Case Presentation:

A 52–year–old gentleman with human immunodeficiency disease (HIV) and CD4 count greater than 500 cells per cubic millimeter of blood presented with 2 days of diarrhea, lethargy, myalgias, arthralgias, and a rash. He was found by his friends to be “ill–appearing” and have altered mental status. Shortly after arrival, he became obtunded and hypotensive. He was intubated, started on vasopressor therapy and broad–spectrum intravenous antibiotics, and transferred to the medical intensive care unit. On exam, he was unresponsive with tachycardia and mild bibasilar crackles on auscultation. He had a diffuse purpuric rash. An arterial blood gas showed a pH of 7.27. His arterial lactate was elevated at 8.1, serum creatinine was 4.5, white blood cell count was 8.4K with 84% neutrophils, platelet count was 111, and prothrombin time was 18.5. Cultures of cerebrospinal fluid and urine were negative for bacterial growth. His initial blood cultures grew Neisseria meningitides, serogroup C. His antibiotics were narrowed to intravenous ceftriaxone and activated drotrecogin alpha was initiated. He slowly improved, vasopressor therapy was weaned off, he was extubated, and subsequently transferred to a general medicine floor. He had persistent hemodialysis requirements due to acute renal failure from fulminant septic shock. He was diagnosed with disseminated meningococcemia.

Discussion:

Disseminated meningococcal disease is caused by the intracellular encapsulated diplococcal bacterium Neisseria meningitides. The bacterium is a common human commensal. The average annual incidence for meningococcal disease in the United States is approximately 1 case per 100,000 persons. The mortality rate is highest in those with the septicemia form of the disease. Risk factors include young age, asplenia, genetic polymorphisms predisposing to immune deficiencies, crowding, climatic conditions, being an ethnic minority, and being of low socioeconomic status. Early in the AIDS epidemic, patients who were HIV–positive were believed to be at increased risk of invasive meningococcal disease. However, there have been no studies in the United States that show an increased risk of meningococcemia or meningococcal meningitis in patients with HIV/AIDS. There have been less than 50 described cases of meningococcal infections in HIV–infected patients reported in MEDLINE. This particular patient’s presentation was most likely a sporadic case of meningococcemia.

Conclusions:

Hospitalists should recognize the signs and symptoms of meningococcal disease early as a delay in diagnosis could lead to increased morbidity and mortality. Without any treatment, upwards of 90% of patients will die. Hospitalists should understand that early introduction of antibiotics can reduce the mortality rate to 10%. The interaction between HIV infection and meningococcal disease is unclear but there has been no described increased risk of invasive meningococcal disease in patients with HIV/AIDS in the United States.