Send letter to journal:
Re: Cranial imaging in meningococcal disease

Editor,

We read with interest the study by Fellick et al [1] of neurodevelopmental outcome in meningococcal disease. No cranial imaging was mentioned in assessment of neurological status. We report a case suggesting cranial imaging may be important in determining prognosis.

A 3 month old presented with vomiting, drowsiness, pyrexia and purpura. Meningococcal disease was diagnosed clinically and confirmed on blood PCR.

Despite resuscitation and cefotaxime she deteriorated becoming shocked with a fluctuating conscious level. She was intubated and ventilated before transfer to our intensive care unit. Adrenaline, mirinone and noradrenaline were required. As is our practice, plasma filtration with heparinization was performed.

Oxygenation was difficult to maintain with conventional ventilation therefore high-frequency oscillatory ventilation was used. Thrombocytopenia and coagulopathy were treated with blood transfusions and fresh frozen plasma.

After extubation, weakness, brisk reflexes and jitteriness were noted. A brain computed tomography scan showed a recent subdural bleed and choroid plexus haemorrhage.

Tone, movements and general condition improved. By day 12 she was alert, reactive and bottle feeding.

Several possibilities were considered as the cause of intracranial bleeding. Firstly, high-frequency oscillatory ventilation has been associated with intracranial haemorrhage. However, studies have been carried out in neonates only and the evidence is conflicting [2].

Secondly, heparinization required for plasma exchange could be a causal factor. Heparinization of umbilical catheters in neonates may increase intraventricular haemorrhage [3]. Infants with deranged clotting heparinized on extracorporeal membrane oxygenation are at increased risk of intracranial haemorrhage [4].

Thirdly, the disease process is considered as an explanation. DIC has been associated with intracranial haemorrhage in other conditions but not in meningococcal disease. Meningitis is presumably a possible cause although there is nothing in the literature to support this.

In fulminant meningococcal disease, especially if high levels of intervention are required, cranial imaging is recommended as a possible predictor of neurological sequelae.

References

(1) Fellick J M, Sills J A, Marzouk O, Hart C A, Cooke R W I, Thomson A P J. Neurodevelopmental outcome in meningococcal disease: a case control study. Archives of Disease in Childhood 2001;85:6-11

(2) Clark R H, Dykes F D, Bachman T E, Ashurst J T. Intraventricular haemorrhage and high-frequency ventilation: a meta-analysis of prospective clinical trials. Pediatrics 1996;98:1058-60

(3) Malloy M H, Cutter G R. The association of heparin exposure with intraventricular haemorrhage among very low birth weight infants. Journal of Perinatology 1995;15(3):185-91