Symptoms of meningococcal infection in adults

Meningococcal infection has an incubation period, which in generalized forms lasts from 1 to 10 days, more often 2-4 days. Symptoms of meningococcal infection are varied. A domestic classification has been developed, close to the international one.

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Forms of meningococcal infection

The symptoms of meningococcal infection allow us to classify this disease. The following forms of meningococcal infection are distinguished:

Localized forms:

• carriage;
• meningococcal nasopharyngitis.

Generalized forms:

• meningococcemia:
  • acute uncomplicated,
  • acute complicated by infectious toxic shock (Waterhouse-Friderichsen syndrome),
  • chronic;
• meningococcal meningitis:
  • uncomplicated,
  • complicated ONGM with dislocation,
  • meningoencephalitis;
• combined (mixed form):
  • uncomplicated.
  • complicated ITSH,
  • complicated ONGM with dislocation:
• other forms:
  • arthritis,
  • iridocyclitis,
  • pneumonia.
  • endocarditis.

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Meningococcal carriage

Meningococcal carriage does not have any symptoms of meningococcal infection, but upon examination, a picture of acute follicular pharyngitis can be detected.

Meningococcal nasopharyngitis

Meningococcal nasopharyngitis is the most common manifestation of meningococcal infection. It may precede the generalized form of meningococcal infection, but in most cases it is an independent form of the disease.

Patients complain of the following symptoms of meningococcal infection: difficulty breathing through the nose, scanty nasal discharge, slight cough, sore throat, headache. Half of the patients report fever (usually subfebrile) lasting up to four days. In more severe cases, the temperature reaches 38.5-39.5 °C, accompanied by chills, muscle and joint pain. On examination, the skin is pale, vascular injection of the sclera and conjunctiva. The mucous membrane of the anterior pharynx is without pathological changes. The mucous membrane of the posterior pharyngeal wall is hyperemic, edematous, mucus deposits are often visible. On the 2nd-3rd day, hyperplasia of the lymphoid follicles appears. Inflammatory changes in the nasopharynx are especially pronounced, they spread to the back of the nasal passages and choanae, leading to impaired nasal breathing. After a few days, the inflammatory changes subside, but follicular hyperplasia persists for up to 2 weeks. In children under 3 years of age, a runny nose and cough are expressed, and inflammatory changes spread to the tonsils, palatine arches, and soft palate.

Changes in the blood picture are uncharacteristic for nasopharyngitis; in more severe cases, there is neutrophilic leukocytosis with a shift in the formula to the left and an increase in ESR.

Meningococcemia

Meningococcemia is characterized by a combination of feverish-intoxication syndrome with skin lesions and a wide range of severity. In typical cases, the onset is sudden or against the background of nasopharyngitis. The following symptoms of meningococcal infection appear: chills, pain in the lower back, joints, muscles, headache, sometimes vomiting, severe weakness, the temperature rises within a few hours to 39 ° C and above. 6-24 hours after the onset of chills, the cardinal symptom of meningococcemia appears - polymorphic hemorrhagic rash. The elements of the rash have an irregular, often star-shaped shape, the size varies from petechiae to large ecchymoses with a diameter of 2-3 cm or more. Large elements are dense to the touch, sensitive to palpation, rise above the surface of the skin. The rash is localized mainly in the distal parts of the extremities, on the lateral surface of the thighs and buttocks. During the day, it may become more abundant: no new elements appear later. Small elements become pigmented and disappear after a few days; large ones undergo necrosis, become covered with a crust, after which erosive-ulcerative defects remain with subsequent formation of scars. The earlier the rash appears and the larger the elements, the more severe the disease. Before the appearance of hemorrhagic elements, there may be minor papular or roseolous rashes, which quickly disappear or transform into hemorrhages. Hemorrhages on the conjunctiva and mucous membrane of the oropharynx, nosebleeds are also possible.

Mild forms of meningococcemia are often not diagnosed or are diagnosed only when complications develop (arthritis, iridocyclitis). They are characterized by short-term fever lasting several hours to a day, a typical but small and not abundant rash or only roseolous and papular elements.

Fulminant meningococcemia proceeds completely differently. The onset is stormy, with a stunning chill. Characterized by pronounced toxicosis from the first hours of the disease, manifested by intense headache and vomiting, dizziness, pain in the lower back, limbs, joints, tachycardia, shortness of breath. The temperature within a few hours reaches 40 ^: C and more. The rash appears, as a rule, within the first 12 hours after the onset of chills. The elements are large, quickly necrotize and acquire a purple-bluish color, localized not only in typical places, but also on the face, neck, abdomen, anterior surface of the chest, and in these places they are often more abundant. Hemorrhagic necrosis of the tip of the nose, earlobes, gangrene of the nail phalanges and even hands and feet are possible. The appearance of the rash is preceded by profuse hemorrhages in the conjunctiva and sclera of the eyes, and the mucous membranes of the oropharynx.

Against this background, symptoms of infectious toxic shock develop.

Symptoms of the first phase of shock: motor restlessness, anxiety, decreased critical attitude to one's condition; hyperesthesia, pale skin, cold extremities, cyanosis of the lips and nail phalanges, shortness of breath. At this time, blood pressure is still within normal limits, sometimes even elevated. The second phase of shock develops after a few hours. Against the background of newly appearing elements of the rash, body temperature decreases, blood pressure falls to 50% of normal (especially diastolic), heart sounds become muffled, shortness of breath increases, diuresis decreases, cyanosis increases. The transition to the third phase of shock is characterized by a drop in blood pressure to less than 50% of normal. Often, the pressure on the ulnar artery cannot be determined, although the pulsation of the carotid and femoral arteries remains. Body temperature drops to 35-36 ° C, cyanosis becomes diffuse. Purple-blue spots appear on the skin. Nasal, gastrointestinal, renal, uterine bleeding, oliguria develop. Patients often retain consciousness, but they are in a state of prostration, indifferent, experience a feeling of cold; hyperesthesia is replaced by anesthesia. Some patients may lose consciousness, convulsions. Heart sounds are muffled, arrhythmia. Breathing in the lungs is weakened, especially in the lower sections. Prognostically, the most severe cases are when the rash appears in the first 6 hours of the disease or the symptoms of shock appear before the skin rash, as well as cases with severe dyspeptic disorders.

Patients die from cardiac arrest, less often from respiratory failure (with concomitant cerebral edema).

During treatment, some patients experience predominantly thrombohemorrhagic syndrome during shock, while others experience shock lung or acute renal failure. In elderly patients, the cause of death in the later stages is progressive heart failure (decreased myocardial contractility according to ultrasound data), cerebral edema with dislocation, and secondary bacterial pneumonia.

The blood picture in patients with meningococcemia is characterized by a pronounced neutrophilic leukocytosis of up to 30-40 thousand cells in 1 μl, a shift in the leukocyte formula to the left, the appearance of myelocytes and promyelocytes in the blood, and moderate thrombocytopenia is often noted. In severe forms of meningococcemia complicated by shock, leukocytosis is often absent, leukopenia and neutropenia are possible, as well as thrombocytopenia up to 40-50 thousand and below. Thrombocytopenia is combined with a sharp decrease in the functional activity of platelets. Leukopenia and thrombocytopenia are unfavorable prognostic signs.

Changes in urine are uncharacteristic, but in severe cases proteinuria, hematuria, and decreased density are noted. Changes in the hemostasis system depend on the severity of the disease. In uncomplicated forms, the tendency to hypercoagulation prevails due to an increase in fibrinogen levels and inhibition of fibrinolysis. In severe cases, consumption coagulopathy develops with a sharp decrease in fibrinogen levels, the activity of platelet and plasma coagulation factors, and the appearance of degradation products in the blood of not only fibrin, but also fibrinogen.

Changes in the acid-base balance are reduced in severe cases to metabolic acidosis (decompensated in the development of shock), hypoxemia, and a decrease in the arterial-venous oxygen ratio due to shunting of blood in the pulmonary circulation. As a rule, hypokalemia is observed in the development of shock, which, in the development of acute renal failure, is replaced by hyperkalemia, combined with an increase in creatinine content.

When examining a blood smear, characteristic diplococci are often found, usually located extracellularly, sometimes in clusters.

Meningococcal meningitis

Meningitis, like meningococcemia, begins acutely, but not so violently. The following symptoms of meningococcal infection appear: chills, headache, temperature during the first day reaches 38.5-39.5 °C. The headache quickly intensifies and by the end of the day becomes unbearable, acquires a bursting character. It is usually diffuse, but can be localized mainly in the frontal-parietal or occipital region. The headache intensifies with sudden movements, under the influence of bright light and loud sounds. Nausea joins in a little later, and then vomiting, often "fountain". At the same time, hyperesthesia of the skin of the extremities and abdomen appears. In the second half of the day or on the second day of the disease, meningeal symptoms are clearly defined during examination, which can be combined with symptoms of tension (Neri, Lasegue symptoms). The severity of the meningeal syndrome progresses as meningitis develops. From the 3rd-4th day of illness, patients (especially children) take a forced meningeal position: on the side with the head thrown back and legs tucked to the body (the "pointer dog" position). In young children, the first symptoms of meningococcal meningitis may be a monotonous cry, refusal to eat, regurgitation, bulging and cessation of pulsation of the fontanelle, the Lesage symptom (suspension), the "tripod" symptom. From the second day, the general cerebral syndrome increases: inhibition, stupor, psychomotor agitation. On the 2nd-3rd days, focal symptoms may also appear: paresis of the cranial nerves (usually the facial and oculomotor), pyramidal signs, sometimes paresis of the limbs. pelvic disorders. The development of purulent labyrinthitis or cochlear neuritis of the VIII pair of cranial nerves is especially serious. At the same time, noise appears in the ear (ears), then deafness immediately develops (patients say "hearing is turned off"). No significant pathology is noted from the side of internal organs. Relative bradycardia, increased blood pressure, especially systolic, are possible.

The blood picture in meningococcal meningitis is similar to that in meningococcemia, but leukocytosis is less pronounced, within 15-25 thousand in 1 μl. There are no changes in the urine. When studying the acid-base state, a tendency to respiratory alkalosis is noted. The most informative changes are in the cerebrospinal fluid. During a spinal puncture, the fluid flows out under increased pressure from the first hours of the disease, but with frequent vomiting, cerebrospinal fluid hypotension is also possible. The first thing noted is an increase in glucose levels to 3.5-4.5 mmol / l. Subsequently, this level falls, and on the 3rd-4th day, glucose may not be detected. Then, neutrophils appear in the cerebrospinal fluid with normal cytosis. At this time, in fact, before the development of inflammation, the pathogen can be detected in the subarachnoid space by all available methods. Then, within a few hours, the cerebrospinal fluid becomes purulent, becomes turbid, contains up to 3-10 thousand neutrophils in 1 μl (and they make up more than 90% of all cells), the amount of protein increases to 1.5-6.0 g / l and more. The lactate content increases to 10-25 mmol / l. Sedimentary tests become sharply positive, the pH of the cerebrospinal fluid decreases to 7-7.1 (acidosis). When examining the cerebrospinal fluid, it is important to pay attention to the presence of xanthochromia and admixture of erythrocytes, indicating subarachnoid hemorrhage against the background of meningitis.

The most common complication of meningococcal meningitis is cerebral edema of varying degrees. Severe, life-threatening cerebral edema with dislocation syndrome and brainstem entrapment is observed in 10-20% of patients with generalized meningococcal infection. Cerebral edema can develop from the first hours of the disease (fulminant meningitis), when purulent exudate has not yet formed in the membranes of the brain, and in patients over 70 years of age with initially reduced cerebral blood flow - up to the 3rd-5th day of treatment.

Symptoms of severe progressive cerebral edema-swelling include confusion, psychomotor agitation with rapid development of coma, generalized clonic-tonic seizures.

Respiratory disorders are of decisive diagnostic importance: tachypnea, arrhythmia (both in frequency and depth of respiratory movements), the appearance of noisy paralytic breathing with the participation of accessory muscles with a small excursion of the diaphragm. This type of breathing is accompanied by an increase in hypoxemia and hypocapnia. It contributes to the suppression of the respiratory center, hypoventilation of the lower parts of the lungs, and subsequently to the development of pneumonia. In some patients, Cheyne-Stokes breathing is recorded. Then apnea occurs (cardiac activity, as a rule, continues for several more minutes). Changes in the cardiovascular system are quite indicative. Bradycardia is rarely observed, more often tachyarrhythmia with a rapid change in heart rate within 120-160 per minute (twice as often as the age norm). Blood pressure is elevated due to systolic to 140-180 mm Hg, unstable. In some patients, especially children, on the contrary, pronounced hypotension is observed. Vegetative disorders are characteristic: purple-blue (with hypotension - ash-gray) coloration of the face, increased sweating and sebum secretion. Blood tests show hyperglycemia, a tendency to hyponatremia, hypoxemia, hypocapnia with a decrease in pCO ₂ to 25 mm and below, decompensated respiratory alkalosis.

Mixed form of meningococcal infection

The most common form of meningococcal infection is the combined (mixed) form. Meningococcemia always precedes the development of meningococcal meningitis, which can develop after a short-term (several hours) remission after the appearance of the rash. The temperature rises again, headache increases, and meningeal symptoms appear. The combined form, as well as meningococcemia, is often preceded by meningococcal nasopharyngitis.

Meningococcal pneumonia is usually not clinically differentiated from pneumococcal pneumonia, so there are no reliable data on its frequency. Meningococcal arthritis and iridocyclitis are usually the result of undiagnosed meningococcemia.

Chronic meningococcemia occurs with periodic temperature increases, accompanied by skin rashes, arthritis or polyarthritis. After several attacks, a systolic murmur appears in the heart area, indicating the development of endocarditis. Patients usually come to the doctor's attention as a result of the development of meningococcal meningitis.

In addition to those described above, the most common complication of the generalized form of meningococcal infection is polyarthritis. It usually develops in patients with meningococcemia and a combined form of the disease and very rarely with meningococcal meningitis. Polyarthritis can develop in the first days of the disease. In these cases, mainly small joints of the hand are affected. On the 2nd-3rd week, arthritis and polyarthritis with damage to large and medium joints (knee, ankle, shoulder, elbow) are more often observed. With late arthritis, serous or purulent exudate accumulates in the joint cavity. Myocarditis or myopericarditis, which occurs as an infectious-allergic type, is also possible. In severe forms of the disease, complicated by shock or cerebral edema, pneumonia caused by staphylococcus, pseudomonas aeruginosa, klebsiella often develops. They can be destructive and significantly aggravate the prognosis. After shock, especially with the use of massive doses of glucocorticoids, sepsis may develop.