Key Facts

Meningococcal disease is a medical emergency that can progress from initial symptoms to death within hours. Rapid recognition and immediate antibiotic treatment are essential. UK vaccination programmes have significantly reduced incidence.

Epidemiology

• UK: ~500–1,000 cases/year (declining due to vaccination)
• Peak incidence: children <5 years and adolescents 15–19
• Case-fatality rate: ~5–10% (meningitis); ~20–30% (meningococcaemia/septicaemia)
• Winter/spring seasonality
• University freshers: increased risk (close living, social mixing)

Aetiology

• Neisseria meningitidis: Gram-negative diplococcus; polysaccharide capsule determines serogroup
• Serogroups: B (~50% of UK cases), W, Y, C (rare since MenC vaccine)
• Transmission: respiratory droplets, close contact; carriage rate ~10% in adolescents
• Risk factors: asplenia, complement deficiency, crowded living (dormitories, barracks), recent viral URTI

Pathophysiology

• Nasopharyngeal colonisation → bloodstream invasion → bacteraemia
• Endotoxin (LOS — lipooligosaccharide) triggers massive inflammatory response
• Complement activation → DIC → purpura fulminans
• Meningeal inflammation → raised ICP, cerebral oedema
• Adrenal gland haemorrhage → Waterhouse-Friderichsen syndrome
• Rapid progression: can deteriorate from well to critically ill within hours

Meningitis Presentation

• Headache, photophobia, neck stiffness
• Fever, vomiting
• Altered consciousness, irritability
• Kernig sign (unable to extend knee with hip flexed), Brudzinski sign (neck flexion causes hip/knee flexion)
• Bulging fontanelle in infants

Meningococcaemia (Septicaemia)

• Non-blanching petechial/purpuric rash — may start as blanching maculopapular then progress to purpura
• Fever, rigors, myalgia
• Rapid deterioration: tachycardia, hypotension, cold extremities
• Purpura fulminans: large ecchymoses, skin necrosis, DIC
• Shock, multi-organ failure

Red Flags

• Non-blanching rash + fever in child/young person
• Rapidly progressive purpuric rash
• Signs of shock (tachycardia, hypotension, prolonged cap refill)
• Reduced consciousness (GCS <12)
• Neck stiffness + fever + headache
• Infants: bulging fontanelle, high-pitched cry, poor feeding, floppiness

Bedside

• Glass test: non-blanching rash does not fade under pressure
• Observations: HR, BP, RR, SpO2, GCS, capillary refill, temperature
• Blood glucose: hypoglycaemia

Bloods

• Blood cultures: BEFORE antibiotics (but do NOT delay treatment to obtain)
• Meningococcal PCR: on EDTA blood — can be positive even after antibiotics
• FBC: leucocytosis or leucopenia
• CRP, lactate: severity markers
• Coagulation screen: DIC (prolonged PT/APTT, low fibrinogen, raised D-dimer)
• U&Es, LFTs: organ dysfunction
• Blood gas: metabolic acidosis

Special Tests

• Lumbar puncture (if safe — NO LP if signs of raised ICP, haemodynamic instability, coagulopathy, GCS ≤12):
  • CSF: turbid, raised WCC (neutrophils), raised protein (>1 g/L), low glucose (<50% of blood glucose)
  • Gram stain: Gram-negative diplococci
  • CSF PCR: meningococcal DNA
  • CSF culture

Imaging

• CT head: before LP if signs of raised ICP (papilloedema, focal neurology, GCS ≤12)
• CXR: if respiratory compromise

Non-pharmacological

• Do NOT delay antibiotics for any investigation
• Resuscitation: ABC approach, high-flow oxygen, IV access × 2
• IV fluids: 20 ml/kg 0.9% NaCl bolus, reassess, repeat up to 60 ml/kg
• ICU referral: early if septic shock, DIC, or GCS ≤12

Pharmacological

Pre-hospital:

• IM/IV benzylpenicillin: 1.2g adult, 600mg child 1–9, 300mg <1 year — give IMMEDIATELY on clinical suspicion before transfer

In-hospital:

• IV ceftriaxone 2g BD (adult); 80mg/kg in children; continue for 7 days (5 days if confirmed meningococcal)
• OR IV cefotaxime: alternative
• Dexamethasone 0.15mg/kg QDS IV for 4 days: if suspected bacterial meningitis in adults — give with or before first antibiotic dose; NOT if meningococcal septicaemia without meningitis
• DIC management: cryoprecipitate, FFP, platelets as needed
• Vasopressors: noradrenaline if fluid-refractory shock

Close contacts:

• Ciprofloxacin 500mg stat (adult) or rifampicin 600mg BD for 2 days
• Children: rifampicin or ceftriaxone IM
• Offer to household contacts and 'kissing contacts' within 7 days
• MenACWY + MenB vaccine for contacts if outbreak serogroup matches

Referral Criteria

• All cases: infectious diseases, ICU
• Public health: immediate statutory notification; contact tracing
• ENT/neurosurgery: if complications (abscess, hydrocephalus)
• Rehabilitation: for survivors with sequelae

• Overall case-fatality rate: 5–10%
• Meningococcal septicaemia without meningitis: mortality 20–30%
• Meningitis alone (without septicaemia): mortality ~5%
• Purpura fulminans/Waterhouse-Friderichsen: mortality >50%
• Survivors: 10–20% have long-term sequelae (deafness, limb amputation, cognitive impairment, skin scarring)
• Sensorineural deafness: ~5% of survivors
• Limb loss (from gangrene/DIC): ~7% of survivors
• With prompt treatment and intensive care, majority survive

UK Meningococcal Vaccination Schedule

CSF Findings in Meningitis