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Fever and rash
The Journal of Emergency Medicine, Vol. 25, No. 3, pp. 315–318, 2003 Copyright © 2003 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/03 $–see front matter
doi:10.1016/S0736-4679(03)00211-7
Case Presentations of the Harvard Emergency Medicine Residency
FEVER AND RASH Tracy Wimbush,
MD,*
David F. M. Brown,
MD*†
and Eric S. Nadel,
MD*†,‡
*Division of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, †Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, and ‡Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts Reprint Address: Eric S. Nadel, MD, Department of Emergency Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115
Dr. Tracy Wimbush: Today’s case is a 21-year-old woman who presented to the Emergency Department (ED) with a chief complaint of fever, vomiting, headache and rash. The symptoms began 1 day before presentation. Initial symptoms included a sore throat, fever, bilateral ear pain, and headache. These symptoms were accompanied by generalized malaise, lethargy, drenching sweats, and approximately 20 episodes of nonbloody emesis. On the morning of presentation, her sister noted a rash of “little red dots” on the patient’s abdomen. Within 3 h, the patient had the same rash on her lower extremities. Her sister brought her for evaluation because she seemed unusually sleepy and somewhat confused. The past medical history included thalassemia minor, syncope, and migraines. The patient also reported a history of low blood pressure, but was uncertain of her baseline blood pressure. She was taking no medications and had no allergies. Are there any questions at this point? Dr. Eric Nadel: Can you tell us a little about her social history? Is she a student? Did she report any exposures? Dr. Wimbush: The patient is an undergraduate at a local university. She is from Iran and her last foreign travel was 10 months ago. She lives in an off-campus apartment with her sister, and works part-time at a local coffee shop. The patient denied any known exposures but
reported that she went to her university health service shortly after her symptoms began, but before the rash developed. She was told it was likely a viral illness and that many students were presenting with similar symptoms. The patient does not smoke or drink, and is not sexually active. She reported receiving several unknown vaccinations before starting college. On review of systems, the patient complained of photophobia, neck pain, and dyspnea, but denied cough or sputum production. She reported epigastric pain that began after several hours of vomiting and retching. Would anyone like to discuss the differential diagnosis of this patient with fever, rash, vomiting and headache? Dr. Vicki Noble: The initial symptoms, sore throat, fever, headache and bilateral ear pain in a young healthy patient, are consistent with an upper respiratory infection or a streptococcal pharyngitis. However, the progressive symptoms reported are more concerning. The differential diagnosis at this point is wide but most concerning is the possibility of bacterial meningitis. Neisseria meningitis, given the description of the rash, seems like the most likely diagnosis. With these symptoms at presentation, were precautions taken at triage? Dr. Wimbush: Yes, even the brief history given at triage along with her appearance was concerning enough that a mask was placed on the patient immediately. On arrival, her vitals were: temperature 38.3°C (101°F),
Case Presentations of the Harvard Emergency Medicine Residency are coordinated by David F. M. Brown, MD, and Eric S. Nadel, MD, of Harvard University Medical School, Boston, Massachusetts
RECEIVED: 13 June 2003; ACCEPTED: 16 June 2003 315
316
blood pressure 73/49 mm Hg, heart rate 124 beats per minute, respiratory rate 24 breaths per minute, and oxygen saturation 100% on room air. Examination revealed an ill appearing young woman. The head was atraumatic. There was no facial asymmetry. Pupils were 4 mm and reactive; the patient demonstrated photophobia to bright light. Extraocular movements were intact without nystagmus. Tympanic membranes were normal bilaterally. Mucous membranes were dry. The oropharynx was clear without exudates; there were no mucosal lesions. The gag reflex was intact. The neck was supple but flexion exacerbated the headache. The heart examination was notable only for tachycardia. There were no murmurs or rubs. The lungs were clear. The abdomen had normal bowel sounds, with mild epigastric and right upper quadrant tenderness without rebound or guarding. There was no organomegaly. The extremities were slightly cool and capillary refill was slightly prolonged. Examination of the skin demonstrated a petechial rash over the lower extremities and lower abdomen. The patient was awake but slightly lethargic. Strength was 4/5 in all extremities. There was no papilledema. She was oriented to person, place, and time. She was able to give a full and coherent history. Dr. Nadel: As stated by Dr. Noble, this presentation is very concerning for meningitis. Although she has a history of low blood pressure, it is unlikely that 73/49 mm Hg is baseline. She is febrile, tachycardic, and hypotensive, and should be regarded as septic until proven otherwise. The petechial rash could be a sign of meningococcemia or of disseminated intravascular coagulopathy (DIC) from another bacterial source. What was done for the patient at this point? Dr. Wimbush: The concerning illnesses mentioned were high on our differential. Two large-bore intravenous catheters were placed and fluid resuscitation was initiated. The patient was administered 10 milligrams of dexamethasone, one gram of vancomycin, and two grams of ceftriaxone intravenously. Consent was obtained to perform a lumbar puncture. However, the procedure was delayed until coagulation studies were available, given the petechial rash and the possibility of DIC. After two liters of normal saline, the patient’s blood pressure improved to 113/41 mm Hg. Laboratory studies revealed white blood cell count 40.6 K/mm3, hematocrit 27.9%, and platelets 136 K/mm3. The differential of her white blood cell count demonstrated 30% bands. Serum chemistry demonstrated sodium 140 mmol/L, potassium 3.6 mmol/L, chloride 107 mmol/L, bicarbonate 23 mmol/L, blood urea nitrogen 22 mg/dL, creatinine 1.6 mg/dL, calcium 9.6 mg/dL, phosphorus 2.0 mg/dL, magnesium 1.3 meq/L, and glucose 122 mg/dL. Liver function tests, amylase, and lipase were normal. The urine
T. Wimbush et al.
pregnancy test was negative. Coagulation studies revealed PT 14.0 seconds and PTT 29.4 seconds. A chest radiograph was normal. The electrocardiogram showed sinus tachycardia. A lumbar puncture was performed. Opening pressure was normal. The cerebrospinal fluid (CSF) contained no xanthochromia. Tube 1 contained 4 white blood cells and 7 red blood cells. Tube 4 contained 2 white blood cells and 4 red blood cells. CSF glucose was 94 mg/dL and protein was 31 mg/dL. The spun CSF demonstrated a moderate number of polymorphonuclear leukocytes, a few mononuclear cells, and very rare red blood cells. There were no organisms seen. Dr. Ben Sun: The CSF does not support a diagnosis of bacterial meningitis. However, the petechial rash and signs of sepsis are extremely concerning for meningococcal infection. Did she remain on droplet precautions to protect others from a potential meningococcemia exposure? Dr. Wimbush: With meningococcemia being the leading diagnosis, the patient remained on droplet precautions. As suggested by Dr. Sun, there is a strong association between petechiae and meningococcal infection, with development of petechiae or purpura in 80% of children with bacteriologically proven disease (1). The patient remained on droplet precautions throughout her ED course. Staff remained concerned regarding the contagious nature of meningococcemia, and were reassured that meningococcal infection is not as highly contagious as many believe, as long as there are precautions in place (2). It may be the devastating outcomes that leave a lasting impression on health care providers. Up to 40% of cases of meningococcal sepsis are fatal and 11–19% of survivors have significant sequelae such as deafness, loss of digits, or even loss of limb (3,4). Dr. Noble: Given her degree of hypotension and continued low mean arterial pressure, was any thought given to starting pressors? Dr. Wimbush: Keeping in mind that many patients with sepsis require large volume resuscitation, normal saline infusion was continued. The literature supports the addition of pressors in sepsis if the patient is not responding to crystalloid resuscitation or if there is evidence of pulmonary edema due to heart failure or capillary leak. After four liters of normal saline, the patient’s blood pressure improved to 106/67 mm Hg. The tachycardia resolved and she demonstrated no evidence of respiratory compromise, with a respiratory rate of 18 breaths per minute and oxygen saturation of 98% on room air. A urinary catheter was placed and urine output was greater than 75 cc per hour, thus further demonstrating adequate resuscitation. Due to the risk of Waterhouse-Friderichsen syndrome in meningococcemia, abdominal computed tomography (CT) scan was considered to evaluate for
Fever and Rash
adrenal hemorrhage, and was not obtained due to her appropriate response to fluid resuscitation. The patient was subsequently admitted to the medical service for further management. Are there any questions about the ED management? Dr. J. Tobias Nagurney: Can you comment on antibiotic choices you initiated? Was there any consideration for a head CT scan before lumbar puncture? Dr. Wimbush: Although the patient’s rash was suggestive of Neisseria infection, the causative agent of her presumed sepsis and signs of meningitis was unknown. Common causative bacteria in this patient’s age group include Streptococcus, Listeria, or even Haemophilus (5). Thus, although penicillin alone is often adequate therapy for Neisseria meningitis, broad coverage was initiated as recommended for immunocompetent children over 3 years old and adults under 50 years old when the causative agent is unknown (1,6). Indications for head CT scan before lumbar puncture in suspected bacterial meningitis include: focal deficit on neurologic examination, seizures, history of head trauma, minimal or no fever, decreased mental status, or papilledema (5). Although the patient’s sister reported a question of confusion, the patient was alert and oriented on examination. Thus, there were no contraindications to lumbar puncture. Within 12 h of hospital admission, the patient’s blood cultures grew Gram-negative diplococci, later identified as Neisseria. She was continued on ceftriaxone. After 24 h of antibiotic therapy, precautions were discontinued. She was discharged on hospital day six in good condition. Home services were arranged to complete a 14-day course of intravenous ceftriaxone. Dr. Nadel: Although contact precautions were initiated at triage, were there any health care worker exposures? What was done to contact and treat those exposed in the community and at home? Dr. Wimbush: Chemoprophylaxis is recommended for all exposed to infectious oral secretions and close contacts (4). Close contacts who should consider prophylaxis include those exposed to oral secretions through kissing, sharing cigarettes, or sharing utensils. The nature of preschool children often means that the sharing of toys may also indicate the sharing of saliva. Thus, prophylaxis is recommended for childcare center classmates and teachers (2). Rifampin has been the antimicrobial prophylaxis of choice. Reports of rifampin resistance have been very rare (4). Alternatives to rifampin (600 mg every 12 h for 2 days) include ciprofloxacin (a 500-mg one-time oral dose), ofloxacin (400-mg one-time oral dose), or ceftriaxone (250-mg one-time intramuscular dose) (2,6). There is approximately a 5% incidence of transmission among household contacts (5). The patient’s sister
317
presented to the ED the following morning and was treated with ciprofloxacin 500 mg as a one-time treatment. Chemoprophylaxis is not recommended for health care workers unless they have come into direct contact with the patient’s oral or nasal secretions such as occurs with mouth-to-mouth resuscitation or endotracheal intubation (2,4,5,7). Treatment of casual contacts, such as customers in the coffee shop where she worked, is not recommended. Dr. Nadel: The patient was a college student. Was this her only risk factor for meningococcal infection? Dr. Wimbush: Risk factors for meningococcal infection include any condition impairing the ability to fight infection, such as asplenia or HIV infection. Incidence of meningococcal disease peaks in the winter months. Adults are less likely to be infected than teenagers and the disease rate is highest among infants ages 3 to 9 months (3). Crowded conditions are thought to be a major contributing factor to the incidence of disease. The patient is a college student but she does not live in a dormitory. The American College Health Association and the Centers for Disease Control studies have shown a 3-fold increase in the incidence of meningococcal infection in freshmen living in the dormitories compared to noncollege students of similar age groups. This increased risk does not hold true for students living in off-campus housing (8). Other risk factors include recent upper respiratory infection and active or passive smoking (2). Other than age, the patient had no risk factors. Dr. Nathan Mick: You stated that her immunization status was unknown. Is it safe to presume that she had not received meningococcal vaccination? Dr. Wimbush: The current recommendation of the American Academy of Pediatrics and the American College Health Association is educating incoming and current freshmen regarding the risk of meningococcal disease and the potential benefit of vaccination. Vaccination is also recommended for those with asplenia, complement or properdin deficiencies, and those traveling to areas with high rates of disease (8). It is unknown if the patient ever lived in a dormitory or had other indications where vaccination would be appropriate.
REFERENCES 1. Pollard AJ, Britto J, Nadel S, et al. Emergency management of meningococcal disease. Arch Dis Child 1999;80:290 – 6. 2. Diaz P. The epidemiology and control of invasive meningococcal disease. Pediatr Infect Dis J 1996;18:633– 4. 3. Munford RS. Meningococcal infections. In: Braunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL, eds. Harrison’s principles of internal medicine, 15th edn. New York: McGraw-Hill; 2001:927–31. 4. Rosenstein NE, Perkins BA, Stephens DS, et al. Medical progress: meningococcal disease. N Engl J Med 2001;344:1378 – 88.
318 5. Lavoie FW. Meningitis, encephalitis, and central nervous system abscess. In: Rosen P, Barkin R, eds. Emergency medicine, concepts and clinical practice, 4th edn. St. Louis, MO: Mosby; 1998:2198 – 211. 6. Roos KL, Tyler KL. Acute meningitis. In: Braunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL, eds. Harrison’s
T. Wimbush et al. principles of internal medicine, 15th ed. New York: McGraw-Hill; 2001:2462–71. 7. Gilmore A, Stuart J, Andrews N. Risk of secondary meningococcal disease in health-care workers. Lancet 2000;369:1654 –5. 8. Georges P. Update on meningococcal vaccine. Pediatr Infect Dis J 2001;20:311–2.
doi:10.1016/S0736-4679(03)00211-7
Case Presentations of the Harvard Emergency Medicine Residency
FEVER AND RASH Tracy Wimbush,
MD,*
David F. M. Brown,
MD*†
and Eric S. Nadel,
MD*†,‡
*Division of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, †Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, and ‡Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts Reprint Address: Eric S. Nadel, MD, Department of Emergency Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115
Dr. Tracy Wimbush: Today’s case is a 21-year-old woman who presented to the Emergency Department (ED) with a chief complaint of fever, vomiting, headache and rash. The symptoms began 1 day before presentation. Initial symptoms included a sore throat, fever, bilateral ear pain, and headache. These symptoms were accompanied by generalized malaise, lethargy, drenching sweats, and approximately 20 episodes of nonbloody emesis. On the morning of presentation, her sister noted a rash of “little red dots” on the patient’s abdomen. Within 3 h, the patient had the same rash on her lower extremities. Her sister brought her for evaluation because she seemed unusually sleepy and somewhat confused. The past medical history included thalassemia minor, syncope, and migraines. The patient also reported a history of low blood pressure, but was uncertain of her baseline blood pressure. She was taking no medications and had no allergies. Are there any questions at this point? Dr. Eric Nadel: Can you tell us a little about her social history? Is she a student? Did she report any exposures? Dr. Wimbush: The patient is an undergraduate at a local university. She is from Iran and her last foreign travel was 10 months ago. She lives in an off-campus apartment with her sister, and works part-time at a local coffee shop. The patient denied any known exposures but
reported that she went to her university health service shortly after her symptoms began, but before the rash developed. She was told it was likely a viral illness and that many students were presenting with similar symptoms. The patient does not smoke or drink, and is not sexually active. She reported receiving several unknown vaccinations before starting college. On review of systems, the patient complained of photophobia, neck pain, and dyspnea, but denied cough or sputum production. She reported epigastric pain that began after several hours of vomiting and retching. Would anyone like to discuss the differential diagnosis of this patient with fever, rash, vomiting and headache? Dr. Vicki Noble: The initial symptoms, sore throat, fever, headache and bilateral ear pain in a young healthy patient, are consistent with an upper respiratory infection or a streptococcal pharyngitis. However, the progressive symptoms reported are more concerning. The differential diagnosis at this point is wide but most concerning is the possibility of bacterial meningitis. Neisseria meningitis, given the description of the rash, seems like the most likely diagnosis. With these symptoms at presentation, were precautions taken at triage? Dr. Wimbush: Yes, even the brief history given at triage along with her appearance was concerning enough that a mask was placed on the patient immediately. On arrival, her vitals were: temperature 38.3°C (101°F),
Case Presentations of the Harvard Emergency Medicine Residency are coordinated by David F. M. Brown, MD, and Eric S. Nadel, MD, of Harvard University Medical School, Boston, Massachusetts
RECEIVED: 13 June 2003; ACCEPTED: 16 June 2003 315
316
blood pressure 73/49 mm Hg, heart rate 124 beats per minute, respiratory rate 24 breaths per minute, and oxygen saturation 100% on room air. Examination revealed an ill appearing young woman. The head was atraumatic. There was no facial asymmetry. Pupils were 4 mm and reactive; the patient demonstrated photophobia to bright light. Extraocular movements were intact without nystagmus. Tympanic membranes were normal bilaterally. Mucous membranes were dry. The oropharynx was clear without exudates; there were no mucosal lesions. The gag reflex was intact. The neck was supple but flexion exacerbated the headache. The heart examination was notable only for tachycardia. There were no murmurs or rubs. The lungs were clear. The abdomen had normal bowel sounds, with mild epigastric and right upper quadrant tenderness without rebound or guarding. There was no organomegaly. The extremities were slightly cool and capillary refill was slightly prolonged. Examination of the skin demonstrated a petechial rash over the lower extremities and lower abdomen. The patient was awake but slightly lethargic. Strength was 4/5 in all extremities. There was no papilledema. She was oriented to person, place, and time. She was able to give a full and coherent history. Dr. Nadel: As stated by Dr. Noble, this presentation is very concerning for meningitis. Although she has a history of low blood pressure, it is unlikely that 73/49 mm Hg is baseline. She is febrile, tachycardic, and hypotensive, and should be regarded as septic until proven otherwise. The petechial rash could be a sign of meningococcemia or of disseminated intravascular coagulopathy (DIC) from another bacterial source. What was done for the patient at this point? Dr. Wimbush: The concerning illnesses mentioned were high on our differential. Two large-bore intravenous catheters were placed and fluid resuscitation was initiated. The patient was administered 10 milligrams of dexamethasone, one gram of vancomycin, and two grams of ceftriaxone intravenously. Consent was obtained to perform a lumbar puncture. However, the procedure was delayed until coagulation studies were available, given the petechial rash and the possibility of DIC. After two liters of normal saline, the patient’s blood pressure improved to 113/41 mm Hg. Laboratory studies revealed white blood cell count 40.6 K/mm3, hematocrit 27.9%, and platelets 136 K/mm3. The differential of her white blood cell count demonstrated 30% bands. Serum chemistry demonstrated sodium 140 mmol/L, potassium 3.6 mmol/L, chloride 107 mmol/L, bicarbonate 23 mmol/L, blood urea nitrogen 22 mg/dL, creatinine 1.6 mg/dL, calcium 9.6 mg/dL, phosphorus 2.0 mg/dL, magnesium 1.3 meq/L, and glucose 122 mg/dL. Liver function tests, amylase, and lipase were normal. The urine
T. Wimbush et al.
pregnancy test was negative. Coagulation studies revealed PT 14.0 seconds and PTT 29.4 seconds. A chest radiograph was normal. The electrocardiogram showed sinus tachycardia. A lumbar puncture was performed. Opening pressure was normal. The cerebrospinal fluid (CSF) contained no xanthochromia. Tube 1 contained 4 white blood cells and 7 red blood cells. Tube 4 contained 2 white blood cells and 4 red blood cells. CSF glucose was 94 mg/dL and protein was 31 mg/dL. The spun CSF demonstrated a moderate number of polymorphonuclear leukocytes, a few mononuclear cells, and very rare red blood cells. There were no organisms seen. Dr. Ben Sun: The CSF does not support a diagnosis of bacterial meningitis. However, the petechial rash and signs of sepsis are extremely concerning for meningococcal infection. Did she remain on droplet precautions to protect others from a potential meningococcemia exposure? Dr. Wimbush: With meningococcemia being the leading diagnosis, the patient remained on droplet precautions. As suggested by Dr. Sun, there is a strong association between petechiae and meningococcal infection, with development of petechiae or purpura in 80% of children with bacteriologically proven disease (1). The patient remained on droplet precautions throughout her ED course. Staff remained concerned regarding the contagious nature of meningococcemia, and were reassured that meningococcal infection is not as highly contagious as many believe, as long as there are precautions in place (2). It may be the devastating outcomes that leave a lasting impression on health care providers. Up to 40% of cases of meningococcal sepsis are fatal and 11–19% of survivors have significant sequelae such as deafness, loss of digits, or even loss of limb (3,4). Dr. Noble: Given her degree of hypotension and continued low mean arterial pressure, was any thought given to starting pressors? Dr. Wimbush: Keeping in mind that many patients with sepsis require large volume resuscitation, normal saline infusion was continued. The literature supports the addition of pressors in sepsis if the patient is not responding to crystalloid resuscitation or if there is evidence of pulmonary edema due to heart failure or capillary leak. After four liters of normal saline, the patient’s blood pressure improved to 106/67 mm Hg. The tachycardia resolved and she demonstrated no evidence of respiratory compromise, with a respiratory rate of 18 breaths per minute and oxygen saturation of 98% on room air. A urinary catheter was placed and urine output was greater than 75 cc per hour, thus further demonstrating adequate resuscitation. Due to the risk of Waterhouse-Friderichsen syndrome in meningococcemia, abdominal computed tomography (CT) scan was considered to evaluate for
Fever and Rash
adrenal hemorrhage, and was not obtained due to her appropriate response to fluid resuscitation. The patient was subsequently admitted to the medical service for further management. Are there any questions about the ED management? Dr. J. Tobias Nagurney: Can you comment on antibiotic choices you initiated? Was there any consideration for a head CT scan before lumbar puncture? Dr. Wimbush: Although the patient’s rash was suggestive of Neisseria infection, the causative agent of her presumed sepsis and signs of meningitis was unknown. Common causative bacteria in this patient’s age group include Streptococcus, Listeria, or even Haemophilus (5). Thus, although penicillin alone is often adequate therapy for Neisseria meningitis, broad coverage was initiated as recommended for immunocompetent children over 3 years old and adults under 50 years old when the causative agent is unknown (1,6). Indications for head CT scan before lumbar puncture in suspected bacterial meningitis include: focal deficit on neurologic examination, seizures, history of head trauma, minimal or no fever, decreased mental status, or papilledema (5). Although the patient’s sister reported a question of confusion, the patient was alert and oriented on examination. Thus, there were no contraindications to lumbar puncture. Within 12 h of hospital admission, the patient’s blood cultures grew Gram-negative diplococci, later identified as Neisseria. She was continued on ceftriaxone. After 24 h of antibiotic therapy, precautions were discontinued. She was discharged on hospital day six in good condition. Home services were arranged to complete a 14-day course of intravenous ceftriaxone. Dr. Nadel: Although contact precautions were initiated at triage, were there any health care worker exposures? What was done to contact and treat those exposed in the community and at home? Dr. Wimbush: Chemoprophylaxis is recommended for all exposed to infectious oral secretions and close contacts (4). Close contacts who should consider prophylaxis include those exposed to oral secretions through kissing, sharing cigarettes, or sharing utensils. The nature of preschool children often means that the sharing of toys may also indicate the sharing of saliva. Thus, prophylaxis is recommended for childcare center classmates and teachers (2). Rifampin has been the antimicrobial prophylaxis of choice. Reports of rifampin resistance have been very rare (4). Alternatives to rifampin (600 mg every 12 h for 2 days) include ciprofloxacin (a 500-mg one-time oral dose), ofloxacin (400-mg one-time oral dose), or ceftriaxone (250-mg one-time intramuscular dose) (2,6). There is approximately a 5% incidence of transmission among household contacts (5). The patient’s sister
317
presented to the ED the following morning and was treated with ciprofloxacin 500 mg as a one-time treatment. Chemoprophylaxis is not recommended for health care workers unless they have come into direct contact with the patient’s oral or nasal secretions such as occurs with mouth-to-mouth resuscitation or endotracheal intubation (2,4,5,7). Treatment of casual contacts, such as customers in the coffee shop where she worked, is not recommended. Dr. Nadel: The patient was a college student. Was this her only risk factor for meningococcal infection? Dr. Wimbush: Risk factors for meningococcal infection include any condition impairing the ability to fight infection, such as asplenia or HIV infection. Incidence of meningococcal disease peaks in the winter months. Adults are less likely to be infected than teenagers and the disease rate is highest among infants ages 3 to 9 months (3). Crowded conditions are thought to be a major contributing factor to the incidence of disease. The patient is a college student but she does not live in a dormitory. The American College Health Association and the Centers for Disease Control studies have shown a 3-fold increase in the incidence of meningococcal infection in freshmen living in the dormitories compared to noncollege students of similar age groups. This increased risk does not hold true for students living in off-campus housing (8). Other risk factors include recent upper respiratory infection and active or passive smoking (2). Other than age, the patient had no risk factors. Dr. Nathan Mick: You stated that her immunization status was unknown. Is it safe to presume that she had not received meningococcal vaccination? Dr. Wimbush: The current recommendation of the American Academy of Pediatrics and the American College Health Association is educating incoming and current freshmen regarding the risk of meningococcal disease and the potential benefit of vaccination. Vaccination is also recommended for those with asplenia, complement or properdin deficiencies, and those traveling to areas with high rates of disease (8). It is unknown if the patient ever lived in a dormitory or had other indications where vaccination would be appropriate.
REFERENCES 1. Pollard AJ, Britto J, Nadel S, et al. Emergency management of meningococcal disease. Arch Dis Child 1999;80:290 – 6. 2. Diaz P. The epidemiology and control of invasive meningococcal disease. Pediatr Infect Dis J 1996;18:633– 4. 3. Munford RS. Meningococcal infections. In: Braunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL, eds. Harrison’s principles of internal medicine, 15th edn. New York: McGraw-Hill; 2001:927–31. 4. Rosenstein NE, Perkins BA, Stephens DS, et al. Medical progress: meningococcal disease. N Engl J Med 2001;344:1378 – 88.
318 5. Lavoie FW. Meningitis, encephalitis, and central nervous system abscess. In: Rosen P, Barkin R, eds. Emergency medicine, concepts and clinical practice, 4th edn. St. Louis, MO: Mosby; 1998:2198 – 211. 6. Roos KL, Tyler KL. Acute meningitis. In: Braunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL, eds. Harrison’s
T. Wimbush et al. principles of internal medicine, 15th ed. New York: McGraw-Hill; 2001:2462–71. 7. Gilmore A, Stuart J, Andrews N. Risk of secondary meningococcal disease in health-care workers. Lancet 2000;369:1654 –5. 8. Georges P. Update on meningococcal vaccine. Pediatr Infect Dis J 2001;20:311–2.