Unusual presentation of meningococcal”>Case Report

Contents lists available at SciVerse ScienceDirect

American Journal of Emergency Medicine

journal homepage: locate/ ajem

An unusual presentation of meningococcal meningitis–timely recognition can save lives!

Abstract

Meningococcal meningitis has been known to have a high fatality rate. A high degree of suspicion is required for early recognition and timely intervention. In this report, a case of a young male is presented who came to the emergency department with predominately lower Gastrointestinal symptoms but was diagnosed with meningococcal meningitis and managed accordingly.

Meningococcal meningitis is caused by Neisserria meningitidis (meningococcus) a gram-negative aerobic diplococcus. Approximately one-fourth of all cases of acute Bacterial meningitis are caused by meningococcus [1]. Typical presentation is a young patient with headache, fever, Nuchal rigidity, and sometimes skin rash. [2]. However, cases presenting initially as pneumonia, pericarditis, arthritis, urethritis, panophthalmitis, conjunctivitis, Otitis media, or epiglottitis have been previously reported [3]. To the best of my knowledge, this is the first case with an unusual initial presentation of colitis.

A 27-year-old Hispanic man with no significant medical history presented to our emergency department (ED) with complaints of lower abdominal pain, diarrhea fever, chills, and mild headaches for

5 days duration. Patient also gave a history of High-risk sexual behavior, sexually active with multiple partners both male and female. On admission, his blood pressure was 105/80, pulse rate was 110, and oral temperature was 36.7?C. Physical examination showed discrete petechiae on the lower extremities bilaterally (see Fig.). His skin was warm to the touch. Chest, cardiac, and abdominal exam- inations were all within normal limits. There was no Neck rigidity. Computed tomography of the abdomen showed wall thickening of the large bowel with mild haziness around the distal sigmoid colon suggestive of pan colitis. While waiting to be admitted, the patient started to become hypotensive and confused in the ED. Due to a change in his mental status, empiric antibiotic therapy was started for suspected meningitis. Central venous catheter was inserted for aggressive intravenous hydration. Computed tomography of head was negative for any acute intracranial pathology. Cerebrospinal fluid (CSF) analysis showed low glucose with high protein indicating bacterial meningitis (see Table). Gram staining of CSF showed numerous Gram-negative cocci that were confirmed on counter- immuno electrophoresis typing as neisseria meningitides. The patient was transferred to the intensive care unit for monitoring and further management. Blood and CSF cultures showed no growth. Human immunodeficiency virus testing was negative. Patient responded well to Intravenous antibiotic therapy and recovered fully without any immediate neurologic sequelae.

N meningitidis is a gram-negative aerobic diplococcus that has at least 13 different serogroups [3]. Serogroups A, B, C, W-135, X, and Y are the major ones. Transmission usually occurs through respiratory droplets and mostly results in asymptomatic carrier state. Patients, in whom meningococcal disease does develop, present either as acute meningococcemia or meningococcal meningitis. Early institution of antibiotic therapy in suspected cases of meningococcal meningitis has been shown to be life saving as the disease progresses very rapidly and has a high case fatality rate [4]. Antibiotic therapy should be promptly started without waiting for lumbar puncture. Polymerase chain reaction can be used with high degree of sensitivity and specificity for organism isolation from the CSF, even in patients already receiving antibiotics [5]. Patients have to be kept on respiratory isolation and droplet precautions for at least 24 hours after initiation of empiric Intravenous antibiotics [6]. Centers for Disease Control and Prevention also recommends chemoprophylaxis for medical staff that had close contact with the patient. Suggested regimens include oral rifampicin 600 mg every 12 hours for 2 days or a single oral dose of ciprofloxacin 500 mg [7].

It is extremely vital for physicians working in the ED to be able to

promptly recognize these atypical and unusual presentations of meningococcal meningitis, as timely institution of antibiotic therapy can prove to be life saving.

Fig. Petechiae on lower extremity.

0735-6757/$ – see front matter.

Table

Cerebrospinal fluid results suggestive of Acute bacterial meningitis

Specimen Color Appearance Glucose Protein WBC Lymphocytes CSF Straw Cloudy 34 mg/dL 314.3 mg/dL 18000 2

Abbreviation: WBC, white blood cell count.

Amil Rafiq MD

Department of Internal Medicine, Wyckoff Heights Medical Center

Brooklyn, NY 11237, USA E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2013.02.012

References

1. David HS, Lisa AJ. Bacterial meningitis. Neurol Clin 2000;17:711-35.
2. Anne S, Katherine R, Jay DW, et al. Bacterial meningitis in United States in 1995. N Engl J Med 1997;337:970-6.
3. Stephens DS, Greenwood B, Brandtzaeg P. Epidemic meningitis, meningococcae- mia, and Neisseria meningitidis. Lancet 2007;369:2196-210.
4. Swartz MN. Bacterial meningitis: a view of the past 90 years. N Engl J Med 2004;351:1826-8.
5. Suri M. Group B Meningococcal meningitis in India. Scan J Infect Dis 1994;26(6): 771-3.
6. American Academy of Pediatrics. Meningococcal infections. In: Pickering LK, Baker CJ, Long SS, McMillan JA, editors. Red book: 2006 report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2006.

   p. 452-60.

   Centers for Disease Control. Control and prevention of meningococcal disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1997;46(RR-5):1-51.