Extracranial organ involvement
When the process becomes generalized, the pathogen affects various body systems, causing a range of characteristic disorders:
- Cardiovascular system: rhythm disturbances may develop.
- Joints: involved in the pathological process during the first days (in 3–13% of patients). Resulting arthritis and arthralgia typically resolve with specific treatment and require no additional interventions.
- Kidneys: the spectrum of impairment ranges from moderate dysfunction to acute kidney injury (AKI).
- Nervous system: meningism frequently occurs—the appearance of meningeal signs in the complete absence of inflammatory changes in the cerebrospinal fluid (CSF). This condition may precede the development of true meningitis.
Fulminant course (purpura fulminans)
The fulminant form is distinguished by an extremely acute onset: sudden chills, a temperature spike up to 40–41°C, intense pain, and rapid clouding of consciousness.
- Exanthema: appears extremely early (in 6–12 hours). The elements tend to coalesce, forming large ecchymoses, including on the face.
- DIC syndrome: pronounced. Accompanied by hemorrhages into the sclerae, conjunctivae, and subarachnoid space, as well as massive nasal and uterine bleeding, and hematuria.
- Tissue ischemia: microcirculatory disorders lead to deep necrosis and gangrene of the distal areas (fingers, tip of the nose, auricles).
The ultimate manifestation of the fulminant course is Waterhouse-Friderichsen syndrome. It develops due to total or subtotal hemorrhages into the adrenal glands, leading to acute adrenal insufficiency. Clinically, this presents as therapy-refractory septic shock, a sharp drop in blood pressure, total cyanosis, and multiple organ dysfunction syndrome.
Septic shock
Shock in meningococcemia progresses rapidly and goes through three clinical stages:
- Compensated (Grade I): Patient is conscious, agitated. Axillary temperature is high, but hands and feet are cold. Blood pressure is normal, diuresis is decreased. The capillary refill time («white spot» sign) is prolonged to 8–10 seconds. Rash is fine and rapidly increasing.
- Subcompensated (Grade II): Agitation is replaced by lethargy. Pronounced acrocyanosis and skin mottling develop. Blood pressure drops to 50% of the age norm, tachycardia reaches 100–120 bpm. Decompensated acidosis and oligoanuria develop. The rash becomes large, confluent, with areas of necrosis.
- Decompensated (Grade III): Consciousness is depressed or absent. Total cyanosis is observed. Pulse is thready, blood pressure drops below 50–70 mm Hg (or is not detectable at all). Complete anuria and profound hypoxemia develop.
Chronic meningococcemia
This is a rare form of infection characterized by prolonged persistence of meningococci in the body with periodic episodes of bacteremia. Intermittent temperature spikes every 2–10 days are typical, while during periods of normal temperature (apyrexia), well-being is fully restored. At the peak of the fever, a sparse maculopapular or petechial rash appears. In the majority of patients (70%), joints are affected, and one in five has an enlarged spleen. The disease can last from a week to several months; the prognosis is generally favorable, although complications such as endocarditis or nephritis are possible.
Nervous system involvement and cerebral edema
In 30–50% of patients, meningitis develops. It manifests with three syndromes: intoxication, cerebral (bursting headache, vomiting that brings no relief), and meningeal (nuchal rigidity, hyperesthesia, Kernig's and Brudzinski's signs).
A most dangerous complication (occurring in 20–30% of cases) is cerebral edema and swelling, which typically develops by the end of the first or on the second day. Without timely assistance, it progresses to herniation syndrome (tonsillar herniation through the foramen magnum). Clinically, this is manifested by respiratory arrest (or Cheyne-Stokes respiration), fixed narrow pupils, sharp fluctuations in blood pressure, and the appearance of pathological reflexes.
Briefly: answers to topical questions
What antibacterial drugs are the drugs of choice for etiotropic treatment of meningococcemia?
The drug of choice for the etiotropic treatment of prominent meningococcemia is chloramphenicol (sodium chloramphenicol succinate).
Depending on the stage of care and clinical presentation, the following drugs are used:
- Chloramphenicol — prescribed at a dosage of 80–100 mg/kg/day at 6-hour intervals; preferred in severe meningococcemia or the threat of septic shock.
- Penicillin / Benzylpenicillin — in case of suspected meningococcemia at the pre-hospital stage, parenteral administration is indicated; a single dose of penicillin is administered immediately after the initial examination.
In the generalized form of meningococcal infection without septic shock, intramuscular administration of antibiotics is permitted; with the development of septic shock, strictly intravenous administration.
What changes in the cerebrospinal fluid (CSF) are characteristic of meningococcal meningitis?
Meningococcal meningitis is characterized by the development of macroscopic and microscopic signs of purulent inflammation in the cerebrospinal fluid.
The following changes are observed in the CSF:
- Macroscopic properties — the fluid exits under increased pressure, has a turbid, whitish, or yellowish-green hue.
- Cytology — pronounced neutrophilic pleocytosis (500–1000 cells or more per 1 µl, where 60–100% are neutrophils).
- Biochemistry — hyperproteinorachia (elevated protein levels up to 2–8 g/L with cyto-protein dissociation) and decreased glucose concentration.
- Bacterioscopy — gram-negative diplococci are detected, located intracellularly and extracellularly.
Which infectious diseases require differential diagnosis of the hemorrhagic rash in meningococcemia?
Differential diagnosis of the hemorrhagic rash in meningococcemia is carried out with diseases whose clinical presentation includes intoxication, exanthematous (especially hemorrhagic), and meningeal syndromes.
Infectious diseases for differential diagnosis include:
- severe forms of influenza;
- hemorrhagic fevers;
- rickettsiosis, including typhus;
- leptospirosis;
- generalized gonococcal infection;
- infective endocarditis;
- sepsis;
- less commonly, measles and rubella.
What doses of glucocorticosteroids are used to manage septic shock in meningococcemia?
Glucocorticosteroids are used when septic shock threatens or develops in meningococcemia.
Regimens indicated in the sources:
- Prednisolone — in severe meningococcemia or threat of septic shock: 0.5–1 mg/kg intravenously.
- Prednisolone — in septic shock as part of pathogenetic therapy: 60–90 mg 2–3 times a day.
- Dexamethasone — 4 mg 6 times a day intravenously.
- Hydrocortisone — infusion for refractory septic shock; dose not specified in the cited sources.
To remember the main groups of meningeal signs, use the «3 H's» rule: Hyperesthesia (photophobia, noise intolerance), Headache (sharp, with reactive pain signs), Hypertonus (nuchal rigidity, posture).
Class and exam questions
What is Guedel's sign?
This is the capillary refill test («white spot» sign) that assesses microcirculation. Normally, after pressure is applied, the spot disappears within 4–6 seconds. In the first stage of shock, the time increases to 8–10 seconds, and in severe septic shock, it exceeds 10 seconds.
Which blood test changes indicate a poor prognosis in shock?
Extremely unfavorable signs include neutropenia, low white blood cell count (less than 8 thousand/µl), pronounced thrombocytopenia (less than 80 thousand/µl), and hypofibrinogenemia.
What else to study on this topic
- Mechanisms of DIC development in purpura fulminans
- Features of meningeal syndrome in infants (Leschke's and tripod signs)
- Pathogenesis of Waterhouse-Friderichsen syndrome
- Technique for eliciting reactive pain points (Mendel's, Bechterew's, Pulatov's signs)
- Laboratory diagnostics and cerebrospinal fluid analysis in meningitis
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