A 30-Year-Old With a Full-Body Rash, Vomiting, and Confusion

Andrea Bianchin, MD; Moreno Agostini, MD


September 22, 2021

All persons who have been in close contact with a patient with meningococcal infection are at elevated risk of contracting the disease. Meningococci are spread via respiratory secretions, and they are easily transmitted to close contacts. For this reason, all household members, classmates, medical staff, or anyone else recently associated with the patient must be considered at risk of acquiring the disease.

The probability of transmission varies with the duration and closeness of exposure; it is highest during the first few days after the onset of disease. The risk for transmission is higher with actions that result in direct exposure of secretions to mucous membranes, including kissing; mouth-to-mouth resuscitation; and sharing of food, glasses, bottles, or cigarettes.

People who have stayed more than 8 hours in close proximity to an infected patient or who have had direct contact with a patient's secretions within 1 week before the onset of symptoms should receive prophylactic treatment. Chemoprophylaxis should be given as soon as possible, because the efficacy of prophylaxis is very low if antibiotics are not started within 10-14 days after exposure. Cultures of oropharyngeal or nasopharyngeal tissue are not useful for determining whether or not antibiotics are necessary, and waiting for the results of these examinations can cause an inappropriate delay in the administration of prophylactic treatment.

Rifampin, ciprofloxacin, or ceftriaxone are all effective choices for prophylaxis. The duration of chemoprophylaxis should be 1-2 days, depending on the antibiotic used. Ciprofloxacin and ceftriaxone require a single-dose treatment, and rifampin may be given twice daily for four doses.[1,3,5]

Several vaccines are available for controlling outbreaks of N meningitidis. The quadrivalent polysaccharide vaccine (Menomune®) was the first meningococcal vaccine approved by the US Food and Drug Administration (FDA) for serogroups A, C, Y, and W-135; however, this vaccine has largely been replaced by two quadrivalent conjugate vaccines (Menactra®, Menveo®) for most populations. Two meningococcal vaccines for serogroup B are also available in the United States (Bexsero®, Trumenba®).

Routine vaccination with Menactra or Menveo is recommended for young adolescents beginning at age 11-12 years, with a booster dose at age 16-23 years.[6] Serogroup B vaccines are not recommended for routine vaccination by the Centers for Disease Control and Prevention (CDC), but adolescents and young adults may receive Trumenba (three doses) or Bexsero (two doses) at age 16-23 years.[6,7]

For outbreak situations, meningococcal vaccines A/C/Y and W-135 plus serogroup B administration are recommended in the presence of at least three cases during 3 months or less, or when 10 cases occur per 100,000 people in larger communities. These vaccines are also recommended for high-risk individuals (eg, complement deficiencies, asplenia, microbiologists routinely exposed).[6,8,9,10]

The patient in this case was admitted to the intensive care unit after early initiation of intravenous ceftriaxone. The patient's blood cultures grew serogroup C N meningitidis. A few hours after admission, petechial lesions appeared and rapidly spread throughout her trunk, legs, back, and face. The lesions became progressively larger and hemorrhagic (Figures 3 and 4).

Figure 3.

Figure 4.

Aggressive fluid therapy, vasopressor support, fresh frozen plasma, and activated protein C therapy were given. The patient required mechanical ventilation after developing acute respiratory failure. Renal failure soon followed, and dialysis was initiated. Her hands and feet became increasingly cyanotic (Figure 5).

Figure 5.

Despite aggressive therapy, multiple organ dysfunction and DIC progressed; the patient died 4 days after admission. The postmortem examination confirmed meningococcal sepsis and revealed acute purulent meningitis, adrenal apoplexy, thrombotic microangiopathy, purpura confluens, and epidermolysis bullosa; these findings are consistent with a diagnosis of Waterhouse-Friderichsen syndrome.


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