🧫 TOACS FCPS Station · Meningococcemia (Neisseria meningitidis)
📷 Clinical Photograph – Meningococcemia
🔍 Key clinical features:
- ✓ Petechial rash – non-blanching, often on trunk and extremities
- ✓ Purpuric rash – confluent, may progress to purpura fulminans
- ✓ Fever, toxicity, septic shock – rapid deterioration
- ✓ Meningitis – nuchal rigidity, headache, photophobia
- ✓ Waterhouse-Friderichsen syndrome – adrenal hemorrhage (hypotension, hyponatremia)
📋 Clinical scenario (examiner prompt)
A 3‑year‑old previously healthy child is brought to the emergency department with high fever (40°C), lethargy, and a rapidly spreading rash that started a few hours ago as small red spots and now has become larger, purplish, and confluent (see image). The child is hypotensive (BP 72/40 mmHg), tachycardic, and irritable. There is no nuchal rigidity. The mother reports that the child had a runny nose and cough for 1 day.
🧑⚕️ Examiner tasks · TOACS
1. Identify the diagnosis from the clinical image and context.
2. Describe the clinical features (petechial/purpuric non-blanching rash, septic shock, fever, rapid progression).
3. Explain the etiology and pathogenesis (Neisseria meningitidis, endotoxin (LOS) → cytokine storm → vascular damage, DIC, purpura fulminans).
4. Discuss emergent management (antibiotics, fluid resuscitation, vasopressors, ICU, chemoprophylaxis).
🎯 Expected answers (for examiners)
- • Diagnosis: Meningococcemia (Neisseria meningitidis septicemia)
- • Clinical features: Fever, petechial/purpuric non-blanching rash, septic shock, rapid progression, lethargy. May have meningitis (nuchal rigidity) or Waterhouse-Friderichsen syndrome (adrenal hemorrhage).
- • Pathophysiology: Gram-negative diplococcus; lipooligosaccharide (LOS) endotoxin → massive cytokine release (TNF, IL-1, IL-6) → endothelial damage, capillary leak, DIC, purpura fulminans.
- • Emergent management: IV ceftriaxone (or cefotaxime) + vancomycin (empiric); dexamethasone if meningitis cannot be excluded. Fluid resuscitation (20 mL/kg NS boluses), vasopressors if fluid-refractory shock. Admit to ICU.
- • Complications: Purpura fulminans (skin necrosis, gangrene), Waterhouse-Friderichsen syndrome (adrenal insufficiency), DIC, amputations.
- • Chemoprophylaxis: For close contacts (household, daycare, direct exposure to secretions): rifampin, ceftriaxone, or ciprofloxacin within 24 hours.
- • Index case: If treated with ceftriaxone, no additional prophylaxis needed (eradicates carriage). If treated with penicillin, give chemoprophylaxis before discharge.
• Rash: Petechial → purpuric → purpura fulminans (non-blanching)
• Pathogen: Neisseria meningitidis (gram-negative diplococcus)
• Treatment: Ceftriaxone + vancomycin (empiric), fluids, vasopressors
• Complications: DIC, purpura fulminans, Waterhouse-Friderichsen syndrome
• Chemoprophylaxis: Rifampin, ceftriaxone, or ciprofloxacin for contacts
• Vaccination: MenACWY and MenB (for high-risk or routine adolescent)
⚡ Quick FCPS‑style MCQ
A 3-year-old presents with fever, petechial/purpuric non-blanching rash, and septic shock. The most likely diagnosis is:
A. Kawasaki disease B. Meningococcemia C. Rocky Mountain spotted fever D. ITP📌 Topic summary · Meningococcemia
Neisseria meningitidis (gram-negative diplococcus)
Fever, petechial/purpuric rash, septic shock, DIC
Purpura fulminans, Waterhouse-Friderichsen syndrome
Ceftriaxone + vancomycin, fluids, vasopressors
Rifampin, ceftriaxone, or ciprofloxacin for contacts
MenACWY and MenB vaccination
| Feature | Meningococcemia |
|---|---|
| Pathogen | Neisseria meningitidis (encapsulated, 12 serogroups; A, B, C, W, Y most common) |
| Presentation | Fever, petechial/purpuric non-blanching rash, septic shock, lethargy; may have meningitis |
| Pathophysiology | Endotoxin (LOS) → cytokine storm → endothelial damage, capillary leak, DIC, purpura fulminans |
| Waterhouse-Friderichsen syndrome | Adrenal hemorrhage and necrosis → adrenal insufficiency (hypotension, hyponatremia, hyperkalemia) |
| Empiric antibiotics | Ceftriaxone (50-100 mg/kg/day) + vancomycin (60 mg/kg/day). Add dexamethasone if meningitis likely. |
| Chemoprophylaxis | Rifampin (2 days), ceftriaxone (single IM), or ciprofloxacin (single PO) for close contacts |
| Index case | No additional prophylaxis if treated with ceftriaxone (eradicates carriage) |
| Vaccination | MenACWY (routine 11-12y, booster 16y) and MenB (shared decision-making 16-23y) |