Assistance Publique-Hôpitaux de Paris (APHP), Tenon University Hospital, Biochemistry Laboratory, 4 Rue de la Chine, 75020, Paris, France.
Assistance Publique-Hôpitaux de Paris (APHP), Tenon University Hospital, Medico-Surgical Intensive Care Unit, 4 Rue de la Chine, Paris, 75020, France.
BMC Infect Dis. 2019 Mar 12;19(1):252. doi: 10.1186/s12879-019-3866-x.
During fulminant meningococcal septicaemia, meningococci are often observed in the cerebrospinal fluid (CSF) although the patients have frequently no meningeal symptoms. Meningococcal meningitis, by contrast, usually features clinical meningeal signs and biochemical markers of inflammation with elevated white blood cell count (pleiocytosis) in the CSF. Cases of typical symptomatic meningitis without these biochemical features are uncommon in adults.
A 21-year-old male presented with meningococcal purpura fulminans and disseminated intravascular coagulation (DIC) associated with multiple organ dysfunction syndrome requiring hospitalization in the Intensive Care Unit. Despite typical meningeal clinical signs, lumbar puncture showed no pleiocytosis, normal glycorachia and normal proteinorachia, whereas the lactate concentration in the CSF was high (5.8 mmol/L). CSF culture showed a high inoculum of serogroup C meningococci. On day 2, after initial improvement, a recurrence of hypotension led to the diagnosis of acute meningococcal myocarditis, which evolved favourably within a week. During the hospitalization, distal ischemic and necrotic lesions were observed, predominantly on the fingertips, which were treated with local and systemic vasodilators.
We report a rare case of adult meningococcal disease characterized by an intermediate form of meningitis between purulent meningitis and meningeal inoculation from fulminant meningococcal septicaemia, without classical signs of biological inflammation. It highlights the diagnostic value of CSF lactate, which may warrant administration of a meningeal dosing regimen of beta-lactam antibiotics. This case also demonstrates the potential severity of meningococcal myocarditis; we discuss its pathophysiology, which is distinct from other sepsis-related cardiomyopathies. Finally, the observed effects of vasodilators on the meningococcal skin ischemia in this case encourages future studies to assess their efficacy in DIC-associated necrosis.
暴发性脑膜炎球菌败血症时，尽管患者常无脑膜刺激征，但脑脊液中常可观察到脑膜炎球菌。相比之下，脑膜炎球菌脑膜炎通常具有临床脑膜刺激征和炎症的生化标志物，脑脊液中白细胞计数升高（白细胞增多症）。成人中不伴有这些生化特征的典型症状性脑膜炎很少见。
一名 21 岁男性因暴发性脑膜炎球菌紫癜和弥漫性血管内凝血（DIC）而就诊，伴有多器官功能障碍综合征，需入住重症监护病房。尽管有典型的脑膜刺激征，但腰椎穿刺显示白细胞增多症、正常糖血症和正常蛋白血症，而脑脊液中的乳酸浓度升高（5.8mmol/L）。脑脊液培养显示高浓度 C 群脑膜炎球菌。第 2 天，在最初改善后，再次出现低血压，诊断为急性脑膜炎球菌性心肌炎，一周内病情好转。住院期间，观察到主要位于指尖的远端缺血性和坏死性病变，并用局部和全身血管扩张剂进行治疗。
我们报告了一例罕见的成人脑膜炎球菌病病例，其特征为暴发性脑膜炎球菌败血症所致化脓性脑膜炎和脑膜接种之间的中间型脑膜炎，无生物炎症的经典征象。该病例突出了脑脊液乳酸的诊断价值，这可能需要给予脑膜内剂量的β-内酰胺类抗生素。该病例还表明脑膜炎球菌性心肌炎的潜在严重性；我们讨论了其病理生理学，与其他与脓毒症相关的心肌病不同。最后，在该病例中观察到血管扩张剂对脑膜炎球菌皮肤缺血的影响，鼓励未来的研究评估其在 DIC 相关坏死中的疗效。
