Meningococcal Septicaemia

Meningococcal Septicaemia – Case study 3
Sarah, an 11-month-old child, has been brought into the emergency department by her parents following a 12-hour
period of coryzal symptoms.
Concerned, her parents decided to take Sarah to hospital, where they noticed Sarah’s body was very warm whilst
her hands and feet were cold. Sarah was diagnosed with a viral infection and sent home. That night Sarah became
increasingly lethargic and vomited. According to Sarah’s mother, the next morning Sarah slept in and had to be
woken up. She remained drowsy with a temperature of 39.9°C, and “just seemed floppy and dazed. She threw up
her milk straight away.”
Sarah’s parents have come to the hospital worried now because they have also discovered small dark purple/red
spots on Sarah’s abdomen around the nappy line, in which the parents fear may be meningococcal disease.
The concept map relates to the above information; the written component of the assignment
relates to the below information**
On examination, you note her cold extremities, abnormally pale skin colour, fever and persistent lethargy. Her
tympanic temperature is 38.7°C. She is tachycardic with a regular heart rate of 158 beats per minute and has a dry
nappy which mum and dad state hasn’t needed to be changed at all overnight.
Her capillary refill is sluggish, her breathing while not laboured, is fast for her age (64/min) and her SpO2 is 92% on
room air, with an arterial blood gas reveals the following:
pH 7.1, PaO2 74mmHg, PaCO2 35mmHg, HCO3 13mmol/L, BE -14 indicating she has an acidosis.
Her blood pressure is palpable brachially at 70 mmHg systolic. After a neurological examination, you find she eye
opens to pain not voice; she has a positive Brudzinski sign and cries intermittently especially when her legs are
moved.
Shortly after her admission, Sarah experiences a generalized tonic seizure lasting approximately 40 seconds,
following which she is unconscious and unarousable. Subsequently she was intubated and commenced on
mechanical ventilation. Intravenous access had been established and she was given fluid resuscitation with urine and
blood samples sent for microscopy. Antimicrobial therapy, a third-generation cephalosporin, ampicillin and an
anticonvulsant are commenced immediately.
Source Javid, M. (2017). Meningococcemia. Medscape. Retrieved from https://emedicine.medscape.com/article/221473-overview
After this initial treatment, Sarah is transferred to the ICU. The cerebrospinal fluid (CSF) Gram stain indicates gramnegative cocci. On closer re-examination of Sarah’s skin, you notice now that the initial ‘rash’ appears to have
become more widespread. It remains non-blanching and is now present on her abdomen and chest, in which you
suspect that Sarah has disseminated intravascular coagulation (DIC).
Blood test results (normal range in parentheses)
Hb (160g/L) 98g/L
Platelets (150-350 x 109/L) 93 x 109/L
Albumin (28-43g/L) 19g/L
PT (11-14 sec) 15.8 sec
APTT (23-35 sec) 160 sec
Fibrinogen (1.5-3.7) 3.6g/L
D- Dimers (0.5µg/mL) 0.8µg/mL
Assignment task

  1. Develop a concept map that explains the pathophysiological processes underpinning Sarah’s presentation,
    and how these processes link to the development of disseminated intravascular coagulation (DIC).
  2. Explain the pathophysiology that relates to each of Sarah’s signs, symptoms and test results.