Meningococcemia Mihai Puia-Dumitrescu , M.D., M.P.H. PGY1 - Pediatrics

1. MeningococcemiaMihaiPuia-Dumitrescu, M.D., M.P.H.PGY1 - Pediatrics Pediatric Emergency Medicine Rotation – May 23, 2013 Conference

2. CASE 1:You are called to examine a 6 year old boy presenting with sore throat and 12 hours history of malaise and new rash (see picture). Temp: 40C, HR: 160, RR: 32, mottled skin, with poor perfusion. What is the empiric therapy of choice for this condition? Supportive care Ceftriaxone Doxycycline IVIG Clindamycin http://see.visualdx.com/diagnosis/meningococcemia_acute.jpg

3. You are called to examine a 6 year old boy presenting with sore throat and 12 hours history of malaise and new rash (see picture). Temp 40C, HR: 160, RR: 32, mottled skin, with poor perfusion. What is the empiric therapy of choice for this condition? Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL, Scheld WM, Whitley RJ. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004;39(9):1267. Supportive care Ceftriaxone Doxycycline IVIG Clindamycin http://see.visualdx.com/diagnosis/meningococcemia_acute.jpg

4. You are called to examine a 6 year old boy presenting with sore throat and 12 hours history of malaise and new rash (see picture). Temp 40C, HR: 160, RR: 32, mottled skin, with poor perfusion. The patient is allergic to Penicillin. What is the empiric therapy of choice for this condition? Supportive care Ceftriaxone Doxycycline IVIG Clindamycin Chloramphenicol http://see.visualdx.com/diagnosis/meningococcemia_acute.jpg

5. You are called to examine a 6 year old boy presenting with sore throat and 12 hours history of malaise and new rash (see picture). Temp 40C, HR: 160, RR: 32, mottled skin, with poor perfusion. The patient is allergic to Penicillin. What is the empiric therapy of choice for this condition? Galimand M, Gerbaud G, Guibourdenche M, Riou JY, Courvalin P. High-level chloramphenicol resistance in Neisseria meningitidis. N Engl J Med. 1998;339(13):868. Supportive care Ceftriaxone Doxycycline IVIG Clindamycin Chloramphenicol http://see.visualdx.com/diagnosis/meningococcemia_acute.jpg

6. Meningococcemia • Etiology: Neiserriameningitidis • Clinical Presentation: • Prodrome: • URI symptoms, pharyngitis, fever • Lethargy, headache, vomiting • Myalgias, arthralgias • Septicemia: • Abrupt worsening of prodromal symptoms • Rash: Tender pink macules, petechiae (75%), purpurafrank necrosis • Shock: Mottling, poor perfusion, +/- hypotension • DIC • Meningitis • Treatment: • 3rd generation cephalosporin – follow cultures and sensitivities • Supportive care: Fluid replacement, pressors as needed

7. One more…

8. CASE 2: After participating in the stabilization of a 12 year old patient with meningococcemia, your student is asking which are the first specific signs and symptoms suggesting early sepsis in a patient with meningococcal disease. Your answer will be: The rash is the classic symptom but is not specific Fever, throat pain, and mottling of the skin Leg pain, cold hands and feet, and abnormal skin color Petechial rash, fever and headache Cold extremities, neck stiffness, abdominal pain http://see.visualdx.com/diagnosis/meningococcemia_acute.jpg

9. After participating in the stabilization of a 12 year old patient with meningococcemia, your student is asking which are the signs and symptoms suggesting early sepsis in a patient with meningococcal disease. Your answer will be: The rash is the classic symptom but is not specific Fever, throat pain, and mottling of the skin Leg pain, cold hands and feet, and abnormal skin color Petechial rash, fever and headache Cold extremities, neck stiffness, abdominal pain http://see.visualdx.com/diagnosis/meningococcemia_acute.jpg

10. Meningococcemia Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL, Scheld WM, Whitley RJ. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004;39(9):1267. http://www.uptodate.com/contents/treatment-and-prevention-of-meningococcal-infection?source=search_result&search=meningococcemia+treatment&selectedTitle=1%7E43#H5 Worrisome signs — Although initial clinical features of patients with meningococcal disease are similar to many common, self-limiting viral illnesses seen in primary care, signs of early sepsis should differentiate the patient who merits clinical monitoring. Based on the retrospective review of 448 children with meningococcal disease cited below, signs and symptoms suggesting early sepsis include: Leg pain Cold hands and feet Abnormal skin color (eg, pallor or mottling)

11. Thank You!