Invasive meningococcal disease presenting with cellulitis

Letters - eMJA - The Medical Journal of Australia

April 2006

Karina J Kennedy, Jhumur Roy and Paul Lamberth

To the Editor:

We recently treated two patients with invasive meningococcal disease presenting with cellulitis. This presentation contributed to a delay in diagnosis and appropriate antibiotic treatment.

The first patient was a 33-year-old woman, recently diagnosed with nephrotic syndrome, who had been unwell for a week with mild upper respiratory tract symptoms. During this time, her nephrologist began treating her with prednisolone (15 mg daily). The day before presentation, she developed abdominal pain, vomiting, chills, myalgia and headache. A rash developed on the day she presented to hospital. The temperature was 39.2°C, heart rate 148 beats per min, and blood pressure 146/57 mmHg. She had an area, measuring 20 cm × 20 cm, of tender cellulitic rash on the right thigh (Box) and mild neck stiffness.

The diagnosis was initially unclear, leading to a delay of several hours before ceftriaxone was administered, and a lumbar puncture performed. Cerebrospinal fluid (CSF) examination revealed a leukocyte count of 4500 × 106/L (98% polymorphs) (reference range [RR], <>

The second patient was a 51-year-old woman with fever and a 2-day history of progressive pain, swelling and erythema of the anterolateral area of the neck. The temperature was 38.5°C, heart rate 115 beats per min, and blood pressure 134/86 mmHg. There was no evidence of upper airway involvement. The anterior area of the neck and upper chest wall were swollen, erythematous, tender and warm. No fluid collections or masses were detected on ultrasound examination.

The patient was admitted to hospital with a diagnosis of cellulitis, and treatment was begun with intravenous flucloxacillin and metronidazole. After 17 hours, culture of blood taken on admission showed N. meningitidis serotype W135. Antibiotic treament was changed to ceftriaxone. After 5 days, the patient had mild residual inflammation and tenderness of the neck. She completed another week of treatment with oral amoxycillin.
Only 14 cases of N. meningitidis cellulitis have been published.1-3 Seven cases involved children with periorbital cellulitis. In adults, three cases involved the face and neck, and four the limbs. N. meningitidis was isolated from blood (eight patients), conjunctival swabs (three), aspirates of the cellulitic areas (two) or CSF (one). There was one death: an elderly woman with bacteraemia and cellulitis of the face and neck.2 As illustrated by our cases, the many guises of meningococcal disease continue to challenge clinicians.

Author details

Karina J Kennedy, MB BS, Microbiology Registrar1Jhumur Roy, MB BS, FRCPA, Microbiologist1Paul Lamberth, MB BS, FACEM, Director of Intensive Care2
1 The Canberra Hospital, Canberra, ACT.
2 Calvary Healthcare ACT, Canberra, ACT.
Correspondence: karina.kennedyATact.gov.au

References

Porras MC, Martinez VC, Ruiz IM, et al. Acute cellulitis: an unusual manifestation of meningococcal disease. Scand J Infect Dis 2001; 33: 56-59.

Cartolano GL, Barbier C, Arnoult L, et al. Fatal acute cellulitis due to Neisseria meningitidis. J Clin Microbiol 2003; 41: 3996-3997.

Chand DV, Hoyen CK, Leonard EG, McComsey GA. First reported case of Neisseria meningitidis periorbital cellulitis associated with meningitis. Pediatrics 2005; 116: e874-e875.

(Received 11 Jan 2006, accepted 15 Mar 2006)Primary KeywordsInfectious diseases and parasitology

Secondary Keywords: Infection — skin

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