A HIGH RISK EXPOSURE TO MENINGOCOCCAL MENINGITIS. L.M. Kosseim 1 , C.M. Stoltz 1 ; 1 University of Pennsylvania, Philadelphia, PA LEARNING OBJECTIVES: 1. Recognize patients at high risk for meningococcal meningitis 2. Understand options for prophylaxis for meningococcal meningitis 3. Identify candidates for the meningococcal vaccine CASE INFORMATION: A 20 year-old male college student made an urgent appointment at his student health service for evaluation of possible meningococcal meningitis. He had returned the day before from a 14 day trip to Israel with other college students. A student with whom he had spent time in Israel became ill prior to boarding the flight home. This contact student died from meningococcal meningitis within hours of landing in the United States. The patient was advised by the airline company to see his physician for evaluation. History was remarkable for sharing a drinking glass at a party with the young man who later died. A thorough physical exam was unremarkable. Because of his potentially high risk exposure to meningococcus, the patient was given rifampin 600 mg PO bid for two days and counselled on the symptoms of meningococcal meningitis. He was also advised to receive the meningococcal meningitis vaccine. As this patient had been on a school trip, the other students from his group were also counselled and given prophylaxis. Additionally, the student health service used this as an opportunity to educate the student body on the availability of the meningococcal vaccine and on recognizing the signs and symptoms of meningitis. DISCUSSION: Meningococcal meningitis is a rare but often deadly infection affecting approximately 2,800 Americans annually. Chemoprophylaxis with antibiotics is recommended for all close contacts of an index case of meningococcal meningitis. Close contacts include household members, daycare workers, and anyone directly exposed to the case patient's oral secretions. Internists should be comfortable prescribing chemoprophylaxis for meningococcal meningitis and also know which patients are advised to get the meningococcal vaccine. The Centers for Disease Control has recently changed its guidelines, and now advises that all college students be aware of the increased risk of meningococcal meningitis in this population and in the availability of the meningococcal vaccine. CASE INFORMATION: A 32-year-old female hotel banquet manager with no signficant past medical or surgical history presented with nausea, diffuse myalgias, clear rhinorrhea, and frontal headache. She took oral contraceptives and just finished her menses. The patient was afebrile and had frontal sinus tenderness. Her physician prescribed trimethoprimsulfamethoxazole for sinusitis. The patient stopped the sulfa after five days because of worsening nausea with diarrhea. She also developed arthralgias of the knees, ankles, and elbows. Two days later she returned to the doctor with a maculopapular rash over her anterior shins with a few urticarial lesions. The elbows appeared discolored. The knees were warm, tender, and swollen. The tissue around the ankles was tender, but they were not swollen or warm. A serum sickness like reaction secondary to sulfa was suspected. A CBC and LFTs were normal, and an antihistamine was prescribed. Over the next week her condition worsened with fever, more extensive arthralgias (now including the hips and wrists) and the development of tender nodules along the anterior tibias and elbows characteristic of erythema nodosum. A chest radiograph showed right hilar and mediastinal lymph nodes. Prednisone 20 mg. daily was begun with rapid improvement of the arthritis, erythema nodosum, fatigue, and fever. The prednisone was tapered over the next month. A CXR three months later showed resolution of the hilar and mediastinal adenopathy. Nine months later the patient remains well without recurrence. DISCUSSION: This case illustrates that some episodes of``serum sickness" are due to an underlying disease for which an antibiotic is used and then blamed. In retrospect, the symptoms of fatigue, myalgias, and URI that lead to the antibiotic prescription were actually the prodrome for acute erythema nodosum (EN). While half of cases of EN are idiopathic, it is important to rule out secondary causes. Infectious etiologies can include streptococcal pharyngitis, non-streptococcal URIs, TB, intestinal pathogens, and systemic fungi such as coccidiomycosis. Drugs such as sulfonamides and oral contraceptives can precipitate EN. One of the most common etiologies of secondary EN is Lo È fgren's syndrome, a triad of EN, bilateral hilar adenopathy, and arthritis. If EN is not clearly due to an infection, medication, pregnancy, or inflammatory bowel disease, a CXR and PPD should be performed. LÐfgrens is an acute, self-limited form of sarcoidosis, most common in young women. EN is a good prognostic sign, in which case an invasive diagnostic procedure for the hilar adenopathy is not necessary. NSAIDs are the treatment of choice; corticosteroids are indicated for severe, debilitating arthritis. A 51-year-old man was seen in the Emergency Department for one week of sore throat, fever, and hoarseness; he was diagnosed with a respiratory virus. Two days later, he was evaluated in a primary care clinic for persistent fever, fatigue, and a new, nonpruritic rash. He was ill-appearing and had a maculopapular rash over his upper back, chest, and thighs; anterior cervical lymphadenopathy was present. Laboratory data revealed WBC 4.2, and a negative monospot and throat culture. HIV testing was obtained two days later when risk factors were identified. Intial HIV antibody was negative, but his viral load was 300,000. His symptoms resolved after two weeks. One month later, his HIV antibody test became positive. CASE 2: A healthy, 35-year-old man was seen for urethral discharge. History revealed recent unprotected intercourse with a new partner. Urethral culture was negative but urine PCR was positive for Chlamydia trachomatis. He was treated with a one-time dose of azithromycin. Two days later he developed a rash over his face and trunk accompanied by chills, fatigue, and headache. He was afebrile with a diffuse maculopapular rash over his face, chest, and abdomen. Although a drug reaction was suspected, HIV serologies were sent. His HIV antibody was indeterminate but his viral load was over 500,000. DISCUSSION: Acute HIV infection is often underdiagnosed, but should be routinely considered in clinical care. More than 80% of people with acute infection seek medical care for their symptoms, yet the diagnosis is considered less then 25% of the time. Nonspecific symptoms such as fever, myalgias, rash, and lymphadenopathy are typical. Initial testing should include HIV antibody as well as HIV RNA viral load or HIV DNA. Early treatment decreases viral burden as well as improves, and perhaps restores, host immune responses. HIV is highly contagious during the acute infectious stage. Early diagnosis is critical in decreasing HIV transmission and has significant impact on public health, treatment, and possibly prognosis. Because the majority of patients present to primary care physicians, they have an important role in recognition of early infection. Further education regarding symptoms and serologic testing, as well as screening strategies, may be needed to increase awareness of acute infection in primary care settings.