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140KUWAIT MEDICAL JOURNAL June 2009Case ReportImmune Associated Complication in MeningococcalDisease: A Report of Two CasesHanan Y Al-Qattan, Osama AEF El-Hashash, Nabila A AbulDepartment of Pediatrics, Farwaniya Hospital, KuwaitABSTRACTKuwait Medical Journal 2009; 41 (2): 140-142Meningococcal disease is one of the most feared infections inchildren. In recent years, little attention has been focused onthe complications of meningococcal disease in the sub-acutephase, the so-called immune associated complications. Itsmain features are arthritis, vasculitis, episcleritis, pericarditisand very rarely nephritis. We report two siblings withmeningococcal disease. The first developed arthritis andvasculitis while the younger sister developed only arthritisof the right ankle. To the best of our knowledge this is thefirst case report to be published in Kuwait.KEY WORDS: arthritis, immune associated complications (IAC), meningococcal septicemia, vasculitisINTRODUCTIONReports of illnesses resembling meningococcaldisease date back to the 16 th century. The descriptionreported by Viesseux in 1805 is generally thought tobe the first definitive identification of the disease. Thecausative organism; Neisseria meningitidis was firstisolated in 1887 [1] . It is one of the most feared infectionsin children due to its possible rapidly fatal course [2]and relatively high incidence of sequelae in survivors.Despite treatment with the appropriate antimicrobialagents and optimal care, the overall case fatality rateshave remained relatively stable over the past 20 yearsat a 9-12% reaching a rate of up to 40% amongst thepatients with meningococcemia [3] . Between 11-19%of survivors of meningococcal disease have sequelaesuch as hearing loss, neurological disability or lossof a limb [4,5] .Most of the research that has been done inrecent years was directed at the pathophysiologicalmechanisms in the acute phase. However, relativelylittle is known about the complications occurringin the sub-acute phase (4-10 days after the initialantibiotic treatment); the so-called type 3 immunecomplex hypersensitivity reactions according to Gelland Coombs [2] .In meningococcal disease type 3 reaction, furthercalled immune associated complication (IAC), canoccur as arthritis, vasculitis, episcleritis, pericarditisor rarely nephritis [2] . More than one complication canoccur concurrently in some patients. We describe twosiblings in this case study. One developed arthritisand the other had arthritis and vasculitis in thesubacute phase of meningococcemia.CASE PRESENTATIONCase OneA nine-year old girl, second in order of siblingsof six children, was admitted with complaintsof fever, headache, vomiting and a skin rash. Onexamination she looked ill with altered level ofconsciousness, had signs of meningeal irritation aswell as purpuric and ecchymotic skin rash all overher body. Intravenous ceftriaxone (100 mg/kg/day) was commenced following admission with aclinical diagnosis of meningococcemia. Completeblood count showed white blood cell of 5.2 x 10 9 /l ,neutrophils 86%, hemoglobin 117 g/l, platelet 267 x10 9 /l. Erythrocyte sedimentation rate (ESR) was 38mm/h and C- reactive protein (CRP) was 259 mg/l. Latex agglutination test for blood and urine aswell as blood cultures were all positive for Neisseriameningitidis serogroup W 135. Complement 3 and 4levels (C3, C4) were 0.241 g/l (0.88-2.01) and 0.179g/l (0.16-0.4) respectively. Parents declined lumbarpuncture. She improved clinically over the first threedays. She became more conscious on the second day,afebrile after about 36 hours and was moving aboutfreely in her room. On the fourth day she developed asecondary rise of temperature which was associatedwith arthritis of the right shoulder and left knee.Tender subcutaneous nodular lesions consistent withvasculitis were seen on both thighs. ESR rose to 80Address correspondence to:Dr.Hanan Y. Al-Qattan, MPPCH, Kuwaiti Board (Ped), Department of Pediatrics, Farwaniya Hospital, Kuwait. Al-Surra, P.O. Box: 61, Postalcode 45701, Kuwait. Tel: (00965) 5212142, Mobile: 9638863, Fax: (00965) 5212142, E-mail: alkatan_07@hotmail.com