ABH secretor status, as judged by the Lewis phenotypes, in Norwegian survivors from meningococcal disease

Survivors from meningococcal disease (serogroups B and C) and a control series (blood donors) were examined for their ability to secrete ABH blood group substance. The examination was done indirectly by determining their Lewis phenotypes. There was no significant difference in the secretor status between the two groups.

Comparative therapeutic results of penicillin plus chloramphenicol versus ampicillin plus sulbactam in childhood meningococcemia

Fifty-seven cases of meningococcemia were evaluated retrospectively. The age of the patients ranged between 2 and 17 years. Of the 57 patients investigated for the efficacy of antibiotic treatment, 31 (54.4%) were treated with benzylpenicillin plus chloramphenicol and 26 (45.6%) with ampicillin plus sulbactam. Patients with criteria for a poor prognosis (presence of disseminated intravascular coagulation, low arterial blood pressure, and altered consciousness) were divided equally into two treatment groups. There were no statistically significant differences between the two treatment groups except for the higher incidence of convulsion in the group given penicillin plus chloramphenicol. The mortality rate was 19.3 percent for patients treated with benzylpenicillin plus chloramphenicol and 7.6 percent for patients treated with ampicillin plus sulbactam (p = 0.19; overall mortality rate 14%).

Severity of meningococcal disease: assessment by factors and scores and implications for patient management

Results from our own and other published series of cases of meningococcal disease were used to study prognostic factors and to compose scores for assessment of severity of disease on admission to the hospital. The difference in risk for fatality was designated the factor fatality difference (FFD); the FFD was determined by subtracting the percent fatality for factor-negative patients from the percent fatality for factor-positive patients. FFD was useful for selection of good indicators of severity of disease. Blood pH of less than 7.35 was the best single factor; low platelet count came next, followed by low blood pressure, cyanosis, ecchymosis, and low blood leukocyte count. New scores were constructed based on multiple regression analyses. Several older and new scores seemed to be comparable. By combining age-adjusted systolic blood pressure (less than 100 mm Hg), cyanosis, ecchymosis, diarrhea before or at admission, cold extremities, absence of nuchal or back rigidity, and rectal temperature of greater than or equal to 40 degrees C, a simple bedside percentage score, the MenOPP bedside clinical score (MOC), was devised. Cross-evaluations on test materials generally confirmed the choice of score. The simplicity of this score made it more clinically suitable than laboratory or mixed laboratory and bedside scores.

Distal tibial physeal arrest: a complication of meningococcal septicemia

Two cases of meningococcal septicemia are presented. Distal tibial physeal arrest occurred in both cases due to hypotension and disseminated intravascular coagulation. To our knowledge, this is the first report of distal tibial physeal arrest with resultant varus deformity at the ankle subsequent to meningococcal septicemia.

Acute meningococcaemia: a case study

A 20-year-old female presented with sudden onset of abdominal pain, diarrhoea and vomiting progressing to fever, tachycardia and mild hypotension. Within 12 hours, a petechial rash appeared on the face and abdomen, spreading to the extremities. Laboratory findings confirmed the diagnosis of acute meningococcaemia. Clinical features of endotoxic shock, vasculitis and skin necrosis rapidly ensued. Aggressive treatment to control the septicaemia, disseminated intravascular coagulation and unstable cardiovascular state ultimately proved successful. Approximately 6 weeks later, amputation of some of the digits and extensive skin grafting were carried out in the Regional Burns Unit. However, serious psychological side effects gradually began to appear which required urgent psychiatric intervention. For an active young woman the challenge of coping with such a severe illness and coming to terms with the disability and disfigurement resulting from it was almost overwhelming. It was, perhaps, particularly hard because of the threat posed to her ambition to complete her nursing education and become a nurse. Little was found in the nursing literature on acute meningococcaemia. But this illness provides considerable challenges not only to those who suffer from it, but also to those who nurse them. A final brief review of published literature on acute meningococcaemia and the clinical manifestations and outcome of it is provided for those who wish to know more about it.

Meningococcal infections in children: a review of 100 cases

One hundred children with meningococcal infection diagnosed from January 1, 1985, to February 29, 1988, were reviewed. Clinical manifestations ranged from fever alone to fulminant septic shock with purpura fulminans. Twenty-nine percent of the children presented without skin lesions. Of the 55 patients with meningitis, 6 lacked cerebrospinal fluid abnormalities on initial lumbar puncture but cerebrospinal fluid cultures were positive. An overall case fatality rate of 10% was noted with the following poor prognostic indicators identified: hypothermia; seizures or shock on presentation; a total peripheral white blood cell count less than 5000/mm3; a platelet count less than 100,000/mm3; and the development of purpura fulminans. Meningococcal infections remain an important cause of morbidity and mortality in children. Infections caused by Neisseria meningitidis (including meningitis) should be considered even in the absence of skin lesions or cerebrospinal fluid abnormalities.

[Study of cardiac function in generalized meningococcal infection based on various biochemical indicators]

The complicated course of meningococcal infection is distinguished by a long-term increase in the level of aspartate transferase and creatine phosphokinase. There were three types of changes in the activity of creatine phosphokinase, while changes in the activity of aspartate transferase were not so diverse. Patients had isolated as well as combined increase in the activity of both these enzymes. Lipid peroxidation was also augmented which corresponded to changes in the level of aspartate transferase. The high level of enzymes in the blood in meningococcal infection is the result of cytolysis as well as myocardial hyperfunction in the acute period of the disease.

Complement deficiencies in selected groups of patients with meningococcal disease

We have examined 125 individuals who have earlier had meningococcal (mgc) disease. They belonged to one or more of the following groups: (1) 2 or more cases of mgc disease in the same family; (2) individuals with 2 episodes of mgc disease or with 1 episode of mgc disease and 1 or more episodes of purulent meningitis of another aetiology; and (3) infections with Neisseria meningitidis belonging to serogroups that are uncommon as causes of disease and presumably low-virulent (W-135, 29E, X, Y). Among these we found 15 complement (C)-deficient individuals (12%). The prevalence of C deficiency in the groups above was 7%, 41% and 19%, respectively. The first group (family cases), is very heterogeneous and may be further subdivided into 2 groups: families whose members fell ill within an interval of 30 days (in these the prevalence of C deficiency was 2%), and families in which the interval between mgc disease cases exceeded 30 days (in those the prevalence of C deficiency was 14%). We found a predominance of defects of the initiation pathways, with properdin deficiency being the most common.

Hemodynamic patterns of meningococcal shock in children

Meningococcal shock still is associated with high mortality. Along with antibiotics and control of metabolic derangements, standard therapy involves monitoring and maintaining numerous cardiorespiratory variables. From 1980 to 1985, 39 children with meningococcal shock were treated in our pediatric ICU. We obtained full hemodynamic monitoring in 18 (12 survivors, six nonsurvivors). Two hemodynamic patterns were observed: hypovolemia and cardiac failure. Early death was generally related to refractory hypovolemia, probably secondary to severe capillary leak. Survival usually occurred when noticeable cardiac failure was controlled with early use of catecholamines and judicious fluid management. Because cardiac failure only slowly recovered, a therapeutic approach that aims not at normal variables but, rather, at survival variables seems appropriate.

[Myocardial incompetence in meningococcal purpura in children. Early hemodynamic study]

In order to investigate the haemodynamic changes involved at the very beginning of meningococcal purpura fulminans, a prospective study was conducted in 10 children in whom a Swan-Ganz catheter was introduced on admission into the pulmonary artery. The first measurements performed 6 to 14 hours (mean: 10.2h) after the first signs of purpura were detected showed in every case a state of shock with fall in tissue oxygen consumption values and reduction of ventricular performance, although the systemic blood pressure was preserved and the central venous pressure was normal. In patients admitted at an early stage, 4 to 6 hours after the onset and directly from home, hypovolaemia predominated and masked the myocardial insufficiency. Patients referred by another hospital and whose hypovolaemia had already been corrected (i.e. 9 to 12 h after the onset) had full myocardial incompetence with fall in cardiac index, rise in capillary pressure and lowering of the ventricular function curve. Under beta-adrenergic stimulants combined with re-expansion of blood volume according to haemodynamic variations, the state of shock was reversed within 48 to 72 hours, and all patients in this series survived. These findings confirm that myocardial incompetence is constant and occurs at an early stage of purpura fulminans.

Pathophysiology of primary meningococcal pericarditis associated with Neisseria meningitidis group C. A case report and review of the literature

Pericarditis associated with Neisseria meningitidis in the absence of meningitis or meningococcemia is an extremely rare event. We report herein a case of a 59-yr-old woman with primary meningococcal pericarditis caused by Neisseria meningitidis group C. The patient responded to a course of penicillin therapy and recovery was uncomplicated. The pathophysiologic features underlying or contributing to the disease are discussed and the pertinent literature is reviewed.

Serum zinc and copper levels in children with meningococcal disease

Mean serum zinc and copper levels were depressed in 94 children aged 1 month to 9 years who presented with meningococcal disease. The mean serum zinc level was 44 micrograms/dl (reference value 78 micrograms/dl, SD 18) and the mean serum copper level 157 micrograms/dl (reference value 159 micrograms/dl, SD 27). Nineteen patients had serum zinc levels less than 25 micrograms/dl and ten patients had serum copper levels less than 101 micrograms/dl. Serum zinc levels were significantly lower in patients who were septicaemic or in whom manifestations of severe disease such as shock, more than 20 petechiae, ecchymoses and evidence of disseminated intravascular coagulation occurred compared to those without these features. Serum copper concentrations were higher than reference levels in patients with meningitis and in less severely ill patients. Copper levels were significantly lower in patients with septicaemia, severe disease, shock, more than 20 petechiae, ecchymoses, disseminated intravascular coagulation, leucopenia and patients who died compared with patients without these features.

[Hemodynamic and echocardiographic investigations in children with severe meningococcosis (author's transl)]

In eight children presenting with severe meningococcosis, hemodynamic investigations were performed at various stages of the disease (thermodilution technique and echocardiography). Surveillance of hypovolemia and myocardial incompetence associated with sceptic shock allows a better adaptation of symptomatic treatment and a better prognosis in these severe cases. It seems that invasive hemodynamic methods (thermodilution) cannot be replaced presently by echocardiography alone.

[Hyperpyrexia and shock (author's transl)]

In childhood hyperpyrexia is the most important factor causing the irreversibility of shock. The combination of high fever and circulatory impairment is more frequent during the first years of life. This behaviour is due to the high resistance of the arterial system in infancy. Marked general vasoconstriction increases the risk of a reduction in circulation and of heat loss, and causes hypoxia and rise of fever. The further course of shock is largely determined by microcirculatory failures. Under hyperpyrexia the disturbance of homeostasis can be intensified by shivering, blocking of perspiratio sensibilis, hyperosmolarity, brain edema, and DIC. In most cases of meningococcal sepsis shock and DIC begin with vasoconstrictive centralisation of circulation. The high-output-shock is extremely rare in children with high fever. The control of all important functions of a febril child in shock is the best baseline for the treatment. It is necessary in all shock patients in hyperpyrexia to reduce the fever and to repair the peripheral circulation. The therapy consists of antipyretic drugs, physical cooling, infusions of buffer-bases, dopamine, antibiotics and so on. In DIC heparin or streptokinase are indicated. In severe circulatory impairment combined with high fever prednisone is useful, in brain edema dexamethasone. The fatality rate of our cases has been diminished by a systematic therapy of hyperpyrexia and shock from 10 to 3 percent.