Title

Neisseria On The Rise: Two Cases Of Fatal Invasive Meningococcal Disease One Month Apart

Authors

Valeria Turcan, MD - Capital Health Regional Medical Center, Trenton, NJ Katerina Chepenko, MD - Dartmouth Hitchcock Medical Center and Clinics, Lebanon, NH Hari V. Brundavanam, MD - Capital Health Regional Medical Center, Trenton, NJ

Introduction

Invasive meningococcal disease (IMD) is a rare life-threatening condition caused by Neisseria meningitidis which most commonly manifests as meningitis or septicemia. Unfortunately, IMD has been on the rise, with 2023 marking the largest number of cases in New Jersey and nationwide since 2013 and 2014 respectively. We present two cases of fatal IMD one month apart seen at our NJ community hospital which have reminded us both of the severity of IMD as well as its rising incidence in the US.

Case Presentation

A 71-year-old male with type 2 diabetes mellitus (T2DM), obesity, and pulmonary embolism was brought to the emergency department (ED) because of a 4-hour history of worsening dyspnea, lethargy, nausea, and vomiting preceded by one week of flu-like symptoms. He was severely hypoxic, tachypneic, tachycardic, and mildly hypotensive on presentation. Physical exam revealed cyanotic skin with areas of non-blanching petechial rash on his face, trunk, and upper extremities, and a palpable right neck mass. Bloodwork showed leukocytosis of 19.6x10^3/mcL with a left shift, bicarbonate of 11mmol/L, lactic acidosis of 12.9mmol/L, and a pH of 7.1 on arterial blood gas (ABG). CT neck with contrast showed a 2.4cm parapharyngeal abscess. Despite prompt administration of cefepime, vancomycin, and intravenous fluids, the patient went into shock with significant hypoglycemia, and pulseless electrical activity (PEA) arrest shortly after. Final blood cultures grew N.meningitidis, serogroup B. A 46-year-old male with T2DM and obesity was brought to the ED one month later because of worsening lethargy, preceded by throat pain, nausea, and vomiting the day prior. He was mildly tachycardic, tachypneic, and febrile. A physical exam revealed a mild petechial rash over the patient’s anterior chest. Bloodwork showed leukocytosis of 30x10^3/mcL with a left shift, bicarbonate of 14mmol/L, lactic acidosis of 9.6mmol/L, and a pH of 7.3 on ABG. He was started on piperacillin/tazobactam and vancomycin for concern of aspiration pneumonia but was switched to cefepime shortly after. While in the ED, the patient had a grand mal seizure. After an unremarkable CT head without contrast, lumbar puncture was performed showing a cerebrospinal fluid (CSF) opening pressure of 25mmH20, WBC count of 1,324/mcL, protein 450mg/dL, and glucose 89mg/dL. Despite initial improvement, on day 3 of hospitalization, he developed shock, multi-organ failure, severe hypoglycemia followed by a PEA arrest, and ultimately death. Final CSF cultures grew N.meningitidis, serogroup Y. NJ Department of Health has been notified of both cases and appropriate post-exposure chemoprophylaxis was given to all close contacts.

Discussion

While initial signs can be non-specific, IMD can rapidly progress to a profound state of shock and lead to death, despite appropriate treatment. Given its fatality rate of up to 15% and the increasing number of cases across the US, we should have a high index of suspicion for IMD in our critically ill patients with new onset altered mental status. This is an opportunity for us to check in with our local healthcare department about the most recent IMD updates, refresh our knowledge on IMD, and remind our eligible patients about the importance of primary prevention.

References

# New Jersey Department of Health - Update on the Increase of Invasive Meningococcal Disease Cases in New Jersey and the United States: Post-Exposure Prophylaxis Recommendations, https://www.nj.gov/health/cd/topics/meningo.shtml # U.S. Centers for Disease Control and Prevention - Meningococcal Disease Surveillance and Trends https://www.cdc.gov/meningococcal/php/surveillance/index.html # U.S. Centers for Disease Control and Prevention - Increase in Invasive Serogroup Y Meningococcal Disease in the United States https://emergency.cdc.gov/han/2024/han00505.asp