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Meningococcal infection is a global health problem worldwide, which is caused by high mortality rates, difficulties in early diagnosis due to the nonspecific nature of the initial manifestations of the disease, and the unpredictability of the course. Invasive forms of infection are registered mainly in children of the first five years of life, which further actualizes this disease. In recent decades, the Republic of Belarus has seen a steady decline in morbidity rates, but given the epidemiological features of meningococcal infection (epidemiological ups and downs with a frequency of 10—20 years), experts are aware of the possible scale of the problem in the coming years. The article presents the results of the analysis (for the last 20 years) structures of invasive forms of meningococcal infection and clinical and laboratory features of meningococcal sepsis in children according to the data of the «City Children's Infectious Clinical Hospital» of Minsk.

Appearance of non-blanching rash in a child is a common reason to seek medical attention. However, most children with non-blanching rash are well from benign self-limiting illness. Only minority of these children have a serious underlying cause such as invasive meningococcal sepsis or malignancy. Therefore a huge responsibility rests on the frontline clinician to unpick the seriously unwell child or the child who could potentially deteriorate from a cohort of all children with non-blanching rash. A good history and examination with specific focus on distribution of non-blanching rash together with vital parameters, baseline blood investigations such as full blood count, clotting, peripheral smear all help to support clinical diagnosis. Presence of bruising and petechial rash over soft tissue areas in a well child in the absence of a clear history or explanation should alert the clinician to think of non-accidental injury in their differential diagnosis.

A boy in his mid teens presented to the dermatology department with a one week history of non-pruritic rash on his legs, and abdominal and bilateral knee pain. On examination, palpable purple papules were present on both legs, extending from the ankles to the thighs (fig 1). Other examination findings were unremarkable. The boy reported no history of upper respiratory tract infection in the four weeks before symptom onset. Table 1 shows the results of relevant blood and urine investigations. Fig 1 Palpable purpura on lower legs View this table: Table 1 Results of relevant blood and urine investigations Several conditions were considered unlikely: meningococcal sepsis, because of the absence of fever, neurological symptoms, and biomarkers of bacterial infection; thrombocytopenia, because the platelet count was within normal range; and coagulopathy, …

Meningokokna sepsa spada u skupinu invazivnih meningokoknih bolesti i zbog svoje naravi oduvijek je izazivala poseban oprez među kliničarima. Uzrokovana je gram negativnim diplokokom, Neisseriom meningitidis i to najčešće serogrupama A, B, C, X, Y i W135. Zahvaljujući raznovrsnim čimbenicima virulencije meningokok vrlo uspješno savladava imunološke napore organizma domaćina i uzrokuje bolest koja najčešće pogađa djecu dojenačke dobi. Klinička slika u početku ove bolesti nije specifična. Hemoragični osip koji se nekada smatrao patognomoničnim znakom ne razvija se u gotovo četvrtine bolesnika, a isprva ne mora biti petehijalan niti blijediti na pritisak. Simptomi koji sugeriraju razvoj sepse uključuju jake bolove u nogama, hladne okrajine te blijedu i marmoriziranu kožu. Liječenje predstavlja složeni medicinski postupak koji uključuje antibiotsku i suportivnu terapiju. S obzirom da bolest može u kratkom periodu promijeniti svoj karakter i ozbiljnost, opravdano je administrirati antibiotik (ceftriakson) već pri najmanjoj sumnji. Iako se radi o rijetkoj bolesti, zbog visoke smrtnosti, učestalosti komplikacija i težine posljedica koje može ostaviti u preživjelih, meningokokna sepsa i dalje predstavlja javnozdravstveni problem. Usprkos postojanju učinkovitih cjepiva, u Hrvatskoj se primarna prevencija aktivnom imunizacijom ne provodi rutinski, odnosno nije sastavnica aktualnog kalendara cijepljenja. Cilj ovog rada jest osvijestiti činjenicu da u diferencijalno dijagnostičkom razmišljanju kod nejasnog febrilnog stanja u djeteta s poremećenim općim stanjem uvijek treba imati na umu meningokoknu bolest., Meningococcal sepsis belongs to the group of invasive meningococcal diseases and due to its nature has always caused special caution among clinicians. It requires urgent recognition of symptoms and adequate care, often in intensive care units. It is caused by gram-negative diplococci, Neisseria meningitidis, most often in serogroups A, B, C, X, Y and W135. Due to various virulence factors, meningococcus very successfully overcomes the immune efforts of the host. The disease most commonly affects infants. The clinical presentation at the beginning of the disease is not specific. Hemorrhagic rash once considered a pathognomonic sign, does not develop in nearly a quarter of patients, and may not initially be petechial. Symptoms that suggest the development of sepsis include severe pain in the legs, cold extremities and pale skin. Treatment includes complex medical procedures like antibiotic and supportive therapy. Since the disease can change its character and severity in a short period of time, it is rational to administer an antibiotic (ceftriaxone) even if there is slightest suspicion. Despite the fact that it is a rare disease, due to high mortality, frequency of complications and severity of the consequences in survivors, meningococcal sepsis remains a public health concern. In Croatia primary prevention by active immunization is not carried out routinely, it is not a component of the current vaccination calendar. The aim of this paper is to raise awareness of the fact that meningococcal disease should always be kept in mind in differential diagnostic thinking in case of unclear febrile condition in a child with a poor general condition.

Symmetrical peripheral gangrene (SPG) is a rare complication of septicaemia and disseminated intravascular coagulation (DIC) characterised by distal ischaemia in two or more extremities without large vessel obstruction. SPG has high mortality and morbidity rates, though consensus guidelines for management have yet to be produced. We herein present the case of a 28-year-old woman with meningococcal septicaemia complicated with extensive bilateral upper and lower limb SPG. We discuss the various management options of SPG. While reported cases are scarce in the literature, early recognition of sepsis and prompt withdrawal of vasoconstrictors in an intensive care setting, combined with timely heparinisation, appear to be the most common management strategy thus far.

Diagnosing sepsis at postmortem is challenging. With respect to meningococcal sepsis, the postmortem microbiological identification of Neisseria meningitidis is nearly always due to true infection, including in cases of decomposition. Previous case series and case reports were able to isolate N. meningitidis in vitreous humor in adult deaths from meningococcal sepsis when blood and/or cerebrospinal fluid was unavailable. It was suggested that vitreous humor polymerase chain reaction (PCR) may be useful in the diagnosis of meningococcal sepsis. We describe a fatal case of meningococcal sepsis in a 5-month-old infant where N. meningitidis was detected in vitreous humor, cerebrospinal fluid, and blood through PCR. The presented case report gives further evidence in the potential use of vitreous PCR analysis in suspected meningococcal sepsis, particularly in the pediatric population.

Meningococcal infection is caused by the bacterium Neisseria meningitidis (also termed meningococcus). Invasive meningococcal disease remains a rare infectious disease not only with high mortality but also with important morbidity and remains as a leading cause of sepsis and septic shock. The pathogenic mechanisms of microcirculatory disorders in meningococcal septic shock have been subject to controversy. This article presents the results of a study of 11 paediatric patients’ (4 boys and 7 girls) with meningococcal septic shock (Group I) who were hospitalized at the Regional Children's Infectious Hospital from 2009 to 2011. The average age of the patients was 37.4 ± 8.4 mo. Septic shock was diagnosed according to International Pediatric Sepsis Consensus Conference: definitions of criteria for sepsis and organ dysfunction in paediatrics. Heart rate, respiratory rate, systolic blood pressure, diastolic blood pressure, average blood pressure, SpO 2 were monitored. The cardiac output, ejection fraction, fraction shortening, stroke volume were measured by ultrasound in M-mode by Teichholz method. Blood circulation in the a. mesenterica , a. hepatica , a. lienalis , a. renal sinister , v. porta , v. lienalis , v. renal sinister was determined by impulse Doppler’s wave. Acid-base and electrolytes level in serum, nitric oxide (NO), endothelin I, creatinine, C-reactivity protein and lactate blood level were measured. The control group consisted of 21 healthy children (9 boys and 12 girls), aged 37.5 ± 5.4 mo. in average (Group II). We used t-criteria (Student’s) and correlation with R-criteria (Spearmen) for statistical analysis. The data showed a statistically significant lower fraction of ejection, fraction of shortening, stroke volume in Group I. Moreover, our data showed a statistically high level of mesenterial and portal blood flow rate and high pulse index in v. renal sinister compared to healthy children. The blood level of NO was increased in Group I as well as in Group II. Direct correlations were determined between the level of NO and mesenteric, hepatic arterial and venous blood flow rate. Statistically significant inverse correlations between the level of NO and pulse resistive index in splanchnic vessels were discovered as well as inverse correlations between the NO level and the indicator of the severity of condition on PRISM scale (r = –0.952). At the same time, we have found no correlation between splanchnic circulation value and cardiac output. Based on the results of this study, we consider that NO has organ protective effects in children with meningococcal sepsis. Future research should aim to introduce new strategies of intensive care for patients with meningococcal septic shock with early use of inotrope and NO-donor therapy in fluid restriction combination.

Emergencies occur infrequently in primary care, and when they do can be daunting for those involved, particularly those who have a non-clinical background. Previous work has described the importance of extending basic life support training to include management of emergencies using the available team and facilities.1 Simulating waiting room emergencies has been demonstrated to increase confidence in the clinical team in managing these challenging situations,2 but we are not aware of publications supporting the use of simulation in the wider primary care team including non-clinical colleagues. Northumbria Primary Care (NPC) is an innovative collaboration between six General Practices and Northumbria Healthcare NHS Foundation Trust (NHFT), serving a population of over 40 000 patients. With the aim of increasing confidence in management of potential encountered medical emergencies in primary care, a shared simulation programme for the clinical and non-clinical multidisciplinary team was developed at the Dinwoodie Assessment and Simulation Hub within NHFT. This state-of-the-art facility consists of multiple simulation areas, including consultation rooms and a waiting area, and several low-fidelity and high-fidelity manikins, which were used to recreate potential primary care emergencies. A programme was developed based on emergencies that may be encountered in a primary care environment, including meningococcal sepsis in a baby, myocardial infarction (MI) leading to cardiac arrest and anaphylaxis to a vaccine (table 1). View this table: Table 1 Scenarios used …

A patient with well-controlled HIV-1 infection presented with fever and rigors, a widespread maculopapular rash, and severe generalised arthralgia. Sepsis of unknown aetiology was diagnosed, and treatment with broad-spectrum antimicrobials commenced. Following initial clinical improvement, a right knee septic arthritis developed. Microscopy and culture of the joint aspirate were negative for organisms but 16S rDNA PCR identified Neisseria meningitidis DNA, subsequently verified as capsular genogroup C, thus confirming a diagnosis of disseminated meningococcal sepsis with secondary septic arthritis.

The description of invasive meningococcal disease that is provoked by Neisseria meningitidis (Nm) is frequently restricted to meningitis. However, a wide panel of clinical presentations can be encountered including severe forms with intense inflammatory reaction leading to multi-organ failure. Several human factors are involved in the development of invasive infections such as transferrin, factor H or CEACAM1. In this study, we used an experimental meningococcal infection in transgenic mice expressing the human transferrin to show multi-organ infection. Mice were infected by an intraperitoneal injection of bacterial suspension (1.5 × 107 colony-forming unit/mouse) of a bioluminescent serogroup C strain belonging to the clonal complex ST-11. Dynamic imaging and histological analysis were performed. The results showed invasion of tissues by Nm with bacteria observed, outside blood vessels, in the kidneys, the heart and the brain as well as skin involvement. These data further support the systemic aspect of invasive meningococcal disease with involvement of several organs including skin as in humans. Thus, our model can be used to study severe forms of meningococcal invasive infections with multi-organ failure.

Introduction : Abu Bakr Mohammad Ibn Zakariya Al‑Razi (865–925 CE), who was known as “Rhazes” in the west, was a famous scientist of medieval ages. He has more than 200 books and treatises. His masterpiece on medicine “ Kitab Al‑Hawi Fi Al‑Tibb ” contains around 900 case reports. Some of the diseases which seem to be recently reported have been stated previously, but not well described. Considering symptoms of the patient described at that time, differential diagnosis will be discussed. Case presentation : Rhazes described a patient with bilious fever. He had developed bloody urine and stool on the fourth day and fatigue. Subsequently, the patient’s urine and stool color turned into dark and black, respectively, and died the following day. According to Rhazes attitude, it was malignant measles. Meyerhof in his book has referred to post‑measles acute glomerulonephritis, but more appropriate differential diagnoses are compatible with this patient. Discussion: One of the best diagnoses for this case can be Weil’s syndrome. Presence of fever, icterus, hemorrhage and renal injury, all suggest Weil’s syndrome without pulmonary involvement. The other probable diagnosis is thrombotic thrombocytopenic purpura (TTP). Meningococcal sepsis is the other possible diagnosis. Conclusion : To sum up, as three compatible diseases with the case; have been described more than a thousand years after Rhazes (Weil’s syndrome 1886, TTP 1925 and meningococcemia 1805); if the case is either Weil’s or TTP or meningococcal sepsis, it is the frst report of the disease in the world by Rhazes. Keywords : Malignant measles, meningococcemia, post‑measles acute glomerulonephritis, Rhazes, thrombotic thrombocytopenic purpura, Weil’s disease

Pediatric meningococcal sepsis often results in morbidity and/or death, especially in young children. Our understanding of the reasons why young children are more susceptible to both the meningococcal infection itself and a more fulminant course of the disease is limited. Immunoglobulin G (IgG) is involved in the adaptive immune response against meningococcal infections, and its effector functions are highly influenced by the glycan structure attached to the fragment crystallizable (Fc) region. It was hypothesized that IgG Fc glycosylation might be related to the susceptibility and severity of meningococcal sepsis. Because of this, the differences in IgG Fc glycosylation between 60 pediatric meningococcal sepsis patients admitted to the pediatric intensive care unit and 46 age-matched healthy controls were investigated, employing liquid chromatography with mass spectrometric detection of tryptic IgG glycopeptides. In addition, Fc glycosylation profiles were compared between patients with a severe outcome (death or the need for amputation) and a nonsevere outcome. Meningococcal sepsis patients under the age of 4 years showed lower IgG1 fucosylation and higher IgG1 bisection than age-matched healthy controls. This might be a direct effect of the disease; however, it can also be a reflection of previous immunologic challenges and/or a higher susceptibility of these children to develop meningococcal sepsis. Within the young patient group, levels of IgG1 hybrid-type glycans and IgG2/3 sialylation per galactose were associated with illness severity and severe outcome. Future studies in larger groups should explore whether IgG Fc glycosylation could be a reliable predictor for meningococcal sepsis outcome., IMPORTANCE Meningococcal sepsis causes significant mortality and morbidity worldwide, especially in young children. Identification of risk factors for a more fulminant infection would help to decide on appropriate treatment strategies for the individual patients. Immunoglobulin G (IgG) plays an essential role in humoral immune responses and is involved in the adaptive immune response against meningococcal infections. Of great influence on the receptor affinity of IgG is the N-glycan on its fragment crystallizable (Fc) portion. In the present study, we analyzed IgG glycosylation during the fast development of meningococcal sepsis in children, and we were able to identify glycosylation features that are different between meningococcal sepsis patients and healthy controls. These features might be indicative of a higher susceptibility to meningococcal sepsis. In addition, we found glycosylation features in the patients that were associated with illness severity and severe disease outcome, having the potential to serve as a disease outcome predictor.

Meningococcal disease is a global burden with an estimated annual death rate of 170000 worldwide. The disease has an overall mortality greater than 10%. Despite these figures, several studies demonstrate that the management of children with severe meningococcal sepsis and septic shock is suboptimal. Most children received inadequate fluid resuscitation and inotropic support during their admission. Hence, this paper presents a review of relevant literature of prediction studies and discusses clinical and methodological issues, which may have influenced the results. It concludes that several studies have investigated the predictors of a poor clinical outcome in this condition, but there is a lack of studies that consider prediction of fluid and inotrope requirements as an outcome measure. The identification of such predictors would allow treatment to be directed to those children most likely to benefit, with a long term goal of improving patient outcome.

Objectives: Children with meningococcal sepsis are highly at risk for fulminant disease, multiple organ failure, and death. Recently, neutrophil extracellular traps levels have been indicated as a marker for severity in different kinds of sepsis. Our aim was to study the role of neutrophil extracellular traposis in meninogococcal sepsis in children. Design: We measured myeloperoxidase-DNA, a marker for neutrophil extracellular traps, in serum of meningococcal sepsis patients upon admission to PICU, at 24 hours, and at 1 month and studied the association with clinical outcome. Subsequently, we tested whether Neisseria meningitidis, isolated from children with meningococcal sepsis, were able to induce neutrophil extracellular traposis, using confocal microscopy live imaging. Setting: We used enzyme-linked immunosorbent assays to measure myeloperoxidase-DNA in patient serum. We also included inflammatory markers that were previously measured in this group. Patients: We included exclusively children with meningococcal sepsis. Interventions: From each patient, serum was collected for analysis. Measurements and Main Results: Myeloperoxidase-DNA levels at admission (n = 35; median, 0.21 AU/mL; interquartile range, 0.12-0.27) and at 24 hours (n = 39; median, 0.14 AU/mL; interquartile range, 0.09-0.25) were significantly higher than the myeloperoxidase-DNA levels after 1 month (controls: n = 36; median, 0.07 AU/mL; interquartile range, 0.05-0.09; p < 0.001). We did not observe a correlation between myeloperoxidase-DNA levels and mortality, cell-free DNA, or other inflammatory markers. In addition, N. meningitidis are fast and strong inducers of neutrophil extracellular traposis. Conclusions: Children admitted to PICU for meningococcal sepsis have higher neutrophil extracellular traps levels at admission and after 24 hours than controls. Neutrophil extracellular traps levels were not associated with outcome, cell-free DNA, or other inflammatory markers. These neutrophil extracellular traps may be induced by N. meningitidis, since these are strong neutrophil extracellular traposis inducers.

Cardiopulmonary resuscitation (CPR) can create a range of unusual lesions and injuries, which may complicate forensic evaluation. Although potentially sinister findings, neck injury and conjunctival petechiae may also be seen in patients who have undergone CPR. We report a case of an individual with subcutaneous bruising and hemorrhage in the deep structures of the neck and florid conjunctival petechiae at autopsy that can be explained by cardiopulmonary resuscitation and meningococcal sepsis.

Neisseria meningitidis is one of the major causes of meningitis in children and adolescents, but it is rarely found during the neonatal period. Here, we describe a neonate with meningococcal sepsis who was admitted to the hospital on postnatal day 10, and we discuss the clinical features of neonatal infection with N. meningitidis in relation to the literature (analysis of a 97-year period).

Meningococcal sepsis and purpura fulminans is a rare but highly lethal disease process that requires a multidisciplinary team of experts to optimise morbidity and mortality outcomes due to the breadth of complications of the disease. The surgical perspective involves the critical care management which utilises all currently available measured outcomes of critical care management as well as experimental therapies. Limb loss is common, and is reflective of the high incidence of compartment syndrome compounded by the significant soft tissue loss secondary to purpura and limb ischaemia, presumptively due to digital microemboli. A multidisciplinary approach involving current standards in critical care and early surgical evaluation are important in improving patient outcomes and limb salvage.

Systemic lupus erythematosus (SLE) is an inflammatory disease with a wide range of clinical manifestations and complications related to disease activity. One of them is the increase risk to infections secondary to immunological alterations due to pharmacological therapy (especially steroids). Few reports have documented the association of SLE and meningococcal infection with subsequent development of immunological activation (continuous inflammation) and intolerance of the immune system. The attempts to make an early and appropriate approach to these type of patients, generate benefits in survival rates and decrease sequelae among those who survive, especially in those in whose infection compromised central nervous system. We present the case of a patient that presented with neurological symptoms compatible with neuroeffector by Neisseria meningitis isolated in CSF cultures. Despite adequate antibiotic treatment the patient continued to deteriorate neurologically, and alternative diagnosis were evaluated after findings of vasculitis in brain CT scan. Immunological panel was performed with positivity of antibodies commonly present in SLE considering that infection by Neisseria meningitis was a trigger of immunological intolerance and development of SLE. We present the following case to understand the physiopathology and relationship between meningococcal infections, complement consumption, immunological intolerance and the development of autoimmune disease.

This study presents a case series of patients with meningococcal purpura fulminans who were treated at a tertiary referral centre within a few days of each other. Presenting with signs and symptoms of florid meningococcal sepsis, they were managed initially by physicians and intensivists, whereas the development of large purpuric areas and tissue necrosis was managed expectantly by plastic surgeons. When the patients were deemed to have recovered clinically and the necrosis delineated, surgical management was implemented with subsequent involvement of various rehabilitation services. This article highlights the cases of two patients, and their clinical presentation, management and rehabilitation together with a current literature review on this area.

CILJ: Ovo provedeno istraživanje za cilj je imalo istražiti učestalost gnojnog meningitisa u odnosu na serozni meningitis i meningokoknu sepsu, demografske karakteristike oboljelih, dob ispitanika, duljinu liječenja, uzročnike bolesti, pojavnost, mjesto liječenja, određene komplikacije koje su se pojavile tijekom liječenja, sestrinske dijagnoze te ishode bolesti. METODE: Istraživanje je provedeno tijekom lipnja 2016. godine na klinici za infektologiju KBC-a Split, uz prethodno odobrenje od strane etičkog povjerenstva KBCa Split. Potrebni podaci prikupljeni su iz povijesti bolesti bolesnika koji su bili liječeni od 2010. do 2015. godine. Za statističku analizu podaci su unijeti u Microsoft Excel tablice i dobiveni podaci su onda analizirani metodom deskriptivne statistike. REZULTATI: Istraživanjem smo dobili uvid u dobnu i spolnu raspodjelu. Najčešće oboljevaju žene, a ugrožena dobna skupina su osobe od 18-65 godina. Gnojni meningitis se po učestalosti javlja nakon seroznog. Najčešći izolirani uzročnik je Streptococcus pneumoniae. Dobili smo saznanje da duljina prosječnog liječenja iznosi 15-21 dan. Gnojni meningitis se najčešće javlja zimi. U 60 % ispitanika svijest je bila očuvana, a težih poremećaja svijesti nije bilo. Kao komplikacije pojavile su se konvulzije kod dvoje oboljelih, a encefalitis kod troje ispitanika. Također su se pojavile i komplikacije dugotrajnog ležanja, dekubitus u 10 % slučajeva. Najčešća sestrinska dijagnoza u oboljelih je smanjeno podnošenje napora. Stupanj samostalnosti 1 je najčešći u bolesnika. Zbog teškoća navedenog stanja 30 % ispitanika se liječilo u jedinici intenzivne skrbi. Od 30 ispitanika, samo je jedan slučaj završio smrtnim ishodom. ZAKLJUČCI: U ovom istraživanju smo ostvarili određene hipoteze. Gnojni meningitis je bolest od koje oboljevaju osobe 18-65 godina, najčešće od uzročnika S. pneuoniae. Hospitalizacija je odužena, 37 % bolesnika se liječilo 15-21 dan. U 60 % bolesnika je svijest očuvana, te je najčešći stupanj samostalnosti je 1. INTRODUCTION AND AIM: The aim of this study was to determine the frequency of purulent meningitis in relations to oseptic meningitis and meningococcal sepsis, demographic characteristics of the patients, the age of the participants, length of the treatment, cause of the disease, incidence, treatment location, specific complications that arised during the treatment and the outcome. MATERIALS AND METHODS: The study was conducted during June, 2016., at the clinic for infectology, Clinical Hospital Center Split. The required information was gathered from patients' history of illness, treated from 2010. to 2015. The data collected was entered in Microsoft Excel Spreadsheet according to a pre-prepared chart of accounts. For processing, descriptive statistic was used. RESULTS: The study provided insight into sex-age ratio. Incidence of illness is higher in the female population, also patients aged 18-65 years have higher risk. Incidence of purulent meningitis is higher than the oseptic meningitis. The most frequently isolated bacteria is streptococcus pneumoniae. The study concluded that the average treatment period is 15 to 21 days. Purulent meningitis has a higher incidence during winter. 60 % of the participants preserved their conscience, there were no severe neurological deficits. Two participants developed convulsions as a complication, while three others developed encephalitis. Moreover 10 % of the participants also developed decubitus as a complication. They were largely autonomous, and the most common nursing diagnosis was decreased exercise tolerance. Because of the severity of their conditions, 30 % of the participants were treated at the ICU. Only 1 out of 30 participants died as a result of the disease. CONCLUSION: All hypothesis from this research were confirmed. Purulent meningitis usually affects people aged 18-65 years. Most common cause of illness is S.Pneumoniae. We found that in 37 % of the cases hospitalization lasted 15 to 21 day which was longer than was expected. Patient were largely autonomous, and 60 % of them preserved their conscience.

This case report describes an invasive meningococcal group B infection followed by the development of Kawasaki disease (KD) complicated by macrophage activation syndrome (MAS) in a 2-year-old child. The presented case indicates the possible etiologic relationship between meningococcal sepsis and KD as support of bacterial toxin induced theory. It’s important to maintain a high grade of suspicious for KD in every relapse of fever also during convalescence phase of severe infection. Usually, initial treatment with intravenous immunoglobulin is sufficient to control the disease, but, in case of refractory KD complicated by MAS, corticosteroid therapy represents a good option inducing prompt fever resolution and clinical improvement.

We report a case of acute hemorrhagic edema of infancy (AHEI) occurred in an 11-month-old male infant after upper respiratory tract infection. The onset was dramatic with petechiae, ecchymosis, and annular, nummular, or targetoid purpuric plaques on the extremities, face, and ears. Acute hemorrhagic edema of infancy is a benign form of leukocytoclastic vasculitis that typically affects children between 4 and 24 months of age. The etiology remains still unknown. The potential triggers of AHEI include preceding bacterial or viral infections, immunizations, and drugs. Although the clinical picture is fearful, in the majority of cases, it involves only cutaneous small vessels. Recognizing this as a distinct clinical entity allows to establish an appropriate prognosis for this rare benign disease in children.This report could be a helpful reminder, especially for emergency physicians, to discriminate AHEI from other more severe diseases, such as meningococcal sepsis.

Objective: The pathophysiological sequelae of meningococcal sepsis are mainly caused by deregulated microvasculature function, leading to impaired tissue blood flow. Because mature enterocytes are known to be susceptible to altered perfusion, we aimed to investigate: (1) the development of enterocyte damage; and (2) the relation between enterocyte damage and severity of disease and outcome in children with meningococcal sepsis.Design: Retrospective human study.Setting: Pediatric intensive care unit at a university hospital.Patients: Nineteen consecutive children with meningococcal sepsis were studied during their pediatric intensive care unit stay.Interventions: None.Measurement and Main Results: Circulating levels of intestinal fatty acid binding protein, a small cytosolic protein constitutively present in mature enterocytes and released on cell injury, were assessed. Severity of disease was represented by meningococcal-specific Rotterdam Score, generic Pediatric Risk of Mortality II score, and circulating interleukin-6. Clinical outcome was measured by length of pediatric intensive care unit stay and number of ventilator days. Highest plasma intestinal fatty acid binding protein values were measured on pediatric intensive care unit stay admission. At the time of admission, eight of 19 patients had higher intestinal fatty acid binding protein plasma levels than the upper reference limit of 30 healthy volunteers. In all survivors, intestinal fatty acid binding protein levels declined to normal values within 12 hrs after starting intensive treatment, whereas the three nonsurvivors maintained elevated intestinal fatty acid binding protein plasma levels. A significant correlation was found among intestinal fatty acid binding protein and Rotterdam Score, Pediatric Risk of Mortality II, interleukin-6 at admission (Spearman's r(2) = 0.402, p =.006; r(2) = 0.243, p = .045; r(2) = 0.687, p Conclusions: Elevated plasma intestinal fatty acid binding protein is found in eight of 19 children with severe pediatric intensive care unit stay at the time of clinical presentation, suggesting the presence of enterocyte damage. Furthermore, prolonged enterocyte damage is found in nonsurvivors. Further studies are needed to clarify the potential role for assessment of plasma intestinal fatty acid binding protein in monitoring treatment of pediatric intensive care unit stay. (Crit Care Med 2010; 38:133-137)

Pediatric emergencies are exceptional challenges for every emergency doctor. Referring to the complete spectrum of all emergencies the percentage of pediatric cases amounts 5-10 %. In adulthood cardiovascular diseases represent the major cause for emergencies whereas in childhood respiratory disturbances and seizures prevail. This article reviews the most common pediatric disease patterns that are of importance for the emergency doctor. The typical clinical symptoms will be outlined as well as the corresponding therapeutic measures.