USC Case # 16USC Case # 16

Pediatric Febrile RashPediatric Febrile Rash

Greg Vigesaa OMSIIIGreg Vigesaa OMSIIIWythe County Community HospitalWythe County Community Hospital

Preceptors: Albert Aymer, DO Preceptors: Albert Aymer, DO Belle Jones, MDBelle Jones, MD

Chief Complaint and HPIChief Complaint and HPI

CC: Fever with a rashCC: Fever with a rash HPI: K.C. is a 10 year-old white HPI: K.C. is a 10 year-old white

female who presented to the ER on female who presented to the ER on 3/5/06 with a one day history of 3/5/06 with a one day history of fever, vomiting, diarrhea, joint pain, fever, vomiting, diarrhea, joint pain, and painful rash. She also and painful rash. She also complained of intermittent complained of intermittent abdominal pain over the past day abdominal pain over the past day and a frontal headache.and a frontal headache.

HPI Cont.HPI Cont.

HPI: K.C. did eat hamburger at a fast HPI: K.C. did eat hamburger at a fast food restaurant two days prior to the food restaurant two days prior to the onset of her symptoms. She has not onset of her symptoms. She has not been hiking or done any foreign been hiking or done any foreign travel. She does have multiple travel. She does have multiple animals at home including a ferret, animals at home including a ferret, finches, and a cockateil bird. finches, and a cockateil bird.

Past Medical/Surgical Past Medical/Surgical HistoryHistory

PMH: History of multiple urinary PMH: History of multiple urinary tract infections since she was three tract infections since she was three years old. She has never been years old. She has never been hospitalized.hospitalized.

PSH: NonePSH: None

Allergies and MedicationsAllergies and Medications

Allergies: penicillin and ciprofloxacinAllergies: penicillin and ciprofloxacin

Medications: Urised- medication Medications: Urised- medication used as a bladder antispasmodic and used as a bladder antispasmodic and antiseptic. It contains atropine, antiseptic. It contains atropine, benzoic acid, hyoscyamine, benzoic acid, hyoscyamine, methenamine, methylene blue, and methenamine, methylene blue, and phenyl salicylate. phenyl salicylate.

Family/Social HistoryFamily/Social History

FH: Significant for kidney disease. FH: Significant for kidney disease. Multiple family members have either Multiple family members have either a single kidney or a history of a single kidney or a history of vesicoureteral reflux.vesicoureteral reflux.

SH: C.K. lives at home with her SH: C.K. lives at home with her father, mother, 18 year-old brother, father, mother, 18 year-old brother, and 14 month old sister.and 14 month old sister.

Review of SystemsReview of Systems General: +fever, +fatigue, no chills, change General: +fever, +fatigue, no chills, change

in weight, appetite. in weight, appetite. HEENT: +HA, no pharyngitis, rhinorrhea, HEENT: +HA, no pharyngitis, rhinorrhea,

tinnitus, epistaxis, hearing or visual changes.tinnitus, epistaxis, hearing or visual changes. CV: No CP, palpitations, orthopnea, syncope. CV: No CP, palpitations, orthopnea, syncope. Resp: No SOB, dyspnea, cough, hemoptysis.Resp: No SOB, dyspnea, cough, hemoptysis. GI: +intermittent abdominal pain, GI: +intermittent abdominal pain,

+vomiting, +diarrhea, no melena or +vomiting, +diarrhea, no melena or hematochezia.hematochezia.

GU: No dysuria, hematuria, increased GU: No dysuria, hematuria, increased frequency, hesitancy.frequency, hesitancy.

Review of SystemsReview of Systems

MS: +arthralgias, no myalgias, MS: +arthralgias, no myalgias, weakness, swelling.weakness, swelling.

Neuro: No change in sensation, Neuro: No change in sensation, strength, LOC, dizziness, seizures or strength, LOC, dizziness, seizures or parathesias.parathesias.

Skin: +painful rash, no puritis.Skin: +painful rash, no puritis. Psych: No depression, anxiety.Psych: No depression, anxiety.

Physical ExamPhysical Exam

Vitals: T 100.9 P 136 BP 94/46 R 20 O2 Vitals: T 100.9 P 136 BP 94/46 R 20 O2 100% 100%

General: overweight, alert, pink, NAD.General: overweight, alert, pink, NAD. HEENT: NC/AT, PERRLA, EOMI, TMs clear HEENT: NC/AT, PERRLA, EOMI, TMs clear

bilaterally, mucous membranes moist.bilaterally, mucous membranes moist. Neck: supple with full range of motion.Neck: supple with full range of motion. Lungs: CTAB.Lungs: CTAB. Heart: RRR without murmur, gallop, rub.Heart: RRR without murmur, gallop, rub.

Physical ExamPhysical Exam

Abdomen: soft, NT/ND, normoactive BS, no Abdomen: soft, NT/ND, normoactive BS, no masses, oragnomegally, guarding, rebound or masses, oragnomegally, guarding, rebound or CVA tenderness. CVA tenderness.

Extremities: no C/C/E, brick capillary refill.Extremities: no C/C/E, brick capillary refill. Skin: petechial, purpuric rash with some Skin: petechial, purpuric rash with some

maculopapular areas throughout her body, maculopapular areas throughout her body, sparing her face.sparing her face.

Neruo: CN II-XII grossly intact, normal tone, Neruo: CN II-XII grossly intact, normal tone, moving all extremities well. Symmetrical moving all extremities well. Symmetrical sensation and strength. Negative Kernig and sensation and strength. Negative Kernig and Brudzinski sign.Brudzinski sign.

Review of Kernig and Review of Kernig and BrudzinskiBrudzinski

Kernig- upon flexion of Kernig- upon flexion of the thigh to 90 the thigh to 90 degrees, there will be degrees, there will be resistance to extension resistance to extension at the knee if at the knee if meningeal irritation is meningeal irritation is present.present.

Brudzinski- involuntary Brudzinski- involuntary flexion of the thighs flexion of the thighs and knees upon flexion and knees upon flexion of the neck when of the neck when meningeal irritation is meningeal irritation is present. present.

ER ManagementER Management Seeing that her blood pressure was only Seeing that her blood pressure was only

94/46 and pulse was 136, it was determined 94/46 and pulse was 136, it was determined that K.C. needed immediate fluid that K.C. needed immediate fluid resuscitation to increase her intravascular resuscitation to increase her intravascular volume and cardiac output. volume and cardiac output.

She received a bolus of NS 20 ml/kg x 2. She received a bolus of NS 20 ml/kg x 2. After the fluids her blood pressure increased After the fluids her blood pressure increased to 116/68. to 116/68.

STAT labs and blood cultures were obtained. STAT labs and blood cultures were obtained. Following labs K.C. received Rocephin 1 Following labs K.C. received Rocephin 1

gram IV x 1. gram IV x 1.

ConsultationConsultation

After interviewing and examining K.C., After interviewing and examining K.C., Dr. Turski consulted Dr. Belle Jones Dr. Turski consulted Dr. Belle Jones who was the pediatrician on call. who was the pediatrician on call.

She agreed with the initial She agreed with the initial assessment and management and assessment and management and agreed to admit her to the hospital. agreed to admit her to the hospital.

It was decided that a lumber It was decided that a lumber puncture was not indicated do to lack puncture was not indicated do to lack of meningeal signs.of meningeal signs.

Assessment and PlanAssessment and Plan 10 year-old female with petechial, purpuric 10 year-old female with petechial, purpuric

rash, fever, gastroenteritis, arthralgias, rash, fever, gastroenteritis, arthralgias, leukocytosis, mild dehydration, metabolic leukocytosis, mild dehydration, metabolic acidosis.acidosis.

Admit to hospital.Admit to hospital. CBC with diff., PT/PTT/FDP, BMP, UA/UC, CBC with diff., PT/PTT/FDP, BMP, UA/UC,

blood cultures, stool cultures, rapid strep blood cultures, stool cultures, rapid strep (TC), influenza A and B.(TC), influenza A and B.

Rocephin 50 mg/Kg q24h pending BC/UC.Rocephin 50 mg/Kg q24h pending BC/UC. Bolus of NS at 20 ml/kg x 2 in ER.Bolus of NS at 20 ml/kg x 2 in ER. D5 1/2 NS IV with 20 mEq of KCL at 100ml/h.D5 1/2 NS IV with 20 mEq of KCL at 100ml/h. NPO.NPO.

Differential DiagnosisDifferential Diagnosis

Rocky Mountain Spotted FeverRocky Mountain Spotted Fever EhrlichiosisEhrlichiosis Hemolytic-Uremic SyndromeHemolytic-Uremic Syndrome Toxic Shock SyndromeToxic Shock Syndrome Henoch-Schonlein PurpuraHenoch-Schonlein Purpura Serum SicknessSerum Sickness MeningococcemiaMeningococcemia MeningitisMeningitis Coxsackie Virus (hand-foot-and-mouth)Coxsackie Virus (hand-foot-and-mouth)

Working Through the Working Through the DifferentialDifferential

RMSF is caused by RMSF is caused by Rickettsia rickettsiiRickettsia rickettsii and can cause fever, and can cause fever, cough, headache, macular and petechial rash. It is cough, headache, macular and petechial rash. It is transmitted by the transmitted by the ixodidixodid ticks in the Atlantic states mainly ticks in the Atlantic states mainly from May to September. A history of a tick bite can be from May to September. A history of a tick bite can be elicited in about 70% of patients. K.C. has no history of elicited in about 70% of patients. K.C. has no history of cough, playing outside, or being bitten by a tick. Being that cough, playing outside, or being bitten by a tick. Being that it is March it is unlikely that she has RMSF.it is March it is unlikely that she has RMSF.

Ehrlichiosis is caused by Ehrlichiosis is caused by EhrlichiaEhrlichia species and causes fever, species and causes fever, chills, headache, malaise, macular or petechial rash chills, headache, malaise, macular or petechial rash involving the trunk and extremities. It can also cause involving the trunk and extremities. It can also cause abdominal pain, vomiting, and diarrhea, DIC. It is an abdominal pain, vomiting, and diarrhea, DIC. It is an obligate intracellular bacteria that invades lymphocytes and obligate intracellular bacteria that invades lymphocytes and neutrophils. It is also transferred by ticks, sometimes neutrophils. It is also transferred by ticks, sometimes carried on canines. We are unsure if she has contact with carried on canines. We are unsure if she has contact with doges. This scenario matches the signs and symptoms of doges. This scenario matches the signs and symptoms of K.C.; therefore, we cannot rule this out without further K.C.; therefore, we cannot rule this out without further investigation. investigation.

Working Through the Working Through the DifferentialDifferential

HUS is most commonly caused by HUS is most commonly caused by Escherichia coli Escherichia coli 0157. It is 0157. It is causes fever, petechial/purpuric rash, micoangiopathic causes fever, petechial/purpuric rash, micoangiopathic hemolytic anemia, thrombocytopenia, diarrhea with bloody hemolytic anemia, thrombocytopenia, diarrhea with bloody stool, and abdominal pain. It is also one of the main causes stool, and abdominal pain. It is also one of the main causes of acute renal failure in children. of acute renal failure in children. E. coli E. coli is transmitted is transmitted through contaminated food such as beef that is undercooked. through contaminated food such as beef that is undercooked. She does not complain of hematochezia or melena, but the She does not complain of hematochezia or melena, but the fact that she ate a hamburger at a fast food restaurant raises fact that she ate a hamburger at a fast food restaurant raises the suspicion that she may have HUS.the suspicion that she may have HUS.

TSS is caused by the exotoxin of TSS is caused by the exotoxin of Staphylococcus aureus Staphylococcus aureus it it causes fever, vomiting, diarrhea, hypotension, and a skin causes fever, vomiting, diarrhea, hypotension, and a skin rash. It occurs most commonly in menstruating women who rash. It occurs most commonly in menstruating women who use tampons. The fact the K.C. has hypotension and other use tampons. The fact the K.C. has hypotension and other symptoms support the diagnosis. But fact that she has not symptoms support the diagnosis. But fact that she has not started menses and dose not uses tampons argues against started menses and dose not uses tampons argues against TSS being the cause of her illness. We can put this farther TSS being the cause of her illness. We can put this farther down on the list of differential diagnosis. down on the list of differential diagnosis.

Working Through the Working Through the DifferentialDifferential

HSP is an acute or chronic vasculitis that affects small blood HSP is an acute or chronic vasculitis that affects small blood vessels of the skin, joints, GI tract, and kidneys. The disease vessels of the skin, joints, GI tract, and kidneys. The disease causes a purpuric rash of the extensor surfaces feet, legs, arms causes a purpuric rash of the extensor surfaces feet, legs, arms which is often preceded by an acute respiratory illness. Patients which is often preceded by an acute respiratory illness. Patients also often complain of fever, arthralgias, abdominal pain, and also often complain of fever, arthralgias, abdominal pain, and edema of the hands and feet. Being that K.C. has no history of edema of the hands and feet. Being that K.C. has no history of previous episodes, URI, or edema of the hands or feet we can put previous episodes, URI, or edema of the hands or feet we can put this lower in the differential diagnosis. We cannot; however, rule this lower in the differential diagnosis. We cannot; however, rule this out without further workup.this out without further workup.

Serum sickness is a type III immune reaction which causes Serum sickness is a type III immune reaction which causes antibody-antigen immune complexes to deposit in various antibody-antigen immune complexes to deposit in various tissues. These complexes initiate inflammation by causing tissues. These complexes initiate inflammation by causing complement activation and recruitment of phagocytic cells. The complement activation and recruitment of phagocytic cells. The signs and symptoms include fever, arthralgias, skin rash. It is signs and symptoms include fever, arthralgias, skin rash. It is usually preceded by administration of vaccinations, new usually preceded by administration of vaccinations, new medications to which the patient develops an allergy to. K.C. medications to which the patient develops an allergy to. K.C. has not received and new vaccinations or medications so this has not received and new vaccinations or medications so this can be put lower in the differential diagnosis.can be put lower in the differential diagnosis.

Working Through the Working Through the DifferentialDifferential

Meningococcemia and meningitis are caused by the bacteria Meningococcemia and meningitis are caused by the bacteria Neisseria meningitidis. Neisseria meningitidis. It can cause fever, vomiting, headache, It can cause fever, vomiting, headache, nuchal rigidity, arthralgias, myalgias, petechial or purpuric rash. nuchal rigidity, arthralgias, myalgias, petechial or purpuric rash. In meningitis the CNS is involved and may cause confusion, In meningitis the CNS is involved and may cause confusion, stupor, or coma. A patient with meningitis will often have a stupor, or coma. A patient with meningitis will often have a positive Kernig or Brudzinski sign. K.C. does not have nuchal positive Kernig or Brudzinski sign. K.C. does not have nuchal rigidity, confusion, or a positive Kernig or Brudzinski sign, this rigidity, confusion, or a positive Kernig or Brudzinski sign, this argues against meningitis. But her symptoms are consistent argues against meningitis. But her symptoms are consistent with meningococcemia. Because this is a potentially fatal with meningococcemia. Because this is a potentially fatal disease we will put this possible diagnosis at the top of the disease we will put this possible diagnosis at the top of the differential diagnosis and possibly begin empiric antibiotics.differential diagnosis and possibly begin empiric antibiotics.

Hand-foot-and-mouth disease is caused by the Coxsackievirus Hand-foot-and-mouth disease is caused by the Coxsackievirus A16. It often causes a fever, vesicular rash that affects the oral A16. It often causes a fever, vesicular rash that affects the oral mucosa, hands, and feet. K.C. has no oral lesions and her rash is mucosa, hands, and feet. K.C. has no oral lesions and her rash is not vesicular, but petechial and purpuric. Hand-foot-and-mouth not vesicular, but petechial and purpuric. Hand-foot-and-mouth disease is self-limiting and the treatment is symptomatic; disease is self-limiting and the treatment is symptomatic; therefore, we will put this at the bottom of the differential therefore, we will put this at the bottom of the differential diagnosis. diagnosis.

Labs/WorkupLabs/Workup

CBC w/differentialCBC w/differential PT/PTT/FDPPT/PTT/FDP BMPBMP UA/UCUA/UC Blood culturesBlood cultures Stool cultures Stool cultures Rapid strepRapid strep Influenza swabInfluenza swab

Labs/WorkupLabs/Workup CBC w/diff: CBC w/diff: BMP:BMP: UA:UA:

WBC- 18,000WBC- 18,000 Na- 134Na- 134 Color-Color-yellowyellowHgb- 13.4Hgb- 13.4 K- 3.2K- 3.2 App-App- clearclearHct- 38Hct- 38 Cl- 103Cl- 103 WBC-WBC- 1-51-5Plts- 291,000Plts- 291,000 CO2- 18CO2- 18 RBC- 1-5RBC- 1-5Neut%- 93.4Neut%- 93.4 BUN- 16BUN- 16 Sp. Gravity- 1.030Sp. Gravity- 1.030Lymp%- 5.0Lymp%- 5.0 Cr- 0.8Cr- 0.8 Mucous- largeMucous- largeBands- 6Bands- 6 Glu- 120Glu- 120 Bacteria- manyBacteria- manyNeut- 80Neut- 80 Ca- 8.4Ca- 8.4 Squamous- manySquamous- manyLymp- 11Lymp- 11 AG-16AG-16 Protein- 30Protein- 30Toxic granulations: moderateToxic granulations: moderate

Labs/WorkupLabs/Workup

PT: 13.3PT: 13.3 9.4-11.09.4-11.0 PTT: 35.2PTT: 35.2 24.3-30.2 24.3-30.2 FDP: 5FDP: 5 <5<5 Rapid strep- Negative.Rapid strep- Negative. Influenza- Negative.Influenza- Negative.

Labs/CulturesLabs/Cultures

UC: >100,000 col/ml gram- rods UC: >100,000 col/ml gram- rods (E.coli).(E.coli).

TC: Normal flora.TC: Normal flora. SC: Normal flora.SC: Normal flora. BC: Gram- cocci predominately in BC: Gram- cocci predominately in

pairs.pairs. Probable Probable Neisseria meningitidis.Neisseria meningitidis. Sent to state lab for serotyping.Sent to state lab for serotyping. Final ID: Final ID: Neisseria meningitidis Neisseria meningitidis serogroup Y.serogroup Y.

DiagnosisDiagnosis

Septic meningococcemiaSeptic meningococcemia Urinary tract infectionUrinary tract infection

Hospital CourseHospital Course

Throughout her admission K.C. Throughout her admission K.C. continued to receive Rocephin 1 g IV continued to receive Rocephin 1 g IV q24h and D5 ½ NS with 20 mEq of q24h and D5 ½ NS with 20 mEq of KCL at 100 ml/h. Routine labs KCL at 100 ml/h. Routine labs included: CBC with differential and included: CBC with differential and BMP. Her CBC, BMP, and vital signs BMP. Her CBC, BMP, and vital signs improved throughout her nine day improved throughout her nine day admission and were normal on the admission and were normal on the day of her discharge.day of her discharge.

Hospital CourseHospital CourseTemperature

94

96

98

100

102

Admission Day3 Day5 Day7 D/C

Tem

p F

Blood Pressure

50

70

90

110

130

Admission Day3 Day5 Day7 D/C

Dia

sto

lic

Sys

toli

c

Heart Rate

60

80

100

120

140

Admission Day3 Day5 Day7 D/C

Pu

lse

Resp and O2 Sat

10

30

50

70

90

110

Admission Day3 Day5 Day7 D/C

Res

p

0

2 sa

t

Labs on 3/10/06Labs on 3/10/06

CBC w/diff: CBC w/diff: BMP:BMP:UA: (3/7/06)UA: (3/7/06)WBC- 6.2WBC- 6.2 Na- 136Na- 136 Color-Color-yellowyellow

Hgb- 11.6Hgb- 11.6 K- 3.7K- 3.7 App-App- clearclear

Hct- 32.9Hct- 32.9 Cl- 105Cl- 105 WBC-WBC- nonenone

Plts- 261,000Plts- 261,000 CO2- 24CO2- 24 RBC- 5-10RBC- 5-10

Neut %- 56.1Neut %- 56.1 BUN- 4BUN- 4 Sp. Gravity- 1.020Sp. Gravity- 1.020

Lymph %- 32.5Lymph %- 32.5 Cr- 0.5Cr- 0.5 Mucous- noneMucous- none

Glu- 98Glu- 98 Bacteria- noneBacteria- none

Ca- 8.8Ca- 8.8 Squamous- fewSquamous- few

AG-11AG-11 Protein- Protein- negativenegative

Discharge InstructionsDischarge Instructions

K.C. was discharged on 3/13/06, nine K.C. was discharged on 3/13/06, nine days after admission in good days after admission in good condition. She was to follow up with condition. She was to follow up with Dr. Belle Jones two days after Dr. Belle Jones two days after discharge at Wythe Bland Pediatrics. discharge at Wythe Bland Pediatrics. Prophylactic antibiotics were given to Prophylactic antibiotics were given to her family and healthcare providers her family and healthcare providers who were in close contact with her.who were in close contact with her.

Etiology Etiology

Neisseria meningitidis.Neisseria meningitidis. Gram-negative diplococcus.Gram-negative diplococcus. Polysaccharide capsule with lipid A Polysaccharide capsule with lipid A

lipooligosaccharide (endotoxin). lipooligosaccharide (endotoxin). 13 serogroups- A, B, C, Y, W-135 cause 13 serogroups- A, B, C, Y, W-135 cause

majority of clinical disease.majority of clinical disease. Grows on Thayer-Martin chocolate agar.Grows on Thayer-Martin chocolate agar. Ferments glucose and maltose.Ferments glucose and maltose.

EpidemiologyEpidemiology Causes outbreaks of bacterial meningitis, Causes outbreaks of bacterial meningitis,

acute and chronic meningococcemica.acute and chronic meningococcemica. 5-10% of the population are nasopharyngeal 5-10% of the population are nasopharyngeal

carriers, higher in daycare centers.carriers, higher in daycare centers. Incidence: 0.8-1.3 / 100,000 personsIncidence: 0.8-1.3 / 100,000 persons Mortality: 8-13%Mortality: 8-13% 50% of cases occur in children < 2yo50% of cases occur in children < 2yo Risk factors: day care centers, military recruit Risk factors: day care centers, military recruit

camps, college freshman living in dorms (2-8 camps, college freshman living in dorms (2-8 fold increased risk), viral illness, smoking, fold increased risk), viral illness, smoking, chromic disease, low socioeconomic status, chromic disease, low socioeconomic status, complement deficiency (c5-c9)complement deficiency (c5-c9)

PathogenesisPathogenesis

Spread through respiratory droplets.Spread through respiratory droplets. Incubation: 1-10 days.Incubation: 1-10 days. Adheres to non-ciliated epithelial cells Adheres to non-ciliated epithelial cells

via a pili (capsule prevents via a pili (capsule prevents phagocytosis).phagocytosis).

Induces host to rearrange microvilli Induces host to rearrange microvilli production which causes endocytosis.production which causes endocytosis.

Traverses the cell in membrane bound Traverses the cell in membrane bound vacuoles, possesses porins that assist vacuoles, possesses porins that assist in escaping complement (c3b, c4b).in escaping complement (c3b, c4b).

PathogenesisPathogenesis Enters the circulation: Enters the circulation:

If abs present- blocks dissemination via If abs present- blocks dissemination via complement-mediated bacterial lysis.complement-mediated bacterial lysis.

If abs not present- meningococcemia with If abs not present- meningococcemia with potential to cause meningitis.potential to cause meningitis.

Lipid A of the LOS activates inflammatory Lipid A of the LOS activates inflammatory cytokines TNF-a, IL-1, IL-6, IL-8, also the cytokines TNF-a, IL-1, IL-6, IL-8, also the intrinsic and extrinsic coagulation cascade.intrinsic and extrinsic coagulation cascade.

The amount of inflammatory response is The amount of inflammatory response is directly proportional to the concentration of directly proportional to the concentration of lipid A in the circulation.lipid A in the circulation.

The inflammatory response can lead to The inflammatory response can lead to progressive capillary leakage and DIC progressive capillary leakage and DIC leading to multi-organ system failure, septic leading to multi-organ system failure, septic shock, and circulatory collapse. shock, and circulatory collapse.

PathogenesisPathogenesis

PathogenesisPathogenesis

Clinical ManifestationsClinical Manifestations

FeverFever PharyngitisPharyngitis HeadacheHeadache Nausea and vomitingNausea and vomiting MyalgiasMyalgias ArthralgiasArthralgias Altered mental status (stupor)Altered mental status (stupor) Nuchal rigidityNuchal rigidity Petechial or purpuric rashPetechial or purpuric rash

Petechial/Purpuric RashPetechial/Purpuric Rash

Purpuric Rash/NecrosisPurpuric Rash/Necrosis

DiagnosisDiagnosis

Isolation of Isolation of N. meningitidis N. meningitidis from a from a sterile body fluid (Blood cultures, sterile body fluid (Blood cultures, CSF, synovial or pleural fluid).CSF, synovial or pleural fluid).

Culture and gram stain of petechial Culture and gram stain of petechial or purpuric scrapings.or purpuric scrapings.

Latex agglutination test of CSF.Latex agglutination test of CSF. PCR used in the United Kingdom.PCR used in the United Kingdom.

Gram-negative DiplococcusGram-negative Diplococcus

ComplicationsComplications

Waterhouse-Friderichsen Syndrome.Waterhouse-Friderichsen Syndrome. GangreneGangrene Endocarditis, myocarditis, Endocarditis, myocarditis,

pericarditis.pericarditis. Renal infarcts.Renal infarcts. Avascular necrosis of epiphyseal Avascular necrosis of epiphyseal

plates.plates.

Waterhouse-Friderichsen Waterhouse-Friderichsen SyndromeSyndrome

Bilateral adrenal hemorrhagic necrosis.Bilateral adrenal hemorrhagic necrosis. Caused by DIC- adrenal glands become Caused by DIC- adrenal glands become

“sacs of clotted blood”.“sacs of clotted blood”. Decreased adrenocortical steroids Decreased adrenocortical steroids

(aldosterone and cortisol) leads to (aldosterone and cortisol) leads to hyponatremia and hyperkalemia.hyponatremia and hyperkalemia.

Tx the underlying cause with Tx the underlying cause with antibiotics, may require supplemental antibiotics, may require supplemental corticosteriods.corticosteriods.

Waterhouse-Friderichsen Waterhouse-Friderichsen SyndromeSyndrome

Hemorrhagic Hemorrhagic necrosis of adrenal necrosis of adrenal gland.gland.

Loss of normal Loss of normal architecture:architecture:– FasiculataFasiculata– GlomerulosaGlomerulosa– ReticularisReticularis

TreatmentTreatment

Neisseria MeningitidisNeisseria Meningitidis is very is very sensitive to antibiotics.sensitive to antibiotics.

Penicillin G 250,000 U/kg/d IV x 5-7 Penicillin G 250,000 U/kg/d IV x 5-7 d.d.

Cefotaxime 200 mg/kg/d IV x 5-7 d.Cefotaxime 200 mg/kg/d IV x 5-7 d. Ceftriaxone 100 mg/kg/d IV x 5-7 d.Ceftriaxone 100 mg/kg/d IV x 5-7 d. Isolation (droplet precautions) for 24 Isolation (droplet precautions) for 24

hrs after initiation of antibiotics.hrs after initiation of antibiotics.

ImmunizationImmunization

There is a quadrivalent meningococcal There is a quadrivalent meningococcal vaccine against serogroups A, C, Y, and W-vaccine against serogroups A, C, Y, and W-135. 135.

It is available to patients older than two It is available to patients older than two years of age. Routine immunization is not years of age. Routine immunization is not recommended because the infection rate recommended because the infection rate in the general population is low. in the general population is low.

However, immunization is recommended However, immunization is recommended for persons in high-risk groups with risk for persons in high-risk groups with risk factors.factors.

Prophylaxis for ContactsProphylaxis for Contacts

Ciprofloxacin 500 mg PO, single dose Ciprofloxacin 500 mg PO, single dose if >18 years old.if >18 years old.

Ceftriaxone 250 mg IM, single dose if Ceftriaxone 250 mg IM, single dose if >12 years old.>12 years old.

Ceftriaxone 125 mg IM, single dose if Ceftriaxone 125 mg IM, single dose if <12 years old.<12 years old.

Osteopathic ConsiderationsOsteopathic Considerations Very little literature about OMM and sepsis.Very little literature about OMM and sepsis. OMM seems contraindicated in a child with septic OMM seems contraindicated in a child with septic

meningiococcemia.meningiococcemia. Would not want to facilitate further dissemination Would not want to facilitate further dissemination

of the bacteria.of the bacteria. Also given the potential for DIC, manipulation Also given the potential for DIC, manipulation

could cause hemorrhage because of decreased could cause hemorrhage because of decreased platelets and clotting factors.platelets and clotting factors.

Osteopathic principles apply to all patients:Osteopathic principles apply to all patients:– Body is a unit.Body is a unit.– Body has self-regulating mechanisms.Body has self-regulating mechanisms.– Structure and function are reciprocally interrelated.Structure and function are reciprocally interrelated.– Rational treatment is based on these principles.Rational treatment is based on these principles.

ReferencesReferences Behrman, Kliegman, Jensen. Behrman, Kliegman, Jensen. Nelson’s Textbook of Nelson’s Textbook of

Pediatrics.Pediatrics. 17 17thth ed. Pgs. 896-899. 2004. Saunders. ed. Pgs. 896-899. 2004. Saunders. Cohen & Powderly: Infectious Diseases.Cohen & Powderly: Infectious Diseases. 2nd ed. 2nd ed.

Pgs. 2173-2187. 2004. Mosby. Pgs. 2173-2187. 2004. Mosby. Long. Long. Principles and Practice of Pediatric Principles and Practice of Pediatric

Infectious Diseases.Infectious Diseases. 2 2ndnd ed. Pgs 748-756. 2003. ed. Pgs 748-756. 2003. Churchill Livingstone. Churchill Livingstone.

Kumar, Abbas, Fausto. Kumar, Abbas, Fausto. Robbins and Cotran Robbins and Cotran Pathologic Basis of Disease.Pathologic Basis of Disease. 7 7thth ed. Pgs. 377-378, ed. Pgs. 377-378, 1214-1215. 2005. Saunders.1214-1215. 2005. Saunders.

The Red Book Report on the Committee of The Red Book Report on the Committee of Infectious Disease.Infectious Disease. American Academy of American Academy of Pediatrics. Pgs. 430-436.Pediatrics. Pgs. 430-436.