Acute meningococcaemia: recent advances in management (with particular reference to children)

Plastic surgery management in pediatric meningococcal-induced purpura fulminans

Purpura fulminans associated with meningococcemia is a devastating disease in children. The tissue loss can be extensive and difficult to determine at the outset. The authors suggest a strategy to manage these wounds with the goal of preserving as much tissue and function as possible. At the present time, conservative therapy to the wounds appears to be the best course in the initial, critical phase, as long as no active local purulence is found. Debridement or amputation is performed when the nonviable tissue margins are delineated. Temporary coverage with allograft may be required; definitive coverage is accomplished when the local tissue perfusion has recovered. Future revisions are often necessary to improve these children's quality of life.

The effects of macrolides on inflammatory cells

Bronchial epithelial damage and mucus hypersecretion are characteristic features of chronic airway inflammation that can impair mucociliary clearance and can cause recurrent or persistent respiratory infection. In response to chemoattractants produced by damaged or inflamed tissue, neutrophils move through sequential steps of recruitment, migration, accumulation, and adhesion to endothelial and bronchial epithelial cells. Neutrophils engage in bacteriocidal activity by phagocytosis, release of lysosomal enzymes, and generation of reactive oxygen species, and they synthesize and release proinflammatory cytokines. Data confirm that many macrolide antibiotics have nonbactericidal properties that include inhibiting inflammatory cell chemotaxis, cytokine synthesis, adhesion molecule expression, and reactive oxygen species production. Macrolides also can decrease airway mucus hypersecretion in patients with diffuse panbronchiolitis, chronic sinusitis, and chronic bronchitis. Macrolides accumulate in neutrophils and macrophages at significantly higher concentrations than in extracellular fluid. This article discusses the action of macrolides on neutrophil accumulation, immune complex-mediated production of nitric oxide, mucin production, and the expanded therapeutic role of macrolides as biological response modifiers.

Current management of purpura fulminans: a multicenter study

Seven burn centers performed a 10-yr retrospective chart review of patients diagnosed with purpura fulminans. Patient demographics, etiology, presentation, medical and surgical treatment, and outcome were reviewed. A total of 70 patients were identified. Mean patient age was 13 yr. Neisseria meningitidis was the most common etiologic agent in infants and adolescents whereas Streptococcus commonly afflicted the adult population. Acute management consisted of antibiotic administration, volume resuscitation, ventilatory and inotropic support, with occasional use of corticosteroids (38%) and protein C replacement (9%). Full-thickness skin and soft-tissue necrosis was extensive, requiring skin grafting and amputations in 90% of the patients. One fourth of the patients required amputations of all extremities. Fasciotomies when performed early appeared to limit the level of amputation in 6 of 14 patients. Therefore, fasciotomies during the initial management of these patients may reduce the depth of soft-tissue involvement and the extent of amputations.

Surgical interventions in children with meningococcal purpura fulminans--a review of 117 procedures in 21 children

BACKGROUND/PURPOSE

There are few reports describing the surgical management and outcome of children suffering purpura fulminans secondary to meningococcal sepsis. New Zealand is in the grips of a meningococcal epidemic, and, with the attendant sequalae of the disease process, the authors sought to formally review the children who have required surgical involvement.

METHODS

A retrospective case review of children with the sequalae of meningococcal disease presenting to the Orthopedic and Plastic Surgical Units in a university teaching hospital was undertaken.

RESULTS

There were 117 procedures in 21 children performed over a 12-year period. Surgical management was separated into 2 phases-early and late. The mean delay from admission with acute sepsis to the first surgical procedure (ie, early intervention) was 15.9 days. Debridement and autologous skin grafting was the mainstay of managing the necrotic defects; however, allograft skin proved a useful adjunct as a physiologic dressing. Local flaps were used with deep defects down to bone, but in the extremities amputation to viable tissue was required once gangrene was demarcated. Amputations were carried out in 9 of 21 children. Late interventions were related to relief of contractures or fibula overgrowth causing stump ulceration. Clinical follow-up showed that all children interviewed over 5 years of age (9 children) attend ordinary regular school classes and were physically active within the context of their physical disabilities.

CONCLUSIONS

The data would suggest that children requiring surgery for purpura fulminans achieve age-appropriate milestones and are primarily limited by their physical disability related to amputations, scarring, and abnormal bone growth.

Assessment of adrenal function in the initial phase of meningococcal disease

OBJECTIVE

To determine the status of the hypothalamic-pituitary-adrenal axis in children who had meningococcal disease and were admitted to 2 regional pediatric intensive care units.

METHODS

Sixty-five children (34 boys; median age: 2.5 years; range: 0.2-15 years) had cortisol and adrenocorticotropic hormone (ACTH) levels measured on admission, then at 8 AM and 8 PM during the next 48 hours. At 48 hours, a low-dose short Synacthen test (LDST) (500 ng of 1-24 corticotropin/m2) was performed in 42 patients (19 boys). Normal ranges for 8 AM cortisol and ACTH levels in unstressed children were 140 to 500 nmol/L and 2 to 11.3 pmol/L, respectively. Adrenal insufficiency (AI) was defined as a peak cortisol <500 nmol/L on the LDST or an 8 AM cortisol value <140 nmol/L.

RESULTS

Five (7.7%) of the 65 children died, including 1 with primary AI. Cortisol levels were elevated on admission (median: 1122 mmol/L; range: 65-2110 nmol/L) with 81% of values more than the 8 AM normal range. The median ACTH level on admission was within the 8 AM normal range, but 40% of values were more than the 8 AM normal range. However, 7% and 8% of cortisol and ACTH values, respectively, were less than the normal range. Both cortisol and ACTH levels fell thereafter and showed no diurnal variation during the 48-hour profile. Six (14%) of the 42 failed the LDST. These patients had significantly lower mean 8 AM cortisol values than those with a normal peak value on the LDST. Five additional patients who did not have the LDST had 8 AM cortisol values <140 nmol/L. In the diagnosis of AI, the sensitivity of the 8 AM mean cortisol value at a cutoff of 400 nmol/L, judged against the LDST, was 83%; the specificity was 81%.

CONCLUSIONS

During the initial phase of meningococcal disease, raised cortisol and ACTH levels indicate an appropriate stress response within the hypothalamic-pituitary-adrenal axis. However, a substantial subpopulation (11 [16.9%] of 65) has evidence of adrenal dysfunction during this period. Morning cortisol values in the initial phase of meningococcal disease could be used as a potential early index of AI.

New therapies and vaccines for meningococcal disease

Meningococcal disease (MCD) is an important cause of morbidity and mortality. The pathophysiology consists of a complex interaction of bacterial and host factors, triggered by the release of endotoxin which initiates the inflammatory cascade, resulting in multi-organ failure, coagulopathy, capillary leak, metabolic derangement and eventually death. Prompt recognition and aggressive management are essential in reducing mortality. Over the past decade, there has been intense research into novel therapies and vaccines, with largely disappointing results. Therapies have been broadly divided into anti-endotoxin and anti-TNF-alpha therapies, treatment aimed at correcting coagulopathy and at blood purification and anti-inflammatory cytokine therapy. The reasons for the disappointing results in the search for new therapeutic strategies are difficult to identify. The disordered physiology in MCD results from a complex interaction of several mediators; therefore attempts to correct this by altering just one step represents a gross oversimplification of the process. In addition, the experimental model of endotoxaemia, which is often used, is a poor representation of an acutely ill patient with rapidly progressive shock. There have been several small or poorly designed trials, which have failed to reach definite conclusions. In order to yield conclusive results any future trials must be multicentre, randomised, controlled trials, but these are expensive and, in practice, difficult to conduct. The BPI trial (vide infra) was a significant step forward in this regard and demonstrated the ability to organise a large multicentred trial which can act as a template for future trials. Although the results were not significant there was an overall trend towards improved outcome in the treatment arm. Whilst the development of effective therapies and vaccines are awaited, the priorities at present must be the prompt recognition and aggressive management of disease.

Antithrombin concentrate with plasma exchange in purpura fulminans

OBJECTIVE: To report successful treatment of three patients admitted with purpura fulminans. DESIGN: Three cases with purpura fulminans: clinical presentation, laboratory findings, treatment, and outcome. SETTING: A seven-bed medical and general surgical Intensive therapy unit in a district general hospital. PATIENTS: Three young patients with clinical and laboratory findings of severe meningococcal sepsis and purpura. INTERVENTIONS: Early replacement therapy with antithrombin concentrate after a single initial plasma exchange, together with conventional antibiotic and supportive treatment. MEASUREMENTS AND MAIN RESULTS: All three cases had abnormal coagulation profile consistent with disseminated intravascular coagulation, adult respiratory distress syndrome, impaired renal function, and severe hemodynamic instability requiring inotropic support. Plasma antithrombin levels were measured in all cases. All patients survived and made a good recovery. CONCLUSIONS: We consider that correction of antithrombin to supranormal levels may have a beneficial effect on survival and outcome in purpura fulminans despite sustained low levels of protein C.

Update on meningococcal disease with emphasis on pathogenesis and clinical management

The only natural reservoir of Neisseria meningitidis is the human nasopharyngeal mucosa. Depending on age, climate, country, socioeconomic status, and other factors, approximately 10% of the human population harbors meningococci in the nose. However, invasive disease is relatively rare, as it occurs only when the following conditions are fulfilled: (i) contact with a virulent strain, (ii) colonization by that strain, (iii) penetration of the bacterium through the mucosa, and (iv) survival and eventually outgrowth of the meningococcus in the bloodstream. When the meningococcus has reached the bloodstream and specific antibodies are absent, as is the case for young children or after introduction of a new strain in a population, the ultimate outgrowth depends on the efficacy of the innate immune response. Massive outgrowth leads within 12 h to fulminant meningococcal sepsis (FMS), characterized by high intravascular concentrations of endotoxin that set free high concentrations of proinflammatory mediators. These mediators belonging to the complement system, the contact system, the fibrinolytic system, and the cytokine system induce shock and diffuse intravascular coagulation. FMS can be fatal within 24 h, often before signs of meningitis have developed. In spite of the increasing possibilities for treatment in intensive care units, the mortality rate of FMS is still 30%. When the outgrowth of meningococci in the bloodstream is impeded, seeding of bacteria in the subarachnoidal compartment may lead to overt meningitis within 24 to 36 h. With appropriate antibiotics and good clinical surveillance, the mortality rate of this form of invasive disease is 1 to 2%. The overall mortality rate of meningococcal disease can only be reduced when patients without meningitis, i.e., those who may develop FMS, are recognized early. This means that the fundamental nature of the disease as a meningococcus septicemia deserves more attention.

Update on meningococcal disease with emphasis on pathogenesis and clinical management

The only natural reservoir of Neisseria meningitidis is the human nasopharyngeal mucosa. Depending on age, climate, country, socioeconomic status, and other factors, approximately 10% of the human population harbors meningococci in the nose. However, invasive disease is relatively rare, as it occurs only when the following conditions are fulfilled: (i) contact with a virulent strain, (ii) colonization by that strain, (iii) penetration of the bacterium through the mucosa, and (iv) survival and eventually outgrowth of the meningococcus in the bloodstream. When the meningococcus has reached the bloodstream and specific antibodies are absent, as is the case for young children or after introduction of a new strain in a population, the ultimate outgrowth depends on the efficacy of the innate immune response. Massive outgrowth leads within 12 h to fulminant meningococcal sepsis (FMS), characterized by high intravascular concentrations of endotoxin that set free high concentrations of proinflammatory mediators. These mediators belonging to the complement system, the contact system, the fibrinolytic system, and the cytokine system induce shock and diffuse intravascular coagulation. FMS can be fatal within 24 h, often before signs of meningitis have developed. In spite of the increasing possibilities for treatment in intensive care units, the mortality rate of FMS is still 30%. When the outgrowth of meningococci in the bloodstream is impeded, seeding of bacteria in the subarachnoidal compartment may lead to overt meningitis within 24 to 36 h. With appropriate antibiotics and good clinical surveillance, the mortality rate of this form of invasive disease is 1 to 2%. The overall mortality rate of meningococcal disease can only be reduced when patients without meningitis, i.e., those who may develop FMS, are recognized early. This means that the fundamental nature of the disease as a meningococcus septicemia deserves more attention.

Recognition, treatment and complications of meningococcal disease

Meningococcal disease remains a major cause of death in young children. A decrease in mortality requires recognition and treatment of the disease at a number of stages in the illness. Life-threatening meningococcal disease usually presents as septicaemia rather than meningitis. The cardinal feature of meningococcal septicaemia is the purpuric rash. Many parents recognise the rash and seek medical advice because of it. When primary care physicians recognise the rash, the administration of parenteral penicillin may decrease mortality. However, antibacterials are not given promptly if there is no rash or if the disease presents in an atypical form. In hospital, antibacterial therapy with a third-generation cephalosporin should be given. Disease severity needs to be assessed by a valid method, such as the Glasgow Meningococcal Septicaemia Prognostic Score (GMSPS). This can identify those patients who need intensive care and/or might benefit from new therapies. The 2 life-threatening complications are septic shock and meningoencephalitis with raised intracranial pressure. Despite numerous case reports of success with potential new treatments, none has been proven safe and/or effective by controlled trials. Although it is tempting to focus on new treatments, the early recognition of severe meningococcal disease by parents, primary care physicians and junior hospital doctors is equally, if not more, important as a potential means of decreasing mortality.

Nitric oxide production in meningococcal disease is directly related to disease severity

OBJECTIVES

Meningococcal disease is a homogeneous and well-characterized form of sepsis. Cardiovascular collapse is prominent in severe meningococcal disease. Nitric oxide overproduction may be a mediator of cardiovascular collapse. We relate the level of nitric oxide metabolites, nitrates and nitrites, to disease severity in meningococcal disease.

DESIGN

Prospective, nonrandomized study.

SETTING

Tertiary referral pediatric intensive care unit.

PATIENTS

Children admitted with a clinical diagnosis of meningococcal disease.

INTERVENTIONS

Blood was sampled from children with meningococcal disease. Disease severity was scored using the Glasgow meningococcal septicemia prognostic score and pediatric risk of mortality score. Plasma nitrates and nitrites were measured in stored plasma using the Greiss reaction after conversion of all the nitrate to nitrite.

MEASUREMENTS AND MAIN RESULTS

Twenty-two children were studied. In 19, the final diagnosis was meningococcal disease. Of the 19 children with meningococcal disease, 7 had a Glasgow meningococcal septicemia prognostic score of <8 (mild) and 12 had a Glasgow meningococcal septicemia prognostic score > or = 8 (severe). Three children died, all of these being in the severely affected group. Higher levels of nitrates and nitrites were seen in the more severely affected children (median admission nitrates and nitrites, 27.5 vs. 59.7 nmol/mL; p = 0.063; median peak nitrates and nitrites, 49.9 vs. 114 nmol/mL; p = .01) or those with an increased predicted mortality using pediatric risk of mortality (Spearman's p 0.742; p = .0003).

CONCLUSIONS

Higher levels of nitrates and nitrites are seen in sicker children with meningococcal disease.

Nursing perspectives in meningococcal disease

Meningococcal sepsis is a potentially life threatening disease. Recent advances have led towards increased emphasis being placed on early identification and prompt aggressive management of these patients. This article outlines the disease pathology, describing a case study to illustrate the management and nursing care of a child with meningococcal sepsis. Current therapies are also discussed.