We describe a typical presentation of meningococcus meningitis, diagnosed by blood culture.
A Congolese man who had recently arrived in New Mexico after living in a Tanzanian refugee camp presented with a 2-day history of worsening diffuse headache, productive cough, non-bloody diarrhea, and persistent fevers. He had not had any sick contacts. He had been screened for certain illnesses to allow him to emigrate but his immunization details were unavailable. He was not on any medication prior to presenting to the hospital. Social history was unrevealing. An initial physical examination revealed only profuse diaphoresis, with a negative neurological, chest, and abdominal examination. He was placed on droplet and contact precautions, and empiric gram-positive and gram-negative antibiotic coverage were started. Blood cultures from 2 bottles grew Neisseria meningitides serotype W. The stool was positive only for Giardia lamblia. CT scan of the abdomen and pelvis showed hepatic steatosis, small ascites, small bilateral pleural effusions; CT chest angiography was negative for pulmonary embolism. All other laboratory and diagnostic studies were normal.
Given the meningococcal bacteria septicemia, a lumbar puncture was performed. His cerebrospinal fluid was consistent with partially treated meningitis. He was started on Ceftriaxone 2 grams IV twice a day for 10 days for meningitis and metronidazole 250 mg three times a day for giardiasis for 7 days. He also received 250 mg twice daily of rifampin for nasal decolonization. On discharge, he was asymptomatic and blood cultures were negative. The New Mexico State department of Health performed contact tracing for ciprofloxacin prophylaxis for at risk-contacts. He was doing well in primary care clinic follow-up.
Discussion:
This case highlights several factors. First, the importance of taking a good travel history. Second, understanding meningococcal epidemiologic factors. The patient had just emigrated from the African “meningitis belt.” The meningitis belt stretches from West Africa to East Africa, into the Arabian Peninsula. Patients coming from the belt, recent pilgrims to Mecca during the Hajj, and refugees living in refugee camps are at high risk for meningitis. Third, the case highlights the need to take a detailed medication history, including antibiotics. Fourth, physicians should have a high index of suspicion for meningitis for people coming from the meningitis belt even if presenting without meningismus. Some patients with meningitis or partially treated meningitis present with non-specific symptoms, which can make for a diagnostic challenge. Foundations of care include rapid identification of potential cases, testing, and treatment, concurrent HIV testing in all patients and malaria testing in patients with a travel history to endemic areas, meticulous infection control, and contact tracing for administration of prophylaxis.
Conclusions:
Hospitalists should be aware that diagnosis of the etiology of meningitis, in this case meningococcal meningitis, in patients from a refugee camp is needed for prompt and appropriate therapy. More than 50% of patients will present atypically, and both HIV and malaria should be ruled out in patients presenting from the meningitis belt.