Symptoms of meningococcal infection in adults

Meningococcal infection has an incubation period, which in generalized forms lasts from 1 to 10, usually 2 to 4 days. Symptoms of meningococcal infection are manifold. The domestic classification, approximated to the international one, has been developed.

[1], [2], [3], [4]

Forms of meningococcal infection

Symptoms of meningococcal infection make it possible to classify this disease. There are following forms of meningococcal infection:

Localized forms:

• carriage;
• meningococcal nasopharyngitis.

Generalized forms:

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

[5], [6],

Meningococcal transport

Meningococcal carriage does not have any symptoms of meningococcal infection, but on examination you can find a picture of acute follicular pharyngitis.

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 in nasal breathing, scanty discharge from the nose, small cough, sore throat, headache. Fever (usually subfebrile) lasting up to four days, notes half of the patients. In more severe cases, the temperature reaches 38.5-39.5 ° C, which is accompanied by chills, pain in the muscles and joints. On examination, the pallor of the skin. Injection of vessels of sclera and conjunctiva. Mucous membrane of anterior sections of throat without pathological changes. Mucous membrane of the posterior pharyngeal wall is hyperemic, edematic, mucus overlays are often visible. On the 2nd-3rd day, hyperplasia of lymphoid follicles occurs. Especially pronounced inflammatory changes in the nasopharynx, they extend to the back of the nasal passages and the khohans, leading to a disruption of nasal breathing. A few days later, inflammatory changes subsided, but follicular hyperplasia persists up to 2 weeks. Children under the age of 3 years have a runny nose, cough, inflammatory changes spread to the tonsils, palatine arch and soft palate.

Changes in the blood picture for nasopharyngitis are small, in more severe cases - neutrophilic leukocytosis with a shift of the formula to the left and an increase in ESR. 

Meningococcemia

Meningococcemia is characterized by a combination of febrile-intoxication syndrome with damage to the skin and a wide range of severity of the course. In typical cases, the onset is sudden or on 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 for several hours to 39 ° C and above. After 6-24 hours after the onset of chills, a cardinal symptom of meningococcemia appears - polymorphic hemorrhagic rash. Elements of the rash have an irregular, often stellate shape, the sizes vary 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. Within a day, it can become more abundant: in the future, new elements do not appear. Small elements are pigmented and after a few days disappear; large ones are subjected to necrosis, they are covered with a crust, after which the erosive and ulcerative defects remain, followed by the formation of scars. The earlier the rash appears and the larger the elements, the more severely the disease proceeds. Until the appearance of hemorrhagic elements, there may be no abundant papular or rosaceous rashes that quickly disappear or transform into hemorrhages. There are also hemorrhages on conjunctiva and mucosa of the oropharynx, nosebleeds.

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

Completely differently fulminant meningococcemia occurs. The beginning is stormy, with a tremendous chill. Characterized by pronounced toxicosis from the first hours of the disease, manifested by intense headache and vomiting, dizziness, back pain, limbs, joints, tachycardia, dyspnea. The temperature for several hours reaches 40 ^: C and more. The rash appears, usually during the first 12 hours after the onset of chills. Elements are large, quickly necrotic and acquire a purplish-cyanotic color, localized not only in typical places, but also on the face. Neck. Stomach, front surface of the chest, and in these places often are more abundant. Possible hemorrhagic necrosis of the tip of the nose, earlobes, gangrene of nail phalanges and even brushes and feet. The appearance of rashes is preceded by abundant hemorrhages in the conjunctiva and sclera of the eyes, mucous membranes of the oropharynx.

Against this background, symptoms of an infectious-toxic shock develop.

Symptoms of the first phase of shock: motor anxiety, anxiety, reducing criticism to one's condition; hyperesthesia, pallor of the skin, cold extremities, cyanosis of the lips and nail phalanx, shortness of breath. At this time, blood pressure is still within normal limits, sometimes even increased. The second phase of shock develops in a few hours. Against the background of newly emerging elements of the rash, body temperature decreases, blood pressure drops to 50% of the norm (especially diastolic), heart sounds become muffled, dyspnea increases, diuresis decreases, cyanosis increases. The transition to the third phase of shock is characterized by a drop in blood pressure of less than 50% of the norm. Often pressure on the ulnar artery can not be determined, although the pulsation of the carotid and femoral arteries persists. Body temperature drops to 35-36 ° C, cyanosis becomes diffuse. On the skin appear purple-cyanotic spots. Nasal, gastrointestinal, renal, uterine bleeding, oligoanuria develop. Patients often remain conscious, but they are in a state of prostration, indifferent, experiencing a feeling of cold; hyperesthesia is replaced by anesthesia. Part of the patients may have unconsciousness, convulsions. Heart sounds are deaf, arrhythmia. In the lungs, breathing is weakened, especially in the lower parts. Prognostically, the most severe cases occur when the rash occurs in the first 6 h of the disease or the symptoms of shock appear before skin rashes, as well as cases with severe dyspeptic disorders.

Patients die from cardiac arrest, less often than breathing (with concomitant edema of the brain).

On the background of treatment in some patients during the shock, thrombohemorrhagic syndrome predominates, in others - shock light or acute renal failure. In elderly people, the cause of death in later terms is progressive heart failure (decreased myocardial contractility according to ultrasound), edema of the brain with dislocation, and secondary bacterial pneumonia. 

The blood picture in patients with meningococcemia is characterized by a pronounced neutrophilic leukocytosis up to 30-40 thousand cells in 1 μl, a shift of the leukocyte formula to the left, the appearance of myelocytes and promyelocytes in the blood, and moderate thrombocytopenia is often noted. With 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 less. Thrombocytopenia is combined with a sharp decrease in the functional activity of platelets. Leukopenia and thrombocytopenia are unfavorable prognostic signs.

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

Changes in the acid-base state are reduced in severe cases to metabolic acidosis (with the development of shock-decompensated), hypoxemia, to reduce the arterial-venous ratio for oxygen due to shunting the blood in a small circle. With the development of shock, as a rule, hypokalemia is observed, which in the development of acute renal failure is replaced by hyperkalemia, combined with an increase in the creatinine content.

When microscopy a blood smear is often found characteristic diplococci, located more often extracellularly. Sometimes clusters.

Meningococcal meningitis

Meningitis , as well as meningococcemia, begins acutely, but not so violently. There are the following symptoms of meningococcal infection: cognition, headache, temperature during the first day reaches 38.5-39.5 ° C. The headache is rapidly increasing and by the end of the day it becomes difficult to bear, acquires a bursting character. It is usually diffuse, but can be localized mainly in the frontal-parietal or occipital region. The headache increases with sharp movements, under the influence of bright light and loud sounds. Somewhat later, nausea joins, and then vomiting, often a "fountain". Simultaneously there is hyperesthesia of the skin of the extremities, abdomen. In the second half of the day or on the second day of the illness, the examination clearly identifies meningeal symptoms that can be combined with symptoms of tension (symptoms of Neri, Lasega). The degree of severity of meningeal syndrome increases with the development of meningitis. From the 3rd-4th day of illness, patients (especially children) take an involuntary meningeal posture: on their side with their head thrown back and legs tucked to the trunk (pose of the "dog"). In young children, the first symptoms of meningococcal meningitis can be a monotonous cry, refusal to eat, regurgitation, swelling and cessation of the fontanelle pulsation, a Lesage symptom (suspension), a "tripod" symptom. From the second day, the general cerebral syndrome increases: inhibition, sopor, psychomotor agitation. On the 2-3rd days, the appearance of focal symptoms is also possible: paresis of cranial nerves (often facial and oculomotor nerves), pyramidal signs, sometimes paresis of limbs. Pelvic disorders. Especially serious is the development of purulent labyrinthitis or cochlear neuritis of the VIII pair of cranial nerves. This causes noise in the ear (ears), then deafness develops immediately (the patients say "the hearing is turned off"). On the part of the internal organs, there is no significant pathology. Possible relative bradycardia, increased blood pressure, especially systolic.

The picture of blood during meningococcal meningitis is similar to that of meningococcemia. But leukocytosis is less pronounced, within 15-25 thousand in 1 μl. Changes in the urine are absent. In the study of the acid-base state, a tendency toward respiratory alkalosis is noted. The most informative changes in the cerebrospinal fluid. With spinal puncture, fluid from the first hours of the illness comes under increased pressure, but with frequent vomiting, it is possible and cerebrospinal fluid hypotension. In the past, glucose is increased to 3.5-4.5 mmol / l. In the future, this level falls, and on the 3-4th day of glucose may not be determined. Further in the cerebrospinal fluid with normal cytosis appear neutrophils. 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, neutrophil contains up to 3-10 thousand in 1 μl (with 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 samples 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 xanthochromy and the admixture of erythrocytes, indicating a subarachnoid hemorrhage against the background of meningitis.

The most common complication of meningococcal meningitis is edema-swelling of the brain to one degree or another. Severe, life-threatening edema-swelling of the brain with a dislocation syndrome and brainstem infringement is observed in 10-20% of patients with a generalized form of meningococcal infection. Swelling-swelling of the brain can develop from the first hours of the disease (fulminant form of meningitis), when purulent exudate has not yet formed in the membranes of the brain, and in patients older than 70 years with initially lowered cerebral blood flow - up to the 3-5th day of treatment. 

Symptoms of severe progressive swelling-swelling of the brain - confused consciousness, psychomotor agitation with rapid development of coma, generalized clonic-tonic convulsions.

Critical diagnostic value is the violation of breathing: tachypnea, arrhythmia (both in frequency and depth of respiratory movements), the appearance of noisy paralytic breathing with the participation of auxiliary muscles with a small diaphragm excursion. A similar type of breathing is accompanied by an increase in hypoxemia and hypocapnia. Promotes oppression of the respiratory center, hypoventilation of the lower parts of the lungs, and further - the development of pneumonia. Part of the patients register Cheyne-Stokes respiration. Then comes apnea (cardiac activity, as a rule, lasts a few more minutes). Changes in the cardiovascular system are quite indicative. Bradycardia is observed rarely, more often tachyarrhythmia with a rapid change in the heart rate in the range of 120-160 per minute (twice the age norm). Arterial pressure is increased due to systolic pressure up to 140-180 mm Hg, unstable. On the contrary, a part of patients, especially children, observe pronounced hypotension. Typical are vegetative disorders: purple-cyanotic (with hypotension - ashy-gray) face color, increased flow and salinity. In the study of blood - hyperglycemia. The tendency to hyponatremia, hypoxemia, hypocapnia with a decrease in pC0 ₂ to 25 mm and below, decompensated respiratory alkalosis.

Mixed form of meningococcal infection

Most often there is a combined (mixed) form of meningococcal infection. In this case, meningococcemia always precedes the occurrence of meningococcal meningitis, which can develop after a short-term (several hours) remission after the appearance of the rash. The temperature rises again, the headache grows and meningeal symptoms appear. Combined form, as well as meningococcemia, is often preceded by meningococcal nasopharyngitis.

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

Chronic meningococcemia occurs with periodic temperature rises, accompanied by rashes on the skin, arthritis or polyarthritis. After several attacks there is a systolic murmur in the region of the heart, indicative of the development of endocarditis. Patients fall into the doctor's field of vision, usually 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 develops usually in patients with meningococcemia and a combination form of the disease and very rarely with meningococcal meningitis. Polyarthritis can develop in the early days of the disease. In these cases, the small joints of the hand are mostly affected. At 2-3 weeks, arthritis and polyarthritis with lesions of large and medium joints (knee, ankle, shoulder, elbow) are more common. With late arthritis in the joint cavity accumulates serous or purulent exudate. It is also possible the development of myocarditis or myopericarditis, which proceeds according to the type of infectious-allergic. In severe forms of the disease, complicated by shock or edema of the brain, pneumonia often develops caused by staphylococcus, Pseudomonas aeruginosa, Klebsiella. They can be destructive and significantly burden the forecast. After the shock, especially with the use of massive doses of glucocorticoids, the development of sepsis is possible.