Sex: M
Vaccine: DT, FLUX, PPV
Symptoms: Intensive care, Meningitis meningococcal, Neisseria test positive, Neurological examination normal, Neutrophil count increased
Clinical narrative: This case was reported in a literature article and described the occurrence of Neisseria meningitides meningitis in a 49-year-old male patient who received Influenza vaccine for prophylaxis. Co-suspect products included Leucovorin unknown for rheumatoid arthritis, pneumococcal vaccine for prophylaxis, DT Vaccine for prophylaxis, adalimumab for rheumatoid arthritis, methotrexate for rheumatoid arthritis, prednisone for rheumatoid arthritis and hydroxychloroquine for rheumatoid arthritis. The patient's past medical history included gastroesophageal reflux disease and obstructive sleep apnea syndrome. Concurrent medical conditions included Hashimoto's thyroiditis, Cowden's disease (Multiple Hamartoma Syndrome) and rheumatoid arthritis. Concomitant products included Fluticasone, omeprazole and Levothyroxine. On an unknown date, the patient received Influenza vaccine at an unknown dose, Leucovorin (oral) 10 mg at an unknown frequency, pneumococcal vaccine at an unknown dose and frequency, DT Vaccine at an unknown dose and frequency, adalimumab (subcutaneous) 14 mg at an unknown frequency, methotrexate (oral) 20 mg weekly and prednisone (oral) 40 mg once daily. On an unknown date, the dose was changed to 30 mg once daily. On an unknown date, the patient started hydroxychloroquine (oral) 200 mg twice daily (400 mg daily). On an unknown date, less than a year after receiving Influenza vaccine and unknown after starting Leucovorin, the patient experienced Neisseria meningitides meningitis (serious criteria hospitalization and GSK medically significant), epiglottitis (serious criteria hospitalization and GSK medically significant), bacteremia (serious criteria hospitalization and GSK medically significant), shortness of breath (serious criteria hospitalization), swallowing difficult (serious criteria hospitalization), throat tightness (serious criteria hospitalization), hoarse voice (serious criteria hospitalization), sore throat (serious criteria hospitalization), stridor inspiratory (serious criteria hospitalization), tachycardia aggravated (serious criteria hospitalization), diaphoresis (serious criteria hospitalization), tachypnea (serious criteria hospitalization), orthopnea (serious criteria hospitalization), soft tissue inflammation (serious criteria hospitalization) and fever. The patient was treated with methylprednisolone, Racemic Epinephrine, vancomycin, ceftriaxone, Piperacillin-Tazobactam, dexamethasone, norepinephrine, prednisone and cefuroxime axetil. Leucovorin was interrupted. Adalimumab was interrupted. Methotrexate was interrupted. Prednisone was interrupted. Hydroxychloroquine was interrupted. On an unknown date, the outcome of the Neisseria meningitides meningitis, epiglottitis, bacteremia, shortness of breath, swallowing difficult, throat tightness, hoarse voice, sore throat, stridor inspiratory, tachycardia aggravated, diaphoresis, tachypnea, orthopnea and soft tissue inflammation were recovered/resolved and the outcome of the fever was unknown. It was unknown if the reporter considered the Neisseria meningitides meningitis, epiglottitis, bacteremia, shortness of breath, swallowing difficult, throat tightness, hoarse voice, sore throat, stridor inspiratory, tachycardia aggravated, diaphoresis, tachypnea, orthopnea, soft tissue inflammation and fever to be related to Influenza vaccine and Leucovorin. Additional information was provided. This case was reported in a literature article and described the occurrence of severe acute Neisseria meningitidis epiglottitis (serotype W135); Neisseria meningitidis bacteraemia (serotype W135) in a 49-year-old male who was vaccinated with unspecified influenza, pneumococcal and tetanus-diphtheria vaccines (manufacturer unknown) for prophylaxis. The patient was non-diabetic. The patient's past medical history was significant for Hashimoto's thyroiditis, Cowden's disease (Multiple Hamartoma Syndrome), gastroesophageal reflux disease, obstructive sleep apnoea, and rheumatoid arthritis (RA). The patient's RA was treated with adalimumab 14 mg subcutaneously every 14 days (last dose was six days before admission), methotrexate (MTX) 20 mg orally weekly with leucovorin 10 mg orally twelve hours after MTX (last dose was 4 days before admission), prednisone 30 mg orally daily (tapered from 40 mg daily five days before admission), and hydroxychloroquine 200 mg orally twice daily. Other pertinent home medications included fluticasone 50 mcg/actuation 2 spray each nostril daily, omeprazole 20 mg orally daily, and levothyroxine 250 mcg orally daily. No information on patient's family history was provided. On an unspecified date, the patient received unspecified influenza, pneumococcal and tetanus-diphtheria vaccines (administration route and site unspecified; dosages unknown; batch number not provided). It was reported that the patient was up to date on vaccines. The age of vaccination was not provided. On an unspecified date in 2018, an unknown period after vaccination, the patient presented to an urgent care clinic with complaint of increased shortness of breath, dyspnoea, and difficulty swallowing due to throat tightness for the previous three days. The patient was immediately transferred to another hospital's Emergency Department (ED). Upon arrival to the ED, the patient was having difficulty forming words and was speaking with a hoarse and muffled voice. The patient was hospitalised. All RA medications were held upon admission. The patient's initial vital signs in the ED were a temperature of 37.8 deg. C, heart rate of 122 beats per minute, blood pressure of 92/59 mmHg, respiratory rate of 30 breaths per minute, and oxygen saturation of 97% on room air (normal range not provided for all). Laboratory values upon presentation were significant for a white blood cell (WBC) count of 37.2 x 10E3/uL, segmented neutrophils of 30.9 x 10E3/uL, bands of 4.1 x 10E3/uL, C-reactive protein 136.3 mg/L, and serum creatinine of 1.30 mg/dL. Two sets of blood cultures were obtained. A neck x-ray of the soft tissue revealed a thickened epiglottis. Medications administered in the ED included methylprednisolone 125 mg intravenously, racemic epinephrine 2.25% nebulizer solution 0.5 mL, vancomycin 1000 mg intravenously, and ceftriaxone 1000 mg intravenously. Over the next 5 hours, the patient developed worsening sore throat with inspiratory stridor, worsening tachycardia and diaphoresis, tachypnoea, orthopnoea, and increased oxygen requirements (3 litres nasal cannula to maintain 95% O2 saturation). Based on the patient's progressive decompensation, he was admitted to the intensive care unit (ICU). The patient was intubated in the operating room (OR) due to significant inflammation of the soft tissues surrounding the epiglottis. In the ICU, the patient's antimicrobials were broadened to piperacillin-tazobactam 4.5 gm intravenously every six hours (vancomycin was not continued). Dexamethasone 10 mg intravenously every eight hours replaced methylprednisolone to account for better anti-inflammatory actions in the upper airway. The patient required low-dose norepinephrine to maintain mean arterial pressure (MAP) greater than 65 mmHg. Within 24 hours, the two sets of initial blood cultures resulted with gram negative coccobacilli. The infectious disease (ID) team was consulted and thought the initial report to be consistent with H. influenzae. No modifications to therapy were initiated. At 48 hours, the blood cultures were positive for N. meningitidis and ID streamlined antimicrobial therapy to ceftriaxone 2 gm intravenously every 12 hour for empiric treatment of meningitis since the patient remained intubated and was unable to provide a clear neurological assessment. An echocardiogram (ECHO) revealed a left ventricular ejection fraction of 45-50% and no vegetations were identified. Over hospital days five through seven, the patient was weaned off of vasopressor support and successfully extubated in the OR with no reported stridor, wheezing, laryngospasm, or other complications. The patient's neurologic status was normal. Ceftriaxone 2 gm intravenously daily was continued to complete a total duration of 14 days. Corticosteroids were changed to prednisone 40 mg orally daily. Repeat blood cultures were negative. The patient was discharged home on day 10 with the above mentioned antibacterial therapy and a steroid taper (30 mg orally daily at discharge with a taper down to 10 mg orally daily). On outpatient follow-up with ID, an additional 10 days of oral cefuroxime axetil 500 mg twice daily was prescribed due to complain of fever and a small elevation in WBC. Steroid therapy was continued by rheumatology with taper of 1 mg per month until off and the patient was instructed to restart his RA medication regimen. The oral course of antimicrobials was completed and repeat blood cultures were negative. The case was reported in 2018. The Department of Health confirmed the meningococcal strain was serotype W135. This case has been considered as serious due to hospitalisation. The author did not comment on the relationship between the event of severe acute Neisseria meningitidis epiglottitis (serotype W135) and Neisseria meningitidis bacteraemia (serotype W135) and unspecified influenza vaccine. The authors stated, "It is unclear if underlying immunosuppression (from baseline RA medications) in our case played a role in developing meningococcal epiglottitis. Our case describes a patient who was not neutropenic, nor diagnosed with cancer or HIV, and not receiving traditional chemotherapy. The pathogenicity of N. meningitidis has been well documented, but its role in epiglottitis is not well defined. The pharynx is the suspected portal of entry. It is reported that meningococcal bacteraemia can result from the invasiveness of the organism on epithelial and endothelial cells so it can cross the nasopharyngeal mucosal barrier and enter the bloodstream. Our case patient was on long-term steroid therapy for RA, but he did not have diabetes mellitus. We believe that our patient developed meningococcal epiglottitis and bacteraemia from community contact". The authors concluded, "Neisseria meningitidis epiglottitis is a rare but important diagnosis that requires immediate recognition and antibiotic treatment. This case documents N. meningitidis W135 as the causative serotype and this serogroup should be considered a potential pathogen. We highlight the importance that physicians should consider epiglottitis in the adult patient who presents with dysphagia and respiratory symptoms. Epiglottitis, once a child-hood illness due to H. influenzae, has evolved into an adult affliction with numerous possible infecting pathogens". Lab Comments: Lab tests were performed on unspecified dates in 2018. Bands of 4.1 x 10E3/uL. Two sets of blood cultures were obtained. A neck x-ray of the soft tissue revealed a thickened epiglottis. Within 24 hours, the two sets of initial blood cultures resulted with gram negative coccobacilli. At 48 hours, the blood cultures were positive for N. meningitidis. An echocardiogram (ECHO) revealed no vegetations were identified. The patient's neurologic status was normal.  The oral course of antimicrobials was completed and repeat blood cultures were negative.