MKSAP Quiz: Follow-up evaluation for meningococcal bacteremia
A 28-year-old woman undergoes follow-up evaluation after a recent hospitalization for meningococcal bacteremia. Lumbar puncture results during hospitalization were negative for meningitis. She completed a course of ceftriaxone 1 week ago and reports feeling well since stopping antibiotics. Following a physical exam, what is the most appropriate preventive measure?
A 28-year-old woman undergoes follow-up evaluation after a recent hospitalization for meningococcal bacteremia. Lumbar puncture results during hospitalization were negative for meningitis. She completed a course of ceftriaxone 1 week ago and reports feeling well since stopping antibiotics. Medical history is notable for gonococcal arthritis of her knee 2 years ago. She has a sister with a history of meningococcal meningitis. She takes no medications.
On physical examination, vital signs are normal. The remainder of the examination is unremarkable.
Which of the following is the most appropriate preventive measure?
A. Intravenous immune globulin
B. Plasma infusion
C. Prophylactic ciprofloxacin
D. Quadrivalent meningococcal conjugate vaccine
MKSAP Answer and Critique
The correct answer is D. Quadrivalent meningococcal conjugate vaccine. This content is available to MKSAP 18 subscribers as Question 71 in the Infectious Disease section. More information about MKSAP is available online.
The most appropriate preventive measure for this patient is immunization with the quadrivalent meningococcal conjugate vaccine. A personal history of recurrent Neisseria infection or history of infection in multiple family members suggests a deficiency in one of the terminal complement components that make up the membrane attack complex (MAC). The MAC comprises C5 to C9, and a deficiency in any of these constituents leads to an impaired ability to combat Neisseria infections, particularly N. meningitidis. Patients are at risk for recurrent meningococcal infection, often caused by unusual serogroups. For unclear reasons, infection in this population is often uncharacteristically mild. Evaluation for terminal complement deficiency is performed by quantitation of total hemolytic complement (CH50). If the CH50 is low, more specific testing for individual components of the MAC may be performed. Immunization is the mainstay of infection prevention in patients with defects in terminal complement. The Advisory Committee on Immunization Practices recommends use of a conjugate quadrivalent meningococcal vaccine as well as a vaccine active against serogroup B meningococcal infection, with a booster of the conjugate quadrivalent meningococcal vaccine given every 5 years for adults with terminal complement deficiency. These patients should also receive both pneumococcal (polysaccharide and conjugate) and Haemophilus influenzae type B vaccines.
Intravenous immune globulin does not have appreciable levels of complement and would not be useful for infection prevention in a patient with terminal complement deficiency.
Although plasma is rich in complement, plasma infusion is not a feasible long-term approach to repletion of complement levels. Additionally, such treatment would be associated with an increased risk of bloodborne diseases and the potential development of antibody against the missing component.
Prophylactic ciprofloxacin has a role in reducing the risk of meningococcal disease after close exposure to an infected person, but no data support using chronic prophylactic antibiotics in patients with terminal complement deficiencies. Instead, patients should be counseled to be vigilant for development of fever, rash, headache, or other symptoms concerning for Neisseria infection.
Key Point
- Immunization with the quadrivalent meningococcal conjugate vaccine is the mainstay of infection prevention in patients with terminal complement deficiency.