June 09-41-2.indd - Kma.org.kw

June 2009KUWAIT MEDICAL JOURNAL 141mm/h on the fifth day. CRP dropped to 60 mg/l onday three and showed secondary rise to 76.2 mg/l onthe fifth day. Intravenous dexamethasone in a doseof 0.4 mg/kg/day for three days and 0.2 mg/kg/day for the next four days as well as oral ibuprofen(40 mg/kg/day) were added to her treatment. Sheshowed remarkable improvement 24 hours later. Shewas discharged after completing 10 days of antibiotictreatment and remained well on follow up after 9 and12 months. Her C3 and C4 levels on follow up afternine months were less than 0.0583 g/l (0.88-2.01) and0.162 g/l (0.16-0.4) respectively. All her contacts exceptthe youngest sister (case 2) received oral antibioticprop hylaxis (rifampicin) and the quadrivalentmeningococcal vaccine.Case twoThis eight month-old girl, the youngest sisterof case one received neither prophylactic antibioticnor meningococcal vaccine. This infant developedfever, vomiting and skin rash four days followingthe onset of her sister’s illness. It was proven to bemeningococcemia with positive blood culture ofN.meningitidis serogroup W135. Complete bloodcount showed white cells of 7.5 x 10 9 /l, neutrophils60%, platelets 230 x 10 9 /l and ESR 25 mm/h. HerC3 and C4 were 0.3 (0.88-2) and 0.152 (0.16-0.4)respectively. She was treated with ceftriaxoneintravenously at a dose of 100 mg/kg/day for 10days. The infant showed initial improvement buton the fifth day she developed arthritis of the rightankle associated with secondary rise of temperatureand raised ESR of 70 mm/h. This was managed byibuprofen with a clinical diagnosis of an immuneassociatedarthritis.She was discharged home after 10 days andremained well on follow up after 9 and 12 months.Her C3 and C4 were 0.06 g/l and 0.166 g/l after ninemonths.DISCUSSIONA recent large study of meningococcal diseasein children showed that 15.3% of the patients hadIAC [2] . However, it is surprising that only 16 caseswere reported in the period between 1960 and 2003.The authors concluded that the incidence of IAC hasnot declined over the past 20 years [2] .IAC can present as arthritis, vasculitis, episcleritis,pericarditis or rarely nephritis. Risk factors for thedevelopment of IAC are severe disease, age of thepatient (being more common in adolescents oradults) [2] , serogroup W135 [6] and group C [7] .The two patients in our report had more than oneof these risk factors. Both of them had severe disease(meningococcemia), the organism was serogroupW135 and the older patient is a pre-adolescent.IAC usually develops 4-10 days after the onsetof meningococcal infection and presents with localmanifestations and a secondary rise in temperatureassociated with secondary increase in ESR andCRP [2] . This was well documented in our twopatients.Differential diagnosis should include secondaryinfection, subdural effusion, persistent infection,primary meningococcal arthritis and allergicreaction to medications.Careful and thorough physical examination willgive clues that aid in the diagnosis of the diseasewithout the necessity of extensive additionalinvestigations [2] .Case one developed arthritis of the rightshoulder and the left knee as well as vasculitisinvolving both thighs on day four with secondaryrise of temperature. There was no evidence ofsubdural effusion such as convulsions, headache orvomiting. There were no itchy skin rashes, no edemaor puffiness of eyelids. A second blood culture andsensitivity on the fifth day showed no growth.Case two developed meningococcemia most probablybecause she did not receive chemoprophylaxis. In factboth patients appeared to be more prone to developmeningococemia in view of their hypocomplementemicstate.Meningococcal vaccine was not given to casetwo considering that it is not immunogenic belowthe age of two years.Treatment of IAC depends on the site involved.Specific treatment for arthritis is generally notindicated except for pain relief and the prognosisis excellent. Pericarditis has a significant mortalityrate related to cardiac tamponade. The effusion oftenrequires treatment but occasionally it may resolvespontaneously. Therapy consists of salyicylates,steroids, pericardiocentesis, or a combination ofthese [2] . Cutaneous digital vasculitis associated withischemia can be treated with prostacycline analogueto obviate the need for amputation [8] .Both our cases were treated with nonsteroidalanti-inflammatory drugs (ibuprofen) for arthritis.However, dexamethasone was added to case one, asshe had cutaneous vasculitis in addition to arthritis.Both of them improved without complications whenreviewed at nine months and one year follow-up.CONCLUSIONDespite the lack of recent publications,IAC remains a well-defined complication ofmeningococcal infection. Arthritis is the mostcommon manifestation of IAC. In addition tolocal clinical manifestations, IAC presents withsecondary fever and secondary increased ESR andCRP. Thorough physical examination with minimal