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Case Report/Case Series |

Corticosteroid-Induced Meningococcal Meningitis in a Patient With Chronic Meningococcemia ONLINE FIRST

Michael Wenzel, MD1; Lena Jakob, MD2; Andreas Wieser, MD3,4; Jürgen Schauber, MD2; Konstantinos Dimitriadis, MD1; Sören Schubert, MD3; Hans-Walter Pfister, MD1
[+] Author Affiliations
1Department of Neurology, Klinikum Grosshadern, Ludwig-Maximilians-University, Munich, Germany
2Department of Dermatology and Allergy, Ludwig-Maximilians-University, Munich, Germany
3Max von Pettenkofer Institute for Hygiene and Medical Microbiology, Ludwig-Maximilians-University, Munich, Germany
4Department of Medical Laboratory Science and Pathology, Jimma University, Jimma, Ethiopia
JAMA Dermatol. Published online February 26, 2014. doi:10.1001/jamadermatol.2013.9350
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Importance  Although chronic meningococcemia is an uncommon disorder, it is of great importance to clinicians across multiple disciplines because it presents similarly to reactive, neoplastic, or rheumatic disorders. Ruling out chronic meningococcemia, however, represents a diagnostic challenge because routine microbiological investigations frequently fail to identify Neisseria meningitidis. Although treatment with corticosteroids might be helpful in various conditions, corticosteroid treatment may lead to severe complications in underlying chronic meningococcemia.

Observations  We describe a patient with a history of recurrent fever, arthralgia, and disseminated skin lesions. The patient was assumed to have Sweet syndrome and was treated with corticosteroids. Subsequently the patient developed meningococcal meningitis and was admitted to the neurointensive care unit. Chronic meningococcemia was confirmed retrospectively by nonroutine polymerase chain reaction and silver staining of skin biopsy specimens. Immunologic workup revealed decreased IgG subclass 3.

Conclusions and Relevance  Consideration of chronic meningococcemia is important when a patient presents with a history of fever and disseminated skin lesions. Polymerase chain reaction testing of skin biopsy specimens should be performed more systematically if the results of routine microbiological investigations remain unrevealing. In addition, silver staining of skin lesions can help establish the diagnosis. Eventually, testing for immune deficiencies should more routinely follow a confirmed diagnosis of chronic meningococcemia.

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Figures

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Figure 1.
Efflorescence of the Skin in Chronic Meningococcemia

Livid-erythematous maculopapular skin lesions on the patient’s right hand (A) and thigh (B) at initial admission. Lesions were localized mainly on the trunk, arms, and legs.

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Figure 2.
Hematoxylin-Eosin Staining of Skin Lesion Biopsy Specimen

Dermal ectatic lymph vessels (A) and capillaries (B) with perivascular lymphohistiocytic infiltration with numerous lymphocytes and a large number of neutrophil granulocytes (original magnification x40).

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Figure 3.
Silver Staining of Skin Lesion Biopsy Specimen

Silver staining of the same specimen revealing neisserial diplococci (arrowhead) (scale bar indicates 10 μm).

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