Acute meningococcaemia: a case study

0266 612x/90/ooo60017/510.00

Acute, meningococcaemia: a case study A Fiorentini

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 amibition 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 literature on acute meningococcaemia nurse them. A final brief review of published and the clinical manifestations and outcome of it is provided for those who wish to know more about it.

Kate

was a lively

nurse

at our hospital.

Home

and

newfound One feeling pain, ing (GP)

20-year-old,

first year

She resided

was enjoying

the

student

infective

in the Nurses

beginnings

gastroenteritis

tive diagnosis

was made

with

a tenta-

of meningitis.

of her

career. evening

after

class,

unwell;

she gave

vomiting,

diarrhoea

examination she

was

by

she

complained

a history

and headache. her

admitted

general to the

of

of abdominal Follow-

practitioner medical

ward,

where it was noted that she also had slight photophobia and mild neck stiffness. Her temperature was normal ___--_____

on admission.

An initial

diagnosis

of

MEDICAL PROGRESS AND TREATMENT Laboratory investigations following admission included full blood picture, electrolyte profile, serum

amylase

and

liver function

tests. All were

found to be within normal range. Stools were sent to the laboratory for culture and X-rays of chest and abdomen At this stage,

were also carried

Kate

was conscious

Attracts Fiorentini, Sister, Intensive Care Unit, Altnagelvin Area Hospital, Londondeny BT47 1 SB.

central

(requests for offprints to AF)

signs were recorded

hourly

Manuscript accepted 5 January 1990

well

and

nervous as frequency

system

out. but drowsy;

observations

and

by the nursing

type

of motion

vital staff as

passed. 17

18

INTENSIVE

CARE NURSING

Dihydrocodeine ache

and

these

tartrate

gave

3 hours

was prescribed

metoclopramide

10mg

temporary

later,

relief.

Kate’s

thready,

respiratory

blood

pressure

informed; venous

fluids

cultures

erected.

and co-codamol neck pain Twelve

Kate

was given dropped

hours

after

on Kate’s

puncture

was carried

was sent

turbid

250mg

in appearance

hydrocortisone

were

tremities

were

cold.

Kate

became

and

was

appeared

cyanosed

pharynx

looked

dity increased.

were given

and

screening

frozen

and oxygen

mask.

sodium

The

tures and the cerebrospinal

fluid

biotics

prescribed.

diplococci with

grossly platelets

Officer,

the medical

nursing

for the

patient

and

the staff and visiting

subcutaneous

especially stained

The blood

cul-

(CSF)

cultured

to the

with Kate

should

pupil

Kate

barrier

transfused.

10 and

After

1 week,

Kate

provement

be

take oral penicillin

V

than

and

moaning,

the left and two

ma1 seizures occurred at an interval of 3 She had diazemuls at that time and phewas prescribed prophylactically. A central

venous

catheter

carried

out

was

sited

for position.

and

Because

continence a urinary catheter In view of the progressive

a check

X-ray

of urinary

was inserted. deterioration

in her

The central

on day five to dropped

catheter

began

to show state.

Aeruginosa The

simple

venous

peated

cultures

A co-axial

from

in-

in her

cerebral state, the abnormal blood gases and coagulopathy, an arrangement was made to

(GCS Her

37°C

being

to genta-

penicillin

were found

A

Pseudomo-

sensitive

checked

were

therapy

was

daily.

Re-

to be negative.

scan (CAT)

and cerebral

to and

for culture.

cultured

gentamicin

tomography lesions

imshe

commands

of benzyl

and

levels

blood

was

doses

commenced,

some

line was removed

of urine

reduced

were

to take some drinks.

which

large

cells

Although

to fluctuate

specimen

to

of packed

transfusions

cerebral

tended

and main-

16.

she obeyed

temperature

was

level

Further

on days

gradually

who would

was restless

was smaller

output

two units

shock,

infusion

urea peaked

3 and

blood

evident.

to endotoxic

urinary

blood

gingival and

clinically

Haemoglobin

on day

vascular

At this stage,

due

required

micin.

also recommended

relatives

although

of skin

infarcted,

extremities;

the tip was sent to the laboratory

anti-

of Infection

staff advised

good

2 1.2 mmol/l.

39°C.

areas

with low dose dopamine

a reasonably tained

Large

also

probably

for

of fresh

and cryopre-

haematuria

were

It The

abnormal

became

the

labialis,

sputum

pyrexic.

10000 units per 24

tissue

affecting herpes

1974;

or moved.

concentrate

for 8 days.

ill,

Glasgow-

infusion

heparin

score 12-l 3) and started

for 5 days.

grand hours. nytoin

was given

and

was drowsy,

by

the Control

Nursing

the right

plasma,

nas

In consultation

in contact

frozen

were rigi-

corrected

sensitive

frequent

a metabolic and

was

remained

despite

8.8g/dl

2 litres was administered acidosis

8.41;.

negative

nuchal was

plasma

bicarbonate

gram

drowsy,

hyperventilating.

inflamed

coagulation Fresh

intrathe ex-

more

screen

days

hours

the

and

coagulation

was treated

and

given

hyperventilating

Intravenous

Unit

& Jennett

for her to be touched

Hypotension,

analysis.

to all limbs;

Blood gases revealed

and

abnormal.

that

fluid

on

(Teasdale

platelet

Care

was extremely

4-7

several

bleeding,

and a specimen

for urgent

spread

giving

rash

(GCS)

was painful

cipitate.

A lumbar

out; the cerebrospinal

rash

face

sponged,

a purpuric

face and abdomen.

The

by

intra-

a stat dose of chloramphenicol

of

acidosis

was

and

intermittently.

venously.

Her

doctor

Her temperat-

persisted

to the laboratory

Meanwhile,

1984),

was tepid

admission,

appeared was slightly

Allan,

and

to the Intensive

semi-comatose,

was weak and

to 38°C but the headache,

and vomiting

was

Scale

taken

orally.

she Coma

The

were

the patient

For the first week, Kate

rose to 40°C

rate was 32 per minute

80/40mmHg.

blood

ure gradually

which

transfer (ICU).

Approximately

temperature

pulse rate to 120 per minute

for head-

for vomiting;

infarcts

to detect

any

was carried

out but no focal lesions were seen. There oedema

was limited of both hands

movement

of all limbs

and

and feet: the tips of some of

her fingers were by now necrotic and the vascular surgeon did not rule out the possibility of amputation

(Fig.

1). In view of the large

infarction and inevitable vascular surgeon decided be transferred

areas

of skin

grafting required, the that the patient should

to the Regional

Burns

Unit

her general condition was more stable. Throughout Kate’s illness her mother

when

was fre-

INTENSIVE

CARE NURSING

19

Fig. 1 Finger tips showing necrosis quently interviewed by the doctors and kept up to date with her daughter’s condition and possible prognosis. She had remained constantly at the bedside during that first crucial week as it was thought that Kate would not survive. The support given by her family was essential to her mental and physical condition and certainly contributed to her progress when she regained consciousness.

407; was administered by face mask. Small doses of intravenous midazolam were given at intervals to reduce hyperventilation, restlessness and delirium. A chest X-ray showed diffuse shadowing at bases of both lungs and a specimen of sputum cultured staph-aureus. At this stage, only passive physiotherapy was carried out because of drowsiness and non-co-operation on the part of the patient.

NURSING

MAINTAINING

CONSIDERATIONS

While effective medical treatment was essential Kate’s survival with as little physical and psychosocial residual damage as possible also depended on nursing care designed to meet her basic human needs, as modified by her illness. Since the model of nursing used was that of Roper, Logan, and Tierney (1985) some of the major considerations in that care are described under headings indicating the activities of living which are a major feature of this model, and from which needs for nursing care may arise during illness.

BREATHING On admission to the Intensive Care Unit, Kate was breathing spontaneously, hyperventilating and appeared slightly cyanosed. Intravenous sodium bicarbonate 8.4% (100 ml) was given to correct a metabolic acidosis and oxygen 51 at

SAFETY

Many factors were included. Since coagulopathy was a major threat to safety this took priority, followed by prevention of infection, controlling any further seizures, relief of headache and arthralgia, controlling body temperature and providing a clean and quiet environment. Coagulopathy

The cause of the disseminated intravascular coagulation was bacterial meningococcaemia, therefore the aim was to control the disease and control haemorrhage. The infective organism was treated with large doses of the appropriate antibiotic and intravenous heparin was given to prevent further clotting and factor depletion. Laboratory screening was carried out daily which showed prolonged prothrombin time (PT) and partial thromboplastin time (PTT), thromboplastin time was increased and platelet count

INTENSIVE

20

CARE NURSING

diminished.

Fibrinogen

fibrinogen

degradation

raised.

Blood

plasma,

platelets

such

also

given

replacement

when

as

nursing

haemoglobin therapy

safety

attention

and delivery

fresh

also

Since unstable,

frozen

cells were

levels

dropped.

was given

under

who visited

depended

to detail

and were

were given

of packed

of the haematologist

patient

levels

and cryoprecipitate

Transfusions

This but

product

products,

as necessary.

guidance

level was decreased

during

daily,

taken

infection.

investigations

system

Unit,

both Kate

polythene

working

nursed

people

as necessary,

of the skin lesions.

masks

the

patient

alternate

were

days

could

to minimise

could

Intravenous early

signs

way

taps

sent

so that

infusion

of

daily.

The

Control

recording

as

a human

changes

on

any infection

and

to

maintaining vital

signs,

observation

in Kate’s

subclavian

of Infection

for

sets,

cassettes

vised on the safe handling

Nursing

catheter

condition

vein and

facilitated

total

on check

ration aged,

nutrition.

a stable

she became

a

via the right

X-ray,

was noted

of drugs

The

central

and

venous

to ensure

adequate

hyd-

cardiovascular

state.

When

conscious

in liaison

to

vena cava. This type of cath-

was recorded and

due

delirium,

the administration

parenteral

pressure

drink

and

was inserted

to be in the superior eter

to eat and

of consciousness

lumen

an oral

diet

was encour-

with the dietitian.

Elimination A

Foley’s

inserted

frequently

giving pump

was unable

state

continence

three

output.

were

and

Officer

and disposal

ad-

of soiled

self-retaining

toilet

sent

The

blood

urine

for several

urea

was

urinary

hourly

in-

urinary

out regularly

laboratory

The

and ketones

the

was carried

to the

for culture.

catheter

to overcome

to monitor

Catheter

creatinine

linen and refuse.

and

urine

blood

silastic

into the bladder

weekly

changed

in addition

and

served

to

skin areas

appropriately.

checked

of inflammation; and

risk

of sputum

to the laboratory

be treated

sites were

be were

the

Specimens

for culture,

occurred

and, care

Scale.

admission

was in constant

systems

Kate

triple

daily

which

Since

from when

Department

and swabs from the affected

the mouth

bedside

to identify

reduced

to wear gloves,

sheets

infection and urine,

A nurse

and

nurses

were

of bed linen was sent

sterile

changed

which

measures

and

Supply

so that

between

on arrival

and other

aprons

Sterile

to be autoclaved

and

and

with her. A supply

to the Central

Unit.

Coma

after

treatment

monitoring these

immediately

All staff were instructed

disposable

Care

was

observations

the Glasgow occurred

at the

providing

system

Eating and drinking

Care

to protect

using

seizures

the Intensive

state of the patient

nervous

and needs.

was isolated

to the Intensive

recorded

No further

on consistent

of treatment.

patient

central

attendance

the

Preventing infection The

were

the neurological

three

was

times

positive

for

days.

rose to 2 1.2 mmol/l

level to 220 mmol/l.

Bowel

and

the

movement

was not a problem. Monitoring

of parameters

Monitoring

of the cardiovascular

state

portant. An infusion of the inotrope, was required for several days to acceptable

blood

Cannulation because pressure

of the radial

level and renal artery

output.

was abandoned

of the ecchymoses but the central venous and electro-cardiograph monitoring

were observed was recorded trolled

pressure

was im-

dopamine, support an

by tepid

continuously. Body temperature and any hyperthermia was consponging,

suppositories (as prescribed cool environment.

the use of paracetamol by the doctor)

and a

Rest and sleep After 1 week Kate’s proved

considerably;

simple

questions

level of consciousness

and

had im-

she was now responding able

to take

some

to

drinks.

Several factors posed a threat to adequate rest and sleep, including anxiety and pain. She was very anxious and did not like to be left alone. She wondered if she would be able to continue with her nursing career but a visit from the Assistant Director of Nursing reassured her that her place would be kept. We allowed

some

of her nursing

pals to pay

INTENSIVE

her a short visit, thinking that it might cheer her up, But to the contrary, when they had left she said how envious she was to see them in their uniforms and she did not wish to see them again. However, although she needed constant reassurance, she did have a sense of humour, evident on one occasion when she commented that she should start charging a fee to the many varied medical personnel who came to see her unusual skin condition. Pain relief was achieved by the use of morphine and oral temazepam used to ensure a good night’s sleep. Amitryptylline was prescribed to allay signs of increasing anxiety. Hygiene and mobility

Kate was totally dependent for her personal cleanliness and feeding during the time spent having intensive care. She was bed-bathed each day and tepid sponged when hyperpyrexial. Bed linen was changed at least three times in each 24 hours. A Spenco mattress was used on the bed and her position changed two hourly. In retrospect, I regret not seeking the use of Clinitron Air Fluidised Therapy. This support system boasts relief of pain, control of infection, mobility of patient, deals with incontinence and wound exudate and avoids tissue maceration. Professionally trained nurse advisors and technicians provide in-service training for hospital staff. Oral hygiene was required during the haemorrhagic phase and the herpes labialis was treated with the application of acyclovir cream. She was visited 2-hourly by the physiotherapist who carried out passive exercises to her limbs and active chest physiotherapy when she regained consciousness. She had to be fed since she could not grip with either hand. Her mother and sister often assisted with this task. At a later stage, Kate was carefully lifted out of bed and sat for a period in a comfortable chair. Control of body temperature

Aims to control the intermittent hyperpyrexia proved difficult to achieve. Vigilance in looking for possible sources of infection, e.g. skin necrosis and invasive equipment, was an important factor. The prescribed antibiotics were given as well as paracetamol suppositories, and tepid

CARE NURSING

sponging carried out as required. kept cool and well ventilated.

21

The room was

Work and play

Since Kate was a keen Elvis Presley fan, her family provided a small radio-cassette player so that she could listen to the music of her choice. She preferred this to watching television. Magazines were placed on a tilted bed-table to enable her to read a little but the pages had to be turned for her. Communication

Kate had no problem in communicating with anyone. She was quite frank in expressing her fears and opinions and was uninhibited about asking questions. She was sometimes understandably bored and impatient but always quick to apologise if she felt she had said anything offensive to the nurses. She enjoyed a very close relationship with her family and liked to have them in close attendance, and as indicated earlier they provided support which was so essential to her. Expressing

sexuality

When Kate began to improve, she was very conscious of the ugly skin lesions and her oedematous limbs and the effect it had on her appearance. She often expressed how ‘terrible’ she looked. However, having two ICU staff who had been psychiatric trained was of benefit as they were able to anticipate and allay some of her fears and anxieties. They also helped to direct her self expression to areas other than her self appearance. She liked to have her hair washed frequently and this helped to make her feel a little better also. Dying

Kate at no time voiced any fear of dying but often asked how long her recovery would take.

FOLLOW

UP

Kate spent 1 month in our care after which she was transferred to a burns unit in another hospital.

22

INTENSIVE

‘I’he

CARE NURSING

surgeon

report

there,

fixwarded

to our unit stating

weeks,

extensive

lower

skin

legs and

amputation fingers

arms

grafting

Kate

and

of 6

thighs,

out as well as phalanges

of the

and one toe.

dysfunction

to fibrosis

in the flexor

condition

not

unlike

gross disfigure-

in her hands

muscles,

She had

great

difficulty

the long course

due

Ischaemic

in eating

of time.

of treatment

con-

Occupational arranged

Therapy

visits

she enjoyed. regularly

to local

and

went

her most recent

return

suicidal

When

department

of

worker,

tuted

allocated

in her care

stress

in that

could

medical

Another

point

after anyone

looking

mia before.

that

for psy-

observation

the disease. the physical

by the

Kate

the psychological

prominent

in the critical

early

nursing

and to do

factor. stages

It is pertinent were

relevant

begin

with,

to discuss

was of its

element

some difficult

the unit

bedded

Intensive

isolation

ward

concerned

Care only

and

Unit

factors

of this patient. is a small

which

includes

this was already

of her illness,

she

that To fiveone occu-

pied by a seriously ill patient. This meant that Kate had to be nursed outside the unit in a single room belonging to the Surgical Ward on the same floor level. A telephone had to be provided so that the nurse on duty could communicate readily with the staff of the intensive care unit. Since nurses

a 12-hour

shift system

did not relish

is in operation

the long periods

from the rest of the staff, apart

the

of isolation

from meal breaks

and assistance with nursing treatments. Every attempt was made to limit the number of nurses involved infection,

in Kate’s care because of the risk of cross while realising that this could seem

was by

This was not evi-

NURSING

to the nursing

of the

Although

required

now feed herself.

FACTORS AFFECTING STAFF

of the

outcome

of the family,

was also essential.

care which

and text

assessment

had to be aware

For the reassurance

tedious,

far the more

patient

and the expected

need to be confident

experi-

discussions

articles

of vital importance, the nurses

ever

she still

very well although

this

with Meningococcae-

Continuous

of the

staff was therefore

dent

to the and

was that none had

in frequent

on this condition.

But on

and had been referred

staff

Staff engaged

at weekends.

She was disappointed

of the

needs,

and felt the need to read relevant

nature

involved

appropriately

to be mentioned

enced

this intelligently

risk.

for those

emotional

or medical

and

a

and

This may have constifactor

of the nurses

books

asked

illness

be difficult.

likely complications

to be a

her

it is the responsibility and

which

she was found

as Kate

about

a lot of reasurance. a potential

centre

centres

I last saw her she was very thin having help.

needed

a rehabilitation

from home

could not move her fingers could

to

by Kate,

and was considered

lost a lot ofweight, chiatric

had

to say,

the social

shopping

home

to be very disturbed serious

The

with

She attended

and

Needless

undergone

took its toll psychologically.

nurses questions

so that she has a

Volkmans

for a period

to thr many

patient’s

tracture. be tube-fed

unfair great

staff to know how to respond

is left with quite

marked

progress

to both

of some of the distal

To date

a

over a period

was carried

on both hands

ment

that

Fig. 2 Legs showing patchy necrosis

but

INTENSIVE

,23

CARE NURSING

Fig. 3 Arm showing patchy necrosis

as Kate aware

began

to improve,

the ICU

nurses

that she had to face the problem

body image evitably

and the disfigurement

result

from

the

were

of altered

that would

infarcted

skin

in-

lesions.

disseminated tality

intravascular

of patients

Lamont

et

effect

nurses who have the closest staff

the exact

relationship

a patient,

et al, 1976).

to help

Kate

image.

come

to terms

As the follow-up

adjustment

it naturally

presented

with

her

information

considerable

her, as well as to those trying

fell to us new

self

shows

this

challenges

to

to help her.

Evans growth

et al (1960) conditions

Acute

meningococcaemia

dition.

The

literature

following

provides

the nature

is a relatively brief

review

of relevant

some useful information

of the condition,

common

about

complica-

tions and outcomes. Gangrene

the skin and

remains

must

a compli-

that

the endotoxin

endotoxin,

producing extravasation tissues

and

oedema,

capillary

of blood subsequent

into

meningitis

(Stiehm

only

tions by Neisseria Meningitidis nificant illness (Godl, 1972).

1966; Hunter,

associated

1 in 10000 infec-

toxin

develops into sigIn a minority of

and

cases where the clinical picture is that of an overwhelming septicaemia with endotoxic shock and

necrosis with antithey pro-

difficult to counteract. leads to vascular damage

thrombosis

diminishes causes

thromthe extra-

patchy

duce prove endotoxaemia

that

injury

of the skin by the meningococcal

feature is more

& Damrosch,

as respons-

skin lesions in meningococ-

recognised prognosis

It is estimated

in its effect

be regarded

cation of fulminant meningococcaemia (Delmas, Courtiere et al, 1979). A high mortality is a

1973).

invasion,

is unique

(Figs 2 & 3). Meningococci can be killed rapidly biotics but the effects of the endotoxins

of this condition, whereas the favourable in meningococcal

bacter-

thrombosis

The end result is a specific

bosis with vascular

of the extremities

favourable

bacterial

state

LMeningitidis

of the vessels

that

(Sotto

by endotoxin.

et al (1974)

cal septicaemia.

damage,

clear

vasculitis,

by direct

ible for the cutaneous rare con-

is not quite

causing

from Neisseria

pathological

vascular

believed

supplemented

Warren

basic

(Adendorff,

in the skin led to rapid

haemorrhage

possibly

upon

The

of which

ial multiplication and

ACUTE MENINGOCOCCAEMIACLINICAL MANIFESTATIONS AND OUTCOMES

1980).

nature

the mor-

40 to 80%

the skin is diffuse

Since it is usually with

al,

upon

coagulation,

is high,

and

the venous

haemorrhage. return

a fall in peripheral

The with Endo-

to the heart

vascular

resist-

ance, thus leading to reduced cardiac output and a fall in arterial blood pressure. The mortality of fulminant infection remains high, mainly

24

INTENSIVE

because when

CARE NURSING

patients

are often

treatment

ring

within

diagnosis

is instituted-most

24 to 48 hours therapy

associated

with

capillary

endotoxic

circulation

vasculitis

Early

Carson

et al, 1989).

under

required

skin grafting

6 years

(Fielding

who suffered

of one foot and American

Journal who

amputations.

1987), and Jayaratpalsy;

female

and all the toes

Galanes

(1984)

of Neurosurgical

16 No. 3, published also

girl

but no ampu-

the tops of the toes on the other

amputation.

grafting,

17-year-old

one 19-year-old

nerve

required

female

requiring

they reported

old. One

&Jenkins,

cranial

et al (1980)

gangrene

to all limbs

nam et al (1989) reported

of patients

skin grafts due

but all of the patients

on were

a case report survived

required

and

in

Nursing

bilateral

This was the only nursing

needing

below-knee reference

on meningococcaemia.

D J, Lament

the Vol.

on one 1g-yearbesides

References Adendorff

of

the effects of

Lamont

reported

the

areas

reports

and/or

Adendorff,

(1985)

amputation

reduces

Meadway published

of

hypotension

shock

amputations

to this condition.

The

and compounds

are several

who required

obtained

occur-

in the vulnerable

(Jayaratnam,

There

old

deaths

of admission.

is vital.

skin and extremities

tations

shock

of onset of shock and commencement

appropriate

and

in irreversible

A, Davies D 1980 Skin Loss in

Meningococcal Septicaemia. BritishJournal ofPlastic Surgery 33: 25 l-255 Allan D 1984 Glasgow Coma Scale. Nursing, Oxford 2: 688 Carson J W K 1985 Gangrene Requiring Amputation in Meningococcal Infection. Irish Medical Journal 78( I I: 14-16 Delmas P, Courtiers B, Lecacheux C, Robert M, Laugier J 1979 Gangerine des extremitis complication du purpura fulmians. Chirurgie Pediatrinue 20: 445447 Evans R W, Glick B, Kimball F, Lobe11 M 1969 Fatal Intravascular Consumption Coagulopathy in Meningococcal Sepsis. American Journal of Medicine 46: 910 Fielding GA, Jenkins A M 1987 Skin Necrosis Secondary to Meningococcal Septicaemia in An Adult. Australian, New Zealand Journal of Surgery 57: 57-60 God1 E 1972 Meningococcal Infection Paediatrics 15th edn. Appleton Century, New York p 622 Galanes S 1984 Meningococcaemia. A case report. Journal of Nrurosurgical Nursing 16(3): 134-139 Hunter J 1973 Heparin Therapy in Meningococcal Septicaemia. Archives ofDisease in Childhood 48: 233. Jayaratnam R, Mcdway J, Burt D E R 1989 Gangrene of the Extremities in Meningococcal Infection. 15: 307308 Roper N, Logan W W, Tierney A.1 1985 The elements of nursing (2nd edn). Churchill Liiingstone, Edinburgh Sotto M N. Lancer B. Horshino-Shimizu. De Brito T 1976 Pathogenesis of Cutaneous Lesions in Acute Meningococcaemia in Humans, Journal of Infectious Diseases 133: 506 Stiehm E R, Damrosch D S 1966 Factors in the Prognosis of Meningococcal Infection. Journal of Paediatrics 68: 457 Teasdale G M, Jennett W B 1974 Assessment of Coma and Impaired Consciousness. Lancet 11: 81 Warren Cpt, Toews H, Bass J W 1975 Skin Manifestations of LMeningococcal Infections. American Journal of the Diseases of Children 127: 173