II. Epidemiology
- Most common in young adults and children with bimodal peak
- Age under 2 years accounts for 50% of cases
- Also peaks in teens
-
Incidence
- Among top 2 causes of Bacterial Meningitis in U.S. (other is Streptococcal Pneumoniae Meningitis)
- Up to 2800 cases per year per year in the U.S.
- One case per 100,000 people
- Exposure risks
- Sporadic cases are most common
- Outbreaks in close quarters (e.g. Dormitory)
III. Pathophysiology
- Neisseria Meningitidis
- Gram Negative Cocci in pairs (diplococci)
- Normal oral flora in 5-10% (provides carriers natural Immunity after age 2 years)
- Transmission
- Respiratory secretions passed via aerosol or contact
-
Polysaccharide capsule surrounds Neisseria Meningitidis
- Resistant to Phagocytosis in the absence of Opsonins (antibodies to capsule)
- Capsular Polysaccharides may become Antigens for Antibody response
- Serogroups are defined by the specific capsular Polysaccharides (13 have been defined)
- Meningitis is most commonly caused by serogroups A, B, C, as well as W-135, Y
-
Endotoxin
- Lipopolysaccharide Endotoxin is released from Meningococcus
- Triggers vascular necrosis, Petechiae, Hemorrhage and Sepsis
- IgA1 Protease
- Enzyme expressed by some pathologic Meningococcus
- Lyses IgA in half
- Pili
- Other pathogenic mechanisms
- Extracts iron from human Transferrin
IV. Risk Factors
- Infants age 6 months to 2 years
- Vertical transmission of maternal Antibody provides protection for first few months
- Living in college dormitory or military barracks
- High rates of exposure to Meningococcus carriers with a wide variety of strains
- More common in white males
- Tobacco use or passive Tobacco exposure
- Recent Upper Respiratory Infection
V. Precautions: Presentations may be cryptic
- Nuchal Rigidity may be absent
- Severe Upper Respiratory Infection may be only initial presentation
- Petechiae and fever confers a 10-15% risk of Meningococcemia
- May present with concurrent other infections (e.g. Otitis Media, Conjunctivitis, Pneumonia)
VI. Symptoms
- Headache
- Myalgias or Arthralgias
- Vomiting
VII. Signs
- See Meningitis
- Fever
- Nuchal Rigidity may be absent
- Rash (70% of cases)
- Centripetal Rash (starts on distal extremities, wrists and ankles)
- May start with light pink maculopapular rash (may even blanch initially)
- Petechiae (non-blanching) are common
- If biopsied and cultures, petechial lesions will yield diplococci
- Fulminant Purpura (20% of cases)
- Central gun-metal gray center
VIII. Findings: Clinical Syndromes
- Meningococcemia
- Bacteremia resulting in toxic appearance, fever, chills, myalgias and petechial rash
- Waterhouse-Friderichsen Syndrome
- Fulminant Meningococcemia with bilateral adrenal Hemorrhage and Adrenal Insufficiency
- Presents with rapid progression within hours, Septic Shock, DIC, coma and very high mortality
-
Bacterial Meningitis
- Most common presentation of Neisseria Meningitidis, typically combined with Meningococcemia
IX. Labs
- See Bacterial Meningitis
-
Gram Stain
- Neisseria Meningitidis appears as Gram Negative diplocci under microscopy
- Each coccus is Kidney bean shaped, with pairs facing and overlapping one another
- Polymerase chain reaction (PCR)
- Neisseria Meningitidis may be identified from body fluids (e.g. blood, CSF)
- Culture
- Blood Agar Plates ("Chocolate agar")
- Named for the brown coloration after agar plates are heated
- Neisseria grow well on blood agar
- Thayer-Martin VCN Media
- Chocolate agar with 3 antimicrobials: Vancomycin, Colistin (Polymixin), Nystatin
- Antimicrobials kill all Gram Negatives except Neisseria, and all Gram Positives and fungi
- High CO2 Environment
- High CO2 concentrations further selects for Neisseria growth
- Acid production from Maltose Metabolism
- Distinguishes Neisseria Meningitidis (metabolizes maltose) from N. gonorrhoeae
- Blood Agar Plates ("Chocolate agar")
X. Management
- See Bacterial Meningitis Management
- If considered, obtain Lumbar Puncture and start empiric Antibiotics immediately
- Manage shock
- See Sepsis (covers fluid boluses and pressor use)
- Consider adding Corticosteroids to the Antibiotic regimen
- Meningococcus may be associated with adrenal infarction Hemorrhage
XI. Complications
- Waterhouse-Friderichsen Syndrome
- Shock, Petechiae and adrenal infarction (bilateral adrenal Hemorrhage)
XII. Prevention
- See Meningococcal Vaccine
-
Vaccination does on confer 100% protection (misses some sub-groups)
- Known exposures to Meningococcal Meningitis need Antibiotic prophylaxis despite Immunization
XIII. Prevention: Post-exposure Prophylaxis
- Indications
- Exposure from 7 days before onset of illness until 24 hours after Antibiotics initiated AND
- Significant exposure (treat if any concern)
- Household contacts (up to 800 fold increase in risk, up to 1 in 250 will be infected)
- Child care centers
- Oral secretion exposure (e.g. health care worker without adequate protection)
- Long-distance (>8 hours) travel next to source
- Prophylaxis options (pick one): Start as soon as possible (up to 14 days after exposure)
- Rifampin
- Age <1 month: 5 mg/kg orally every 12 hours for 2 days
- Age >1 month: 10 mg/kg (max: 600) orally every 12 hours for 2 days
- Adults: 600 mg orally every 12 hours for 2 days
- Ciprofloxacin (adults) 500 mg orally for one dose
- Ceftriaxone (Rocephin)
- Age <15 years: 125 mg IM for one dose
- Age >15 years: 250 mg IM for one dose
- Rifampin
- References
XIV. Prognosis
- Mortality: Approaches 14% despite treatment
- Serious residual morbidity approaches 19%
XV. References
- Claudius in Herbert (2012) EM:Rap 12(11): 8
- Kimmel (2005) Am Fam Physician 72:2049-56 [PubMed]
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Related Studies
| Definition (MSH) | A fulminant infection of the meninges and subarachnoid fluid by the bacterium NEISSERIA MENINGITIDIS, producing diffuse inflammation and peri-meningeal venous thromboses. Clinical manifestations include FEVER, nuchal rigidity, SEIZURES, severe HEADACHE, petechial rash, stupor, focal neurologic deficits, HYDROCEPHALUS, and COMA. The organism is usually transmitted via nasopharyngeal secretions and is a leading cause of meningitis in children and young adults. Organisms from Neisseria meningitidis serogroups A, B, C, Y, and W-135 have been reported to cause meningitis. (From Adams et al., Principles of Neurology, 6th ed, pp689-701; Curr Opin Pediatr 1998 Feb;10(1):13-8) |
| Concepts | Disease or Syndrome (T047) |
| MSH | D008585 |
| ICD9 | 036.0 |
| ICD10 | A39.0 |
| SnomedCT | 28476005, 186363003, 154307005, 192644005 |
| English | Meningitis, Meningococcal, Meningitis, Meningococcic, Meningococcal Meningitis, MENINGOCOCCAL MENINGITIS, MENINGITIS MENINGOCOCCAL, meningococcal meningitis (diagnosis), meningococcal meningitis, Neisseria meningitides meningitis, Meningitis meningococcal, Meningitis, Meningococcal [Disease/Finding], Meningitis;meningococcal, meningitis meningococcal, meningococcic meningitis, epidemics meningitis, Epidemic meningitis, Meningococcal meningitis (disorder), Meningococcal meningitis (disorder) [Ambiguous], Meningococcal meningitis |
| French | MENINGITE MENINGOCOCCIQUE, Méningite à Neisseria meningitides, Méningite cérébro-spinale, Méningite méningococcique, Méningite cérébrospinale à méningocoques, Méningite cérébrospinale, Méningite à Neisseria meningitidis, Méningite à méningocoques, Méningite à méningocoque |
| Portuguese | MENINGITE MENINGOCOCICA, Meningite a Neisseria meningitidis, Meningite Meningoccócica, Meningite por Meningococos, Meningite meningocócica, Meningite Meningocócica |
| Italian | Meningite menigococcica, Meningite da Neisseria meningitides, Meningite meningococcica |
| Dutch | meningokokkenmeningitis, Neisseria meningitides meningitis, Meningitis door meningokokken, meningokokkenhersenvliesontsteking, Meningitis, meningokokken, Meningokokkenmeningitis |
| German | Neisseria meningitides Meningitis, Meningokokken-Meningitis, MENINGITIS DURCH MENINGOKOKKEN, Meningokokkenmeningitis, Meningitis durch Meningokokken, Meningitis, Meningokokken- |
| Spanish | Meningitis por Neisseria meningitidis, Meningitis Meningocóccica, meningitis epidémica, meningitis meningocócica (concepto no activo), meningitis meningocócica (trastorno), meningitis meningocócica, Meningitis meningocócica, Meningitis Meningocócica |
| Swedish | Hjärnhinneinflammation, meningokock |
| Japanese | ｽﾞｲﾏｸｴﾝｷﾝｾｲｽﾞｲﾏｸｴﾝ, 髄膜炎-髄膜炎菌性, 流行性脳脊髄膜炎, 流行性髄膜炎, 髄膜炎菌性脳脊髄膜炎, 髄膜炎菌性髄膜炎, 脳脊髄膜炎-流行性, 脳脊髄膜炎-髄膜炎菌性, 髄膜炎-流行性 |
| Czech | meningitida meningokoková, Meningitida vyvolaná Neisseria meningitidis, Meningokoková meningitida |
| Finnish | Meningokokkimeningiitti |
| Russian | MENINGIT MENINGOKOKKOVYI, МЕНИНГИТ МЕНИНГОКОККОВЫЙ |
| Korean | 수막알균 수막염 |
| Croatian | MENINGITIS, MENINGOKOKNI |
| Polish | Meningokokowe zapalenie opon mózgowo-rdzeniowych, Zapalenie opon meningokokowe |
| Hungarian | Meningococcus okozta agyhártyagyulladás, meningococcalis meningitis, Neisseria meningitidis meningitis |
| Norwegian | Meningokokkmeningitt |
Ontology: Meningococcal Infections (C0025303)
| Definition (MEDLINEPLUS) |
Meningococci are a type of bacteria that cause serious infections. The most frequent is meningitis, which is an inflammation of the thin tissue that surrounds the brain and spinal cord. Meningococci can also cause other problems, including a serious bloodstream infection called sepsis. Meningococcal infections can be spread from person to person. They are common in people living in close quarters, such as college students or military recruits. In its early stages, you may have flu-like symptoms and a stiff neck. But the disease can progress quickly and can be fatal. Early diagnosis and treatment are extremely important. Treatment is with antibiotics. Since the infection spreads from person to person, family members may also need to be treated. A vaccine can prevent meningococcal infections. |
| Definition (MSH) | Infections with bacteria of the species NEISSERIA MENINGITIDIS. |
| Concepts | Disease or Syndrome (T047) |
| MSH | D008589 |
| ICD9 | 036.9, 036 |
| ICD10 | A39 , A39.9 |
| SnomedCT | 186377000, 187328003, 154306001, 23511006 |
| English | Infections, Meningococcal, Meningococcal Infections, Infection, Meningococcal, Meningococcal Infection, Meningococal infectn,unspcf, Meningococcal infection, unspecified, [X]Meningococal infectn,unspcf, [X]Meningococcal infection, unspecified, INFECT MENINGOCOCCAL, MENINGOCOCCAL INFECT, meningococcal infection, meningococcal infection (diagnosis), Neisseria meningitidis infection NOS, Unspecified meningococcal infection, Meningococcal infect NOS, Meningococcal disease NOS, Meningococcal Infections [Disease/Finding], disease meningococcal, meningococcal diseases, meningococcal disease, meningococcal infections, Infection;meningococcal, Meningococcal infection NOS (disorder), [X]Meningococcal infection, unspecified (disorder), Meningococcal infection (disorder), Meningococcal infectious disease, Meningococcal infection, Infection due to Neisseria meningitidis, Meningococcal infectious disease (disorder), infection; meningococcal, meningococcal; infection, Meningococcal infection, NOS, Meningococcal infectious disease, NOS, Meningococcal infection NOS, Meningococcal diseases |
| Italian | Infezione meningococcica, Infezione meningococcica, non specificata, Infezione meningococcica non specificata, Infezione da Neisseria meningitidis NAS, Infezioni meningococciche |
| Dutch | Neisseria meningitidisinfectie NAO, meningokokkeninfectie, niet-gespecificeerd, niet-gespecificeerde meningokokkeninfectie, infectie; meningokokken, meningokokken; infectie, Meningokokkeninfectie, niet gespecificeerd, meningokokkeninfectie, Infectie, meningokokken-, Infecties, meningokokken-, Meningokokkeninfectie, Meningokokkeninfecties |
| French | Infection méningococcique, non précisée, Infection méningococcique non précisée, Infection à méningocoques SAI, Infection méningococcique, Infections méningococciques, Infections à méningocoques, Méningococcies |
| German | Neisseria meningitidis-Infektion NNB, unspezifische Meningokokken-Infektion, Meningokokken-Infektion unspezifisch, Meningokokkeninfektion, nicht naeher bezeichnet, Meningokokkeninfektion, Meningokokkeninfektionen |
| Portuguese | Infecção a Neisseria meningitidis NE, Infecção meningocócica NE, Infecção miningocócica NE, Infecções por Meningococos, Infecções por Neisseria meningitidis, Infecção meningocócica, Infecções Meningocócicas |
| Spanish | Infección meningocócica no especificada, Infección por Neisseria meningitidis NEOM, [X]infección meningocócica, no especificada, [X]infección meningocócica, no especificada (trastorno), infección meningocócica, SAI (trastorno), infección meningocócica, SAI, Infecciones por Meningococos, Infecciones por Neisseria meningitidis, enfermedad infecciosa meningocócica (trastorno), enfermedad infecciosa meningocócica, infección meningocócica (trastorno), infección meningocócica, infección por Neisseria meningitidis, Infección meningocócica, Infecciones Meningocócicas |
| Japanese | 髄膜炎菌感染, 髄膜炎菌感染、詳細不明, 髄膜炎菌感染ＮＯＳ, 詳細不明の髄膜炎菌感染, ｽﾞｲﾏｸｴﾝｷﾝｶﾝｾﾝNOS, ｼｮｳｻｲﾌﾒｲﾉｽﾞｲﾏｸｴﾝｷﾝｶﾝｾﾝ, ｽﾞｲﾏｸｴﾝｷﾝｶﾝｾﾝｼｮｳｻｲﾌﾒｲ, ｽﾞｲﾏｸｴﾝｷﾝｶﾝｾﾝ, 髄膜炎菌感染症 |
| Swedish | Meningokockinfektioner |
| Czech | Meningococcus - infekce, Meningokoková infekce, Infekce Neisseria meningitidis NOS, Meningokoková infekce, blíže neurčená, Blíže neurčená meningokoková infekce |
| Finnish | Meningokokki-infektiot |
| Russian | MENINGOKOKKOVYE INFEKTSII, МЕНИНГОКОККОВЫЕ ИНФЕКЦИИ |
| Korean | 수막알균 감염, 상세불명의 수막알균 감염 |
| Croatian | MENINGOKOKNE INFEKCIJE |
| Polish | Zakażenie Neisseria meningitidis, Infekcja meningokokowa, Infekcje meningokokowe, Zakażenia meningokokowe |
| Hungarian | nem meghatározott meningococcalis fertőzés, meningococcus fertőzés, Neisseria meningitidis fertőzés k.m.n., meningococcus fertőzés, nem meghatározott |
| Norwegian | Meningokokkinfeksjoner |
Ontology: Neisseria meningitidis (C0027575)
| Definition (NCI_CDISC) | Any bacterial organism that can be assigned to the species Neisseria meningitidis. |
| Definition (NCI) | A species of aerobic, Gram-negative, diplococci shaped bacteria assigned to the phylum Proteobacteria. This species is catalase and oxidase positive, non-hemolytic, non-pigmented, does not reduce nitrate or nitrite, does not synthesize polysaccharides, grows on blood, chocolate, or Muller-Hinton agar, and produces acid from glucose and maltose but not fructose, sucrose, mannose, or lactose. N. meningitidis, known commonly as meningococcus, is the causative agent of cerebrospinal meningitis, but is also associated with other human infections, but can be commensal in the oropharynx and nasopharynx of carriers. |
| Definition (MSH) | A species of gram-negative, aerobic BACTERIA. It is a commensal and pathogen only of humans, and can be carried asymptomatically in the NASOPHARYNX. When found in cerebrospinal fluid it is the causative agent of cerebrospinal meningitis (MENINGITIS, MENINGOCOCCAL). It is also found in venereal discharges and blood. There are at least 13 serogroups based on antigenic differences in the capsular polysaccharides; the ones causing most meningitis infections being A, B, C, Y, and W-135. Each serogroup can be further classified by serotype, serosubtype, and immunotype. |
| Definition (CSP) | gram-negative, aerobic bacteria; a commensal and pathogen only of humans, and can be carried asymptomatically in the nasopharynx; when found in cerebrospinal fluid it is the causative agent of cerebrospinal meningitis; also found in venereal discharges and blood; there are at least 13 serogroups based on antigenic differences in the capsular polysaccharides; the ones causing most meningitis infections being A, B, C, Y, and W-135; each serogroup can be further classifed by serotype, serosubtype, and immunotype. |
| Concepts | Bacterium (T007) |
| MSH | D009345 |
| SnomedCT | 17872004 |
| LNC | LP16660-0, MTHU006713 |
| English | Micrococcus intracellularis, Meningococcus, Neisseria meningitidis, N. meningitidis, neisseria menningitidis, Neisseria meningitidis (Albrecht and Ghon 1901) Murray 1929, Beta-Lactamase Negative Neisseria meningitidis, meningitidis n, meningitidis neisseria, meningococcus, n. meningitidis, neisseria meningitidis, NEISSERIA MENINGITIDIS, Diplokokkus intracellularis meningitidis, Micrococcus meningitidis, Micrococcus meningitidis cerebrospinalis, Neisseria weichselbaumii, BETA-LACTAMASE NEGATIVE NEISSERIA MENINGITIDIS, Neisseria intracellularis, Neisseria meningitidis (organism) |
| French | Meningococcus, Méningocoque, Neisseria meningitidis |
| Swedish | Neisseria meningitidis |
| Czech | Neisseria meningitidis |
| Finnish | Meningokokki |
| Italian | Meningococco, Neisseria meningitidis |
| Russian | MENINGOKOKKI, NEISSERIA MENINGITIDIS, МЕНИНГОКОККИ |
| Japanese | 髄膜炎菌, ナイセリア･メニンジティディス, ナイセリアメニンギチジス |
| Croatian | NEISSERIA MENINGITIDIS, MENINGOKOK |
| Polish | Dwoinki zapalenia opon mózgowych, Ziarenkowce oponowe, Neisseria meningitidis, Meningokoki |
| Norwegian | Neisseria meningitidis, Meningococcus |
| Spanish | Neisseria meningitidis (organismo), meningococo, Neisseria meningitidis, Meningococcus |
| German | Meningokokkus, Neisseria meningitidis |
| Dutch | Meningococcus, Meningokokken, Neisseria meningitidis |
| Portuguese | Meningococcus, Neisseria meningitidis |
Ontology: Waterhouse-Friderichsen Syndrome, Meningococcal (C1403891)
| Concepts | Disease or Syndrome (T047) |
| MSH | D014884 |
| ICD9 | 036.3 |
| ICD10 | A39.1 |
| SnomedCT | 154309008, 36102002 |
| English | Waterhouse-Friderichsen syndrome, meningococcal, Ac adr insuf + meningococ sept, Meningo haemorr adrenalitis, Waterhouse-Friderichsen synd, Friderichsen-Waterhouse syndrome, meningococcemia with Waterhouse-Friderichsen syndrome (diagnosis), meningococcemia with Waterhouse-Friderichsen syndrome, Meningococc adrenal synd, Meningococcic adrenal syndrome, Waterhouse-Friderichsen disease, Waterhouse-Friderichsen syndrome, Meningococcal Waterhouse-Friderichsen syndrome, Meningococcal adrenal syndrome, Meningococcal hemorrhagic adrenalitis, Acute adrenal insufficiency with meningococcal septicaemia, Acute adrenal insufficiency with meningococcal septicemia, Meningococcal haemorrhagic adrenalitis, Waterhouse-Friderichsen syndrome (disorder), infection; meningococcal, adrenalitis, hemorrhagic (manifestation), meningococcus; infection, adrenalitis, hemorrhagic (manifestation), Waterhouse-Friderichsen syndrome, NOS, Fulminant Meningococcal Sepsis with Adrenal Apoplexy, Adrenalitides, Meningococcal Hemorrhagic, Adrenalitis, Meningococcal Hemorrhagic, Hemorrhagic Adrenalitides, Meningococcal, Hemorrhagic Adrenalitis, Meningococcal, Meningococcal Hemorrhagic Adrenalitides, Meningococcal Hemorrhagic Adrenalitis, Meningococcal Waterhouse Friderichsen Syndrome, Syndrome, Meningococcal Waterhouse-Friderichsen, Waterhouse-Friderichsen Syndrome, Meningococcal, Meningococcal Waterhouse-Friderichsen Syndrome, Waterhouse-Friderichsen syndrome NOS |
| Italian | Sindrome di Waterhouse-Friderichsen, Sindrome di Friderichsen-Waterhouse, Sindrome Waterhouse-Friderichsen, meningococcica, Sepsi meningococcica fulminante con apoplessia surrenalica, Sindrome di Waterhouse-Friderichsen meningococcica |
| Dutch | syndroom van Waterhouse-Friderichsen, meningokokken, infectie; meningokokken, adrenalitis, hemorragisch, meningokokken; infectie, adrenalitis, hemorragisch, Syndroom van Waterhouse-Friderichsen, syndroom van Waterhouse-Friderichsen, Hemorragische meningokokkenadrenalitis, Meningokokkensepsis, fulminante |
| French | Syndrome de Waterhouse-Friderichsen, méningococcique, Syndrome de Friderichsen-Waterhouse, Purpura Fulminans à méningocoques, Syndrome de Waterhouse-Friderichsen méningococcique, Syndrome de Waterhouse-Friderichsen, Surrénalite hémorragique à méningocoques, Syndrome méningococcique surrénalien |
| German | Waterhouse-Friderichsen Syndrom, Meningokokken, Friderichsen-Waterhouse-Syndrom, Waterhouse-Friderichsen-Syndrom durch Meningokokken, Waterhouse-Friderichsen-Syndrom, Waterhouse-Friderichsen Syndrom, Fulminante Meningokokkensepsis mit Nebennierenapoplexie, Meningokokkensepsis, fulminante, Hämorrhagische Adrenalitis durch Meningokokken, Hämorrhagische Entzündung der Nebenniere durch Meningokokken |
| Portuguese | Síndrome de Waterhouse-Friderichsen meningocócica, Sepse Meningocócica Fulminante com Apoplexia Suprarrenal, Síndrome de Waterhouse-Friderichsen, Adrenalite Meningocócica Hemorrágica |
| Spanish | Síndrome de Waterhouse Friederichsen, Síndrome de Waterhouse-Friderichsen meningocócico, adrenalitis hemorrágica meningocócica, enfermedad de Waterhouse - Friderichsen, síndrome de Waterhouse - Friderichsen (trastorno), síndrome de Waterhouse - Friderichsen meningocócico, síndrome de Waterhouse - Friderichsen, síndrome suprarrenal meningocócico, Síndrome de Waterhouse-Friederichsen, Adrenalitis Meningocócica Hemorrágica, Sepsis Meningocóccica Fulminante con Apoplejia Suprarrenal |
| Japanese | フリーデリクセン・ウォーターハウス症候群, ウォーターハウス・フリーデリクセン症候群, ウォータハウス・フリデリクセン症候群、髄膜炎菌性, ｳｫｰﾀﾊｳｽﾌﾘﾃﾞﾘｸｾﾝｼｮｳｺｳｸﾞﾝｽﾞｲﾏｸｴﾝｷﾝｾｲ, ﾌﾘｰﾃﾞﾘｸｾﾝｳｫｰﾀｰﾊｳｽｼｮｳｺｳｸﾞﾝ, ｳｫｰﾀｰﾊｳｽﾌﾘｰﾃﾞﾘｸｾﾝｼｮｳｺｳｸﾞﾝ |
| Czech | Waterhouse-Friderichsenův syndrom, Meningokokový Waterhouse-Friderichsenův syndrom, Friderichsen-Waterhouseův syndrom |
| Korean | 워터하우스-프리데릭센 증후군 |
| Hungarian | Waterhouse-Friderichsen-syndroma, meningococcalis, Waterhouse-Friderichsen-syndroma, Friderichsen-Waterhouse syndroma |
| Norwegian | Fulminant meningokokksepsis med binyreinfarkt, Hemoragisk meningokokkadrenalitt |
