Meningococcal Septicaemia, Purpura Fulminans, Bacterial Meningitis, and Endocrine Complications: Diagnosis and Treatment

By SWA

Introduction
Meningococcal disease, caused by the bacterium Neisseria meningitidis, presents in two severe forms: meningococcal meningitis and meningococcal septicaemia. Both forms are medical emergencies and can be rapidly fatal if untreated. The progression from meningococcal infection to septicaemia can lead to complications like disseminated intravascular coagulation (DIC) and purpura fulminans. Additionally, endocrine complications such as adrenal insufficiency (Waterhouse-Friderichsen syndrome), hypoglycemia, and hyponatremia can arise during the disease, significantly worsening the prognosis.

This article explores the key clinical features, complications, and management strategies for these conditions, with a focus on prompt medical intervention to reduce mortality and morbidity.

Clinical Features and Pathophysiology

  1. Meningococcal Septicaemia and DIC
    Meningococcal septicaemia results when Neisseria meningitidis enters the bloodstream, triggering an overwhelming systemic inflammatory response. The bacteria release endotoxins, leading to endothelial injury, increased vascular permeability, and widespread microvascular thrombosis, culminating in disseminated intravascular coagulation (DIC). In DIC, blood clots form in small vessels, depleting clotting factors and leading to severe bleeding.

    • Purpura Fulminans is a hallmark of severe meningococcal septicaemia, characterized by the rapid development of purpuric skin lesions, progressing to necrosis. It reflects the severe microvascular thrombosis seen in DIC, often requiring aggressive medical and surgical interventions, such as skin debridement or amputations.

    • Bacterial Meningitis: When N. meningitidis crosses the blood-brain barrier, it causes meningitis, leading to inflammation of the protective membranes of the brain and spinal cord. Symptoms include fever, headache, neck stiffness, photophobia, and altered mental status.

Endocrine Complications

  1. Waterhouse-Friderichsen Syndrome (Adrenal Insufficiency)
    A critical endocrine complication of severe meningococcal septicaemia is Waterhouse-Friderichsen Syndrome (WFS), in which bilateral adrenal hemorrhage results in acute adrenal insufficiency. The sudden loss of adrenal function leads to a catastrophic drop in cortisol levels, which can cause:

    • Hypotension
    • Refractory shock
    • Electrolyte imbalances (e.g., hyponatremia and hyperkalemia)
    • Hypoglycemia due to impaired gluconeogenesis.

    Without cortisol replacement, adrenal insufficiency can rapidly become fatal. WFS is often identified post-mortem, as adrenal hemorrhage progresses rapidly.

  2. Hypoglycemia and Hyponatremia

    • Hypoglycemia occurs due to adrenal insufficiency or metabolic disturbances during sepsis, where glucose production is impaired.
    • Hyponatremia (low sodium levels) may result from a combination of adrenal insufficiency (leading to a deficiency in aldosterone, which regulates sodium), the syndrome of inappropriate antidiuretic hormone secretion (SIADH), and aggressive fluid resuscitation.

Diagnosis

Early diagnosis is crucial in meningococcal disease and its complications. Diagnostic approaches include:

  • Blood cultures and lumbar puncture: These are essential for confirming N. meningitidis in cases of meningitis or septicaemia.
  • Coagulation studies: D-dimer, fibrinogen, and platelet levels can help confirm DIC.
  • Cortisol levels: A low morning cortisol level in the setting of septic shock suggests adrenal insufficiency, which could indicate Waterhouse-Friderichsen Syndrome.
  • Imaging: In suspected adrenal hemorrhage (WFS), abdominal CT scans may show adrenal gland enlargement or hemorrhage.

Treatment

The cornerstone of managing meningococcal disease is prompt antimicrobial therapy, alongside aggressive supportive care to manage complications such as DIC, adrenal insufficiency, and electrolyte disturbances.

  1. Antibiotic Therapy
    Immediate empirical antibiotic therapy is critical while awaiting culture results. The most commonly used antibiotics are:

    • Ceftriaxone or Cefotaxime (third-generation cephalosporins): These are the first-line treatments for bacterial meningitis and septicaemia. They cover most strains of N. meningitidis.
    • Penicillin G: May be used in confirmed cases where the strain is susceptible.
    • If an allergic reaction to cephalosporins is a concern, chloramphenicol is an alternative.

    Important Note: Antibiotics should be administered as soon as meningococcal infection is suspected, even before confirmatory testing, due to the high fatality rate if treatment is delayed.

    Prophylaxis: Close contacts of patients with meningococcal disease should receive prophylactic antibiotics such as rifampicin or ciprofloxacin to reduce the risk of secondary transmission.

  2. Management of DIC and Purpura Fulminans

    • Supportive care: Fluid resuscitation, vasopressors, and transfusions (platelets, fresh frozen plasma, or cryoprecipitate) are required to manage DIC.
    • Heparin therapy: In some cases of early DIC, low-dose heparin can prevent further clot formation, though its use in severe cases remains controversial.
    • Wound care: For purpura fulminans, aggressive wound management is needed, often involving skin grafts or amputations in cases of extensive necrosis.

  3. Adrenal Insufficiency (Waterhouse-Friderichsen Syndrome)

    • Hydrocortisone: High-dose intravenous corticosteroids (hydrocortisone) should be administered immediately in cases of suspected adrenal insufficiency or shock refractory to fluids and vasopressors. Dosing typically starts at 100 mg IV bolus, followed by continuous infusion or repeated doses every 6–8 hours.
    • Fluid resuscitation: Isotonic saline should be given to correct hypotension, while dextrose-containing fluids may be required to manage hypoglycemia.

  4. Correction of Metabolic Abnormalities

    • Hypoglycemia: Prompt intravenous glucose (dextrose) administration is critical.
    • Hyponatremia: This should be corrected carefully with intravenous saline, with close monitoring to prevent rapid shifts in sodium, which can lead to neurological complications.

Prognosis and Prevention

Despite aggressive treatment, the prognosis for patients with severe meningococcal septicaemia, especially those with DIC, purpura fulminans, or Waterhouse-Friderichsen Syndrome, can be poor. Survivors may experience long-term sequelae such as limb loss (from necrosis), hearing loss, or neurological deficits.

Prevention:

  • Vaccination: Meningococcal vaccines (such as the quadrivalent meningococcal conjugate vaccine and the serogroup B meningococcal vaccine) are effective in preventing disease, especially in high-risk populations (e.g., college students, military recruits, or travelers to endemic areas).
  • Prophylaxis for Close Contacts: As noted, chemoprophylaxis with antibiotics can prevent secondary cases in close contacts of infected individuals.

Conclusion

Meningococcal septicaemia and bacterial meningitis, along with their severe complications such as DIC, purpura fulminans, and adrenal insufficiency (Waterhouse-Friderichsen Syndrome), represent life-threatening conditions requiring immediate intervention. The prompt initiation of antibiotic therapy, aggressive supportive care, and the management of endocrine and metabolic complications are critical to improving survival. Public health measures, including vaccination and prophylaxis, are essential in preventing the spread of this deadly disease.

References:

  1. Centers for Disease Control and Prevention (CDC). Meningococcal Disease. Link
  2. National Health Service (NHS), Meningitis. Link
  3. MedlinePlus, Waterhouse-Friderichsen Syndrome. Link
  4. UpToDate, Disseminated Intravascular Coagulation (DIC). Link
  5. World Health Organization (WHO), Meningococcal Meningitis Fact Sheet. Link
  © 2000-2025 Sieglinde W. Alexander. All writings by Sieglinde W. Alexander have a fife year copy right.
Library of Congress Card Number: LCN 00-192742
ISBN: 0-9703195-0-9

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