1 Introduction

The organism Neisseria meningitidis can cause meningitis, septicemia, and/or less commonly pneumonia in adolescents. Of the patients who develop meningococcemia, the majority will have cutaneous manifestations.

3.2 Epidemiology

Adolescents are a group with a higher incidence of risk for Neisseria meningitides infections (Red Book 2018). Meningococcal infections are spread through respiratory droplets. Household and other close contacts are affected at much higher rate than other contacts. The length of the incubation is 1–10 days.

3.3 Clinical Findings

Initially, the symptoms may be nonspecific, e.g., fever, headache, malaise, myalgias, and/or cold hands and feet. Some patients may have meningismus, photophobia, and/or vomiting (findings in meningitis). Patients are typically ill-appearing.

Cutaneous manifestations may be morbilliform macules and papules in the beginning, then later petechiae, purpura, vesicles, or pustules are noted. Characteristically, the purpura have jagged edges (Fig. 3.1). Necrotic lesions and ulcers may develop (Fig. 3.2).
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Fig. 3.1

Purpuric lesions with jagged borders

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Fig. 3.2

Progression of meningococcal lesions with crusting

With further progression, patients may develop hypotension, shock, or disseminated intravascular coagulation (DIC). “Purpura fulminans” (Fig. 3.3) is a term used to describe DIC accompanied by necrotic and purpuric plaques.
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Fig. 3.3

Purpura fulminans in a patient with meningococcemia

3.4 Laboratory

Positive blood and/or cerebrospinal fluid cultures can establish the diagnosis. Some public health or research laboratories may have PCR assays.

3.5 Treatment

Per the 2018 Red Book: Report of the Committee on Infectious Diseases (www.​aapredbook.​org) treatment recommendations are as follows:

  • Empiric therapy with ceftriaxone or cefotaxime is recommended. Once a microbiological diagnosis is established, intravenous penicillin G is recommended at a dose of 300,000 U/kg per day up to a maximum of 12 million units per day divided every 4–6 hours for 5–7 days. Cefotaxime, ceftriaxone, and ampicillin are acceptable alternatives. In a patient with life-threatening anaphylactic penicillin allergy, meropenem or ceftriaxone can be used, recognizing that the rate of cross-reactivity in penicillin-allergic adults is low. Consultation with a pediatric infectious disease specialist is recommended.

  • Intermediate penicillin resistance is an increasing concern (especially in travelers from areas where penicillin resistance has been reported); as a result, some recommend using ceftriaxone, cefotaxime, or chloramphenicol until susceptibilities are available.

  • A quadrivalent conjugate meningococcal vaccine immunization is now routinely recommended beginning at age 11 years. It can be used to prevent infection in high-risk groups from age 2 months to 55 years.

  • A meningococcal B vaccine is routinely recommended for ages 16–18 years. For high-risk groups, individuals should receive the vaccine starting at age 10 years of age.

  • In addition, supportive therapy (e.g., vasoactive agents and fluids) may be necessary.

  • Close contacts within 5–7 days prior to onset of illness (e.g., household, child care, slept or ate in same dwelling) should receive chemoprophylaxis.

3.6 Prognosis

Invasive meningococcemia has a mortality of 8–10%. Morbidities includes limb or digit amputations, skin scarring, neurologic sequelae, and hearing loss.