A 12-year-old boy is brought to the emergency department by paramedics after being found unresponsive at home. He had 24 hours of headache, nausea, and fever, which his parents were treating with acetaminophen. His temperature is 39.6 C (103.4 F). Physical examination reveals neck stiffness. Lumbar puncture is performed. Analysis of cerebrospinal fluid shows marked pleocytosis, and Gram stain shows gram-negative cocci in pairs. The parents are concerned about their younger son, who shares a bedroom with the patient. Which of the following is the most appropriate management of this patient's household contacts?

Question

A 12-year-old boy is brought to the emergency department by paramedics after being found unresponsive at home.  He had 24 hours of headache, nausea, and fever, which his parents were treating with acetaminophen.  His temperature is 39.6 C (103.4 F).  Physical examination reveals neck stiffness.  Lumbar puncture is performed.  Analysis of cerebrospinal fluid shows marked pleocytosis, and Gram stain shows gram-negative cocci in pairs.  The parents are concerned about their younger son, who shares a bedroom with the patient.  Which of the following is the most appropriate management of this patient's household contacts?

Quizplus · Accepted Answer

This patient's presentation and the finding of gram-negative diplococci highly suggest meningitis due to Neisseria meningitidis. N meningitidis is transmitted by direct contact with contaminated respiratory secretions or aerosolized droplets. As a result, people with close or intimate contact (eg, household contacts, kissing contacts, health care workers who directly contacted secretions) are at markedly increased risk of meningococcal infection. Antibiotic chemoprophylaxis can prevent these secondary cases if given promptly. A history of meningococcal vaccination does not preclude the need for antibiotic chemoprophylaxis. Of the listed agents, rifampin is the only effective choice. Rifampin penetrates well into all body compartments, including the upper respiratory tract, and will eliminate nasopharyngeal colonization. Other effective agents include ciprofloxacin (not routinely used in children due to concerns about connective tissue injury) and intramuscular ceftriaxone, which is effective but not widely used due to the painful mode of administration. Chemoprophylaxis should be given as soon as possible, preferably within 24 hours of diagnosis. (Choice A) Vaccination is an important public health strategy for control of meningococcal disease in general, but does not play a role in post-exposure prophylaxis. Immunity following a post-exposure vaccination does not occur in time to prevent disease. (Choice B) A person's risk for infection is 500-1,000 times greater following an exposure to a meningococcal disease patient, and disease onset can be rapid. Therefore, observation alone is not an appropriate strategy for exposed close contacts. (Choice C) Although penicillin can be used for treatment of susceptible meningococcal infections, it has not been shown to eliminate nasal carriage or prevent secondary cases. Therefore, it should not be used for chemoprophylaxis. (Choice E) Sulfamethoxazole was the first agent to be used as chemoprophylaxis for meningococcal disease. However, it is no longer an effective agent due to widespread resistance. Educational objective: Rifampin is the most frequently used agent for chemoprophylaxis of meningococcal disease. Persons with exposure to the respiratory secretions of a patient with meningococcal disease require chemoprophylaxis. Vaccination is an important public health strategy but is not useful for post-exposure prophylaxis. __________ References: Meningococcal disease in childhood: epidemiology, clinical features and prevention. (http://www.ncbi.nlm.nih.gov/pubmed/26788732)

A 12-Year-Old Boy Is Brought to the Emergency Department by Paramedics