4-41
Skin: Meningococcemia
MAJ Daniel Schissel, MC, USAIntroduction: Neisseria meningitides is a gram-negative coccus found in the nasopharynx of approximately
5 – 15% of the general population. It invades the blood stream, causing acute meningococcal septicemia
and meningitis. Transmission is through person-to-person inhalation of droplets of infectious nasopharyngeal
secretions. The highest incidence is observed midwinter in children ages 6 months to 1 year, while the lowest
is in adults over 20 years during the midsummer. Infants, asplenics, immunodecient or complement (blood
proteins important in immune response) decient individuals are considered at increased risk.
Subjective: Symptoms
Prodrome of spiking fever, chills, myalgia, arthralgia; rash, photophobia, headache
Objective: Signs
Using Basic Tools: Abnormal vital signs: high fever, tachypnea, tachycardia, mild hypotension; rash: small,
palpable, petechial lesions with irregular borders and pale gray, vesicular centers most commonly observed on
the trunk and extremities (but may be seen anywhere, including the palms, soles and mucous membranes);
posterior neck rigidity and tenderness with stretching; photophobia; altered consciousness; severely ill patients
may display ecchymosis and coalescence of the purpuric lesions into bizarre shaped gray-to-black necrotic areas
(see Color Plates Picture 16) associated with disseminated intervascular coagulation.
Using Advanced Tools: Lab: Gram stain scrapings from lesions to identify characteristic organism. Culture
blood to identify organism.
Assessment:
Differential Diagnosis: Rocky Mountain Spotted Fever, other rickettsial diseases, staphylococcal toxic shock
syndrome, enteroviral infections and acute bacteremia.
Plan:
Treatment: Initiate treatment immediately if meningococcemia is suspected and evacuate ASAP.
Primary: Cefotaxime 2.0 gm IV q 4-6 hrs + vancomycin 1.0 gm q 6-12 hrs
Alternate: Ceftriaxone 2 gm IV q 12 hrs + vancomycin 1.0 gm q 6-12 hrs
Patient Education
General: Recovery rate is >90% if adequately treated, and 50% or lower if not treated.
Prevention and Hygiene: Exercise protective measures for patient and provider by using a surgical mask (or
other respiratory protection) on both the patient and support staff exposed. Close contacts of patient and others
exposed should receive prophylaxis:
Ciprooxacin (adults): 500mg po x 1
Ceftriaxone (adults): 250 mg IM x 1
(child <15): 125 mg IM x 1
Spiramycin (child): 10 mg/ kg po q 6h x 5d
Follow-up Actions
Evacuation/Consultation Criteria: Evacuate cases after instituting immediate therapy.
Skin: Erysipelas
MAJ Daniel Schissel, MC, USAIntroduction: Erysipelas is most commonly an acute, dermal and subcutaneously spreading cellulitis caused
by Group A beta-hemolytic Streptococcus pyogenes or Staph. aureus. It is characterized by an erythematous,
warm, raised, tender area of the skin. Inoculation is through a break in the skin barrier (puncture, laceration,