Generalized Forms Of Meningococcal Infection Research Articles

Перикардит – осложнение или проявление менингококковой инфекции, вызванной Neisseria meningitidis серогруппы W, у ребенка?

Meningococcal infection is one of the most insidious and dangerous infections (due to the risk of lethal outcome up to 80% when septic shock develops). The article presents a clinical observation of patient A. 4 years old, who had a generalized form of meningococcal infection (GFMI) caused by meningococcus of serogroup W. Despite targeted adequate etiopathogenetic therapy, heart damage developed, which was diagnosed late in the course of the disease (day 26 of the disease). The world literature describes cases of development of complications of GFMI in children caused by N. meningitidis serogroup W at late stages of the disease in the presence of targeted therapy and with CSF sanitation. All of the above necessitates a complex clinical and neurophysiological examination in the periods of early and late recuperation and an individual program of medical rehabilitation. It should be emphasized that if there is a suspicion of complications in the late recovery period, the prescription of complex pathogenetic therapy, including the use of non-steroidal anti-inflammatory drugs and drugs with antioxidant, antihypoxic and cytoprotective effect, such as cytoflavin, is shown to improve the outcome of the disease. Key words: meningococcal infection, children, N. meningitidis serogroup W, meningitis, pericarditis, cytoflavin, medical rehabilitation

Epidemiological Features of Purulent Bacterial Meningitis in the Russian Federation at the Present Stage

Relevance. The decrease in the number of cases of invasive diseases caused by N. meningitidis, S. pneumoniae, H. influenzae and in the world has been associated with measures against the spread of the 2019 coronavirus disease (COVID-19).Aim. Presentation of the epidemiological features of purulent bacterial meningitis (PBM) in the Russian Federation at the present stage.Materials and methods. On the basis of the Russian Reference Center for Monitoring Bacterial Meningitis (RCMC), an in-depth personalized system for recording PBM cases has been established. Since 2010, all territories of the Russian Federation have been included in the monitoring system. In 2022, the RCMC received information on 1596 cases of PBM. The descriptive-evaluative epidemiological method was used in the work: a retrospective analysis.Results. The increase in the incidence of a generalized form of meningococcal infection (GFMI), which began in 2017, was recorded in 2018 and 2019, but in 2020–2021 growth was interrupted: the indicator dropped sharply, amounting to 0.26–0.21 per 100 thousand of the population, which is most likely due to the disunity of the population as a result of measures aimed at combating the new coronavirus infection. Measures to combat COVID-19 were canceled in 2021, and already in 2022 the incidence rate of GBM increased by 1.4 times, while the GFMI by 2 times, amounting to 0.44 per 100 thousand of the population. A sharp decrease in the incidence of PBM caused by S. pneumoniae and H. influenzae in 2020-2021 was replaced in 2022 by an increase in the incidence of pneumococcal meningitis, however, the incidence of meningitis caused by H. influenzae remained at the same level.Conclusion. Continued monitoring of the incidence of PBM and the properties of the pathogen are extremely important tasks in order to identify risk groups and areas for the timely optimization of vaccination measures, given that the three infections that cause bacterial meningitis are vaccine-controlled, and vaccination is recognized as the most effective measure to combat meningococcal, pneumococcal and hemophilic infections.

КЛИНИКО-ЭПИДЕМИОЛОГИЧЕСКАЯ ХАРАКТЕРИСТИКА ГЕНЕРАЛИЗОВАННЫХ ФОРМ МЕНИНГОКОККОВОЙ ИНФЕКЦИИ В ГРОДНЕНСКОЙ ОБЛАСТИ ЗА ПЕРИОД 2018-2022 гг.

The article presents an analysis of the epidemiological situation of meningococcal infection in the Grodno region over the past five years. Aim. Analysis of the dynamics of morbidity and factors affecting the frequency of meningococcal infection in the Grodno region. Material and methods. A retrospective comparative analysis of the morbidity of the population of the Grodno region was carried out using statistical reporting forms of the database of the Grodno Regional Center for Hygiene, Epidemiology and Public Health, as well as an analysis of the medical histories of the Grodno Regional Infectious Clinical Hospital and the Grodno Regional Children's Clinical Hospital. Results. An analysis of the epidemiological situation in the Grodno region over the past five years has revealed fluctuations in morbidity rates, the replacement of leading strains of meningococci, concomitant diseases in patients, the "maturation" of meningococcal infection: children account for about 61.5% of cases of generalized forms of meningococcal infection which is less than the usual 75-80%. Conclusions: Over the past five years, there has been a decrease in the incidence of meningococcal infection in the Grodno region. The epidemic situation in general for meningococcal infection in the Grodno region for the period 2018–2022 is characterized by signs of an interepidemic period, i.e. sporadic morbidity persists. The leading serotypes in patients are meningococci of serogroup B and C. In the structure of patients with generalized forms of meningococcal infection, a group of homeschooled children prevails. Concomitant chronic diseases were registered in most patients.

MENINGOCOCCAL INFECTION: A BRIEF REVIEW AND PERSONAL OBSERVATIONS OF THE GENERALIZED FORM OF THE DISEASE IN THREE-MONTH-OLD TWINS

Meningococcal infection in the form of sporadic cases or minor group outbreaks, mostly among children, is registered in all countries of the world. The disease has a wide range of clinical manifestations – from an asymptomatic bacterial carriage and acute nasopharyngitis to the rapid development of meningococcemia, acute meningococcal sepsis and meningitis. The article highlights and summarizes literature data related to the incidence of meningococcal infection, ways of infection, features of the clinical course of the disease in the newborn period, and modern views on the problem. A rare clinical case of the development of severe generalized forms of meningococcal infection in 3-month-old twins with a fatal outcome in one child is described. The decisive role in the development of the disease of twins is determined by the way and duration of children’s contact with their father, who has a bacteriologically confirmed (Neisseria meningitidis, biovar C) meningococcal nasopharyngitis. Early diagnosis and treatment of all forms of meningococcal infections are important to prevent the development of GMI. The key method of MI prevention is vaccination.

Features of diagnosis of generalized forms of meningococcal infection at present stage

Despite the low level of morbidity, the significance of meningococcal infection (MI) persists and is primarily due to the predicted rise in morbidity after a long period of relative well-being (decline), instability of the serogroup landscape, an increase in morbidity caused by previously rare serotypes (meningococcus W), lack of routine vaccination, as well as severe course, the development of formidable complications and high risk of death. The risk of up to 30–60 % disabling complications after generalized forms of meningococcal infection (GFMI), including physical and neuropsychiatric problems, is also important. The reason for the unfavorable prognosis of the disease is the late diagnosis at the pre-hospital stage, hospitalization in non-core hospitals, the severity of the pathological process. With a low incidence, a wide range of antibacterial drugs, the mortality from GFMI is significant, from 6 to 14 %. The main means to significantly reduce the incidence and mortality from GFMI is currently the introduction of mass vaccination of the population against MI.

Antibiotic Sensitivity of <i>Neisseria meningitidis</i> Isolated From Patients with Generalized Forms of Meningococcal Infection and From Healthy Carriers

The study included 50 isolates of Neisseria meningitidis isolated from patients with generalized forms of meningococcal infection and 48 isolates, which were isolated from carriers. The isolates were identified by MALDI-TOF mass spectrometry using a Microflex LT mass spectrometer (Bruker Daltonics, Germany). Minimum inhibitory concentrations (MICs) of benzylpenicillin, ampicillin, ceftriaxone, meropenem, ciprofloxacin, azithromycin, rifampicin, and chloramphenicol were assessed by the method of serial agar dilution with interpretation of the results according to EUCAST 2021 criteria. Clinical resistance to penicillin was detected in 7% of isolates. However, all isolates with MIC >0.064 µg/ml (n=26) had mutations in the penA gene. Decreased sensitivity to rifampicin was found in four isolates isolated from patients and four isolated from carriers. Seven out of eight isolates with reduced sensitivity to rifampicin had mutations in the rpoB gene. Resistance to ceftriaxone, meropenem, ciprofloxacin was not detected.

THE COURSE OF GENERALIZED FORMS OF MENINGOCOCCAL INFECTION IN CHILDREN OF THE LVIV REGION DURING 2011-2019

Relevance. Meningococcal infection (MI) is one of the most significant bacterial infections in children, it is characterized by life-threatening and unpredictable fulminant course in the structure of infectious diseases.
 Objective. To analyze the clinical and laboratory features of generalized forms of MI in children of Lviv region during 2011-2019.
 Materials and methods. Retrospective analysis of 254 case reports of patients with generalized forms of MI, hospitalized in regional infectious diseases clinical hospital during 2011 -2019 years, was conducted, as well as 14 protocols for post-mortem examination of deceased from generalized forms of MI children during 2011-2019. 203 medical records with confirmed diagnosis of the disease were selected.
 Results. Meningitis as a clinical form was diagnosed in 48 children (23.6%), meningoencephalitis in 6 (3%), meningococcemia − in 82 (40.4%), combined form − in 67 children (33%).
 In children aged 1 month to 1 year and aged 1 to 3 years the combined form of the disease occurred significantly more often than the isolated clinical form. Analysis of clinical symptoms and major laboratory parameters in various clinical forms of MI were exemplified.
 12 children from 5 months up to 4 years 10 months diagnosed with MI generalized form: meningococcemia fulminant form, and one 6-year-old child with purulent meningoencephalitis had died.
 Conclusions. Despite of gradual decrease of morbidity level and respectively amount of hospitalized patients throughout 2011-2019, a difficult course of generalized forms of MI with development of toxische Schocksyndrom in 77,9% in patients with meningoccocemia were observed. Mortality in meningococcemia was 8,1%, most of the deceased were children aged 3-5 years. Misdiagnosis at the primary level were observed in 14,3%.

Improving the therapy of generalized forms of Meningococcal infection in children using extracorporeal hemocorrection

Invasive meningococcal infection is a significant cause of death, reaching 80% in septic shock. The Pediatric Research and Clinical Center for Infectious Diseases (PRCCID) has developed an algorithm for the treatment of children with invasive meningococcal infection with refractory septic shock and multiple organ failure syndrome, which includes basic drug therapy with polymyxin hemoperfusion in combination with extended methods of extracorporeal hemocorrection.Purpose: to evaluate the effectiveness of extracorporeal hemocorrection operations in children with invasive meningococcal infection with refractory septic shock and multiple organ failure syndrome.Materials and research methods: to the intensive care unit of the PRCCID for the analyzed period 2006—2020 34 children were hospitalized with invasive meningococcal infection with refractory septic shock and multiple organ failure syndrome. Two groups were formed: Group 1 — children admitted to the PRCCID in the period 2014—2020 (n = 23), who underwent polymyxin hemoperfusion simultaneously with extended methods of extracorporeal hemocorrection, group 2 — children hospitalized in 2006—201 3 (n = 1 1), methods of extracorporeal hemocorrection were not performed. The Mann-Whitney U-test and ANOVA were used to evaluate the results.Results and discussion: the use of extracorporeal hemocorrection operations in the complex therapy of invasive forms of meningococcal infection with refractory septic shock and multiple organ failure syndrome in children provides stabilization of central hemodynamics, reduces clinical and laboratory inflammatory reactions, helps to reduce the dose of vasopressor drugs and parameters of respiratory support, and also increases patient survival rate by 82.6%.

The Level of Meningococcal Carriage and Genotyping of N. meningitidis Strains in the Group of Labor Migrants

Relevance. Population migration can play a crucial role in the spread of invasive strains of meningococcus, initiating outbreaks of meningococcal infection, and changing the incidence at the local level.Aim. To assess the prevalence of meningococcal carriage among migrants arriving in Moscow and to characterize the antigenic and genetic properties of carrier strains of meningococcus.Materials and methods. The study was conducted in March 2020 at the bases of the Multifunctional Migration Center of Moscow and the Federal Budget Institution of Science «Central Research Institute of Epidemiology». Samples of nasopharyngeal mucus were collected from 352 people. Nasopharyngeal strains of meningococcus were identified and identified using microbiological, serological, and molecular biological methods.Results. The overall level of the carriage was 5.7%. Of the twenty selected strains, 10 have a serogroup defined: Y – 5 strains, W - 3, A, and B – 1 each. The obtained genetic and antigenic characteristics do not allow talking about the import into the RF of representatives of known hypervirulent clonal complexes. In this study, strains were identified that are part of the clonal complex ST-175 complex, which has not been previously described in the Russian Federation.Conclusion. It seems promising to continue the dynamic monitoring of carriage of meningococcus in various groups, including among people entering the country to obtain a migration patent, as well as identifying risk factors for acquiring carriage. The data obtained will supplement current information on the incidence of the generalized form of meningococcal infection and will be crucial for determining the epidemiology at the country level, the population groups responsible for the transmission of the disease, and the need for targeted vaccination.

КЛИНИЧЕСКИЙ СЛУЧАЙ МЕНИНГОКОККОВОЙ ИНФЕКЦИИ У РЕБЕНКА 1 ГОДА ЖИЗНИ

One of the dangerous infections in childhood is a meningococcal infection, characterized by pronounced polymorphism of clinical forms, frequent development of severe complications, often leading to the death of the patient. The problem of diagnosis and treatment of meningococcal infection, despite modern advances in medicine, is still relevant. The article provides basic information on meningococcal infection, diagnosis and the optimal choice of antibiotic therapy, describes the clinical case of a severe course of a generalized form of meningococcal infection in a child of the first year of life.

Meningococcal infection in modern conditions: clinical, microbiological and preventive aspects

The problem of meningococcal infection remains relevant due to the high epidemiological and social significance throughout the world, the unpredictability of the course, a wide range of clinical manifestations (from asymptomatic carriage to extremely severe generalized forms) with a high risk of life-threatening conditions and deaths, and a significant incidence of disability after past illness (loss of limbs, deafness, mental inferiority, and more). The changing serogroup landscape of meningococcal infection with an increase in the incidence of diseases caused by Neisseria meningitidis serogroup W, Y and others is noteworthy. The article presents an analytical review of literature and reflects current clinical, epidemiological, diagnostic and preventive trends in the Russian Federation and abroad. The review focuses on the epidemiological features of meningococcal infection, depending on the serogroup affiliation of meningococcus, the variety of clinical manifestations of the generalized form of meningococcal infection, including atypical manifestations, age-related features, depending on the serogroup of the pathogen. New diagnostic approaches and the possibilities of specific prophylaxis are highlighted. Attention is focused on the importance of monitoring the clinical and epidemiological characteristics of meningococcal infection depending on the genetic characteristics of the pathogen, and the need for further in-depth studies of this problem.

Rare generalized form of meningococcal disease caused by Neisseria meningitidis serogroup W

The article presents current data on the high epidemiological and social significance of meningococcal infection caused by Neisseria meningitidis W in the Russian Federation and abroad. The article contains a review of the literature on the clinical features of the course of generalized forms of meningococcal infection caused by serogroup W. The clinical observation of a rare variant of generalized meningococcal infection with the development of acute epiphyseal osteomyelitis of the distal epiphysis of the right tibia, arthritis of the right ankle joint, right wrist joint, joints of 1-st right toe in an early childhood is described.

Role of genotyping in prediction of disseminated intravascular coagulation and multiple organ failure in children with generalized forms of meningococcal infection

Aim: To investigate the features of allelic polymorphism, of several immune- and hemostasis-related genes in children with generalized, meningococcal infections and. to assess the usefulness of genotyping for prediction, of severe disseminated intravascular coagulation (DIC) and. multiple organ dysfunction, syndrome in these patients. Materials and methods : we studied. 20 children aged, from 8 months up to 17 years with generalized, meningococcal infections who developed DIC or/and multiple organ dysfunction syndrome. The control group consisted, of 200 blood, donors. Genomic DNA was isolated, from peripheral blood, leucocytes. Allelic variants of genes coding for plasma hemostatic factors (FI-A, FI-B, FXIII-A, PAI-1, ТРА ) or pro-inflammatory cytokines (IL-6, IL-1B, TNF-A) were detected by PCR and. subsequent restriction, analysis. Allele and. genotype frequencies were calculated, by direct counting, and. their differences between the groups were assessed, by Fisher's exact test. For statistical analysis, the GraphPad. Prism, ver.4.0 software was used. Results: in the group of children with generalized, meningococcal infections, the frequency of heterozygotes for the IL-6 -174 G/C polymorphism, was 1.5-fold higher than in the controls (75.0% vs. 50.0%, respectively, OR=3.0; 95% CI: 1.1-8.6; p=0.037). Genotype TPA Del/Del was detected 4-fold more frequently in children who developed multiple organ dysfunction syndrome than in those with the more favorable disease course (45.4% vs. 11.1%, respectively, OR=6.7; 95% CI: 0.6-73.1; p=0.16). Moreover, among the patients having multiple organ dysfunction, syndrome, we observed, more frequently individuals who possessed, at least 2 unfavorable genetic variants (p=0.022). Conclusion: Simultaneous assessment of nucleotide variations in 8 studied genes could help to define the group of children with high, risk of multiple organ dysfunction, syn-drome.Genotype TPA Del/Del, associated, with decreased, production, of this factor, might serve as a marker of unfavorable DIC course and possible predictor of multiple organ dysfunction. syndrome in children with generalized, meningpcoc-cal infections.

Clinical cases of meningococcal infection caused by Neisseria meningitidis serogroup W

Meningococcal infection remains a socially significant disease due to a wide range of clinical manifestations, severe course with high mortality, reaching 40-80% for certain forms. In recent years we observe a change in the serogroup picture of meningococcal infection, in particular, an increase in the proportion of meningococcal serogroup W, characterized by polymorphism of clinical manifestations. The authors present two their own clinical observations of a generalized form of meningococcal infection with a severe course in adolescents caused by Neisseria meningitidis of W serogroup with fatal outcome. They describe the peculiarities of the cases, namely, inconsistency of the clinical picture at the beginning of the disease and post-mortem changes. The article describes heart damage in the form of focal purulent septic myocarditis and purulent foci of destruction in the brain stem, hemorrhagic infarction of the choroid plexus with hemotamponade of the lateral ventricles of the brain, the predominance of septicopia over septicemia. The revealed changes are likely to reflect clinical and morphological features of meningococcal infection caused by N. meningitidis of serogroup W.

Meningococcal infection in children: factors influencing outcome

Generalized forms of meningococcal infection are characterized by high risk of complication and fatal outcomes. In Russian Federation, 2016, meningococcal infection was the second most common cause of pediatric deaths (25%) due to infectious diseases after community associated-pneumonia. Mandatory vaccination against meninococcal infection is not regulated, and immunization coverage according to epidemic indications is insufficient. During first 6–8 hours of illness clinical signs of this infection may be non-specific, because of that it is difficult to make correct diagnosis at outpatient department. Aim of the study was to analyze mistakes of diagnostics of meningococcal infection and to assess factors influencing the disease outcome. Material and methods. Retrospective cohort study was performed including 113 pediatric cases of generalized meningococcal infection occurred in Arkhangelsk region (46 cases with fatal outcome and 67 patients, who recovered). Factors influencing the outcome were recognized using Cox regression. Results. Median age of patients was 11 months. Clinical forms were meningitis (13,3%), meningococcemia (40,7%), mixed form (46%). The diagnosis of meningococcal infection was made at outpatient department in 36,9% of cases. The main causes of diagnostic mistakes were the lack of experience among primary care physicians and non-specificic symptoms during the first hours of the disease. Age younger 2 years, septic shock and time between onset of the diseases and admission to the hospital were associated with fatal outcome. Conclusion. To manage meningococcal disease we need to have good compliance with clinical guidelines for outpatient departments and hospitals; to optimize medical students education for prevention of diagnostic mistakes. Vaccination is the most effective method of prevention of deaths associated with meningococcal infection.

Extracorporeal hemocorrection in treatment of meningococcal septic shock in children

Purpose: to estimate the effectiveness of extracorporeal hemocorrection in treatment of refractory meningococcal septic shock in children.Methods: patients with generalized form of meningococcal infection, multi-organ system failure and refractory septic shock admitted to the resuscitation department of Children’s Clinical Research Center for Infectious Diseases of the Federal Medical and Biological Agency of Russia underwent extracorporeal hemocorrection (polymyxin adsorption, continuous veno-venous hemofiltration, continuous veno-venous hemodiafiltration). MultiFiltrate apparatus was used (Fresenius Medical Care, Germany).Results: application of extracorporeal hemocorrection technique in the therapy of refractory meningococcal septic shock reduced the mortality from 44.4% to 25%.Conclusion: effectiveness of extracorporeal hemocorrection when treating patients with refractory meningococcal septic shock is established. A small number of examined patients is a limitation of the study.

CLINICAL-EPIDEMIOLOGICAL FEATURES AND OUTCOME OF GENERALIZED FORMS OF MENINGOCOCCAL INFECTION IN CHILDREN

The objective of the research was to study clinical and epidemiological features and outcomes of generalized forms of meningococcal infection in children from Krasnoyarsk and Krasnoyarsk Territory during the period from 2012 to 2016. Materials and methods. A retrospective analysis of 57 medical records of hospital patients with generalized forms of meningococcal infection was carried out in the infectious and resuscitative departments of the Krasnoyarsk Clinical Hospital No. 1 from 2012 to 2016, including 12 protocols of pathologoanatomical studies of the deceased patients and 45 medical cards of ambulatory patients – convalescents of the disease from 2012 to 2016. Results. The epidemic situation for meningococcal infection in Krasnoyarsk Territory from 2012 to 2016 is characterized by signs of inter-epidemic period. Children of the first 3 years of life are in the group of high risk for the development of GFMI, which accounts for 74% of the total number of cases of children aged 14. There are signs of meningococcal infection « aging » – in the age structure the number of children in the first year of life decreased, while the proportion of children aged 4 – 7 and 7 – 14 increased compared to previous decades. There is a tendency to a decrease in the proportion of the combined forms with an increase in the frequency of « pure » meningococcemia. In recent years there has been an « atypical » course of generalized forms of the disease, when classical hemorrhagic necrotic rashes appear only on the 3rd – 4th day of the disease. In convalescents who underwent a combined form of MI and « pure » meningitis severe residual effects leading patients to disability are possible to develop. Conclusion. The use of polyvalent conjugated vaccines in potential risk groups will allow us to reduce the morbidity and mortality from generalized forms of meningococcal infection, including younger children.

INNOVATIONS IN THE MANAGEMENT OF CHILDREN’S NEUROINFECTIONS

The article describes some topical problems of neuroinfections in children and the ways of their solutions on the basis of the experience of a leading institution — Pediatric Research and Clinical Center for Infectious Diseases. There are introduced some innovation approaches of diagnostics and therapy of bacterial purulent meningitis tested at the institution. There are described diagnostic markers of meningitis in children, method of ultrasound evaluation monitoring of the condition of kidneys, renal blood flow, adrenal glands in the patients with a fulminant course of generalized form of meningococcal infection, and innovation therapeutic approach by recombinant interleukin-2 — roncoleukin introduction to the complex therapy. There is reflected an innovation method of differential diagnostics by the determination of acute-phase protein haptoglobin in cerebrospinal fluid. There are presented the tested methods to diagnose sensorineural deafness in children with bacterial purulent meningitis, critical condition polyneuropathy, and inflammatory polyneuropathy by the technique of rehabilitation potential evaluation.

Meningococcal Infection in Children in the Krasnoyarsk Territory: Analysis of Fatal Outcomes

Meningococcal infection (MI) for many years has occupied one of the most important places in the structure of acute neuroinfections in children. Some decline in MI morbidity in recent years has reduced the alertness of doctors to early detection of the disease that in some cases becomes the cause of late hospitalization, development of decompensated shock and ineffective resuscitation. The purpose of the given research is to identify the causes of deaths from generalized forms of MI and the prospects of mortality reduction. The paper gives the expert analysis of 22 medical histories of children who died of generalized forms of MI during the period from 2005 to 2014 in Krasnoyarsk. The work describes the features of the clinical picture of MI generalized forms in children at the present stage, reveals the causes of deaths during the period of sporadic morbidity in the Krasnoyarsk Territory and determines the adverse prognostic features that indicate the particular severity and the development of fulminant course of the disease.

Lifetime diagnosis of adrenal hemorrhage in an infant with meningococcal infection

The generalized forms of meningococcal infection are a serious health care problem. Fulminant meningococcemia is a form of infection with extremely rapid progression and high mortality, which more frequently occurs in infants of the first year of life. Autopsy study revealed bilateral adrenal hemorrhage (hemorrhagic necrosis). Acute adrenal insufficiency requires the administration of glucocorticosteroids (GCS) in particularly severe forms of meningococcemia. However, it is unadvisable to use GCS in patients with infectious toxic shock in the absence of adrenal insufficiency as it fails to affect survival in the early period and increases death rates in the late period due to the fact that superinfections may develop. Ultrasonography may be useful in detecting adrenal hemorrhagic necrosis in a patient with meningococcal infection just on his/her admission and in making an immediate decision to initiate GCS therapy. The paper describes a case of the lifetime diagnosis of adrenal hemorrhage in a paper with fulminant meningococcemia.