Infections by Neisseria meningitidis range from self-limited conditions to fulminant forms such as meningococcemia, with or without meningitis. Among its less frequent manifestations is pericarditis, whose reactive form (reactive meningococcal pericarditis, RMP) can have a severe outcome, with cardiac tamponade. Based on medical record review and literature, we report the case of a 31-year-old female patient, previously healthy, with fever and flu-like symptoms, who developed meningeal signs and purpura in the lower limbs over 3 days. She was hospitalized on the 4th day of symptoms, with leukocytosis, left shift and elevated C-reactive protein. Contrast-enhanced cranial CT was normal, and cerebrospinal fluid (CSF) showed pleocytosis with neutrophilia, hyperproteinorrachia and hypoglycorrhachia. Blood and CSF cultures were negative, but multiplex molecular panel (FilmArray) of blood and CSF identified Neisseria meningitidis serogroup C (NmC). Ceftriaxone 2g every 12 hours was started with an adequate response. However, on the 10th day of symptoms, the patient developed dyspnea, cough, crackles and muffled heart sounds. Chest X-Ray showed increased cardiac silhouette, and point-of-care ultrasound confirmed a large pericardial effusion with signs of pre-tamponade. Pericardial drainage was performed, yielding serous fluid with normal protein and glucose levels and negative cultures. The drain was removed after 5 days, once a sustained reduction in pericardial output was observed. The patient received 21 days of antibiotics, with complete resolution of symptoms and no neurological or cardiovascular sequelae. Her clinical course was compatible with RMP associated with NmC. RMP typically appears between the 6th and 16th day of illness, with sterile cultures, and its pathophysiology involves immune complex deposition and type III hypersensitivity, in contrast to isolated meningococcal pericarditis and pericarditis associated with meningococcemia, which occur in the early phases of bacteremia, are purulent and have positive cultures. RMP is the form most often associated with cardiac tamponade and may develop even with adequate treatment, NmC being the main serogroup implicated in immune-mediated manifestations. This case highlights the importance of close monitoring of patients with invasive meningococcal infection, even after initial improvement. Early diagnosis was essential for surgical management and prevention of fatal complications. RMP should be considered in the presence of respiratory worsening or cardiovascular symptoms during the course of meningococcemia.
Boghossian et al. (Sun,) studied this question.