CIRCULATORY FAILURE (SHOCK) IN FULMINANT MENINGOCOCCAL INFECTION

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Abstract
NO OCCASION in medical experience makes the awful meaning of this aphorism more clear than the patient prostrated by the sudden onslaught of fulminant meningococcal infection. Prompt relief is imperative; the patient is in too precarious a state to tolerate a fumbling attack, too feeble to withstand meddlesome and overzealous treatment with drugs of uncertain action; and critical decisions must he made in the presence of extreme anxiety. Here, as in all medical care, the truly practical thing to do can best be determined by adequate comprehension of underlying processes. The physician is not often faced with a patient overwhelmed by acute infection, but the alarming and distressing prospect makes so lasting an impression that the manifestations are familiar: pallor, cyanosis, disorientation or unconsciousness, cold extremities, rectal temperature greatly elevated, pulse rapid and feeble, cardiac sounds loud, veins collapsed and arterial pressure reduced. These are the signs of failure of the circulation. In overwhelming infection it is this physiologic disturbance that deserves emphasis and demands first consideration, for it must be corrected promptly to forestall death or disastrous complications. Specific treatment of the infection is important but quite incidental—the patient must be kept alive long enough to reap the benefit of elimination of the causative organism. To the signs of circulatory failure, add purpuric lesions in the skin, leukopenia progressing to leukocytosis and hyperglycemia, and the syndrome of fulminant meningococcal infection is complete. Viewed in their entirety, the manifestations are those of an intoxication affecting many organs and systems. It is of particular interest that most often the circulatory failure precipitated by infection is associated with gram-negative, endotoxin-producing organisms. Meningococcus happens to be the most conspicuous offender in infants and children. Pediatricians have reason for especial concern with this matter; 79% of all the deaths from meningococcal infections in the United States occur in childhood (Table I) and the continuing mortality is largely from the fulminant form, which accounted for 65% of the deaths in a recent series of cases in children. To gain a clear understanding of the pathogenesis of all the manifestations of fulminant meningococcal infection, it will be necessary to consider the biologic effects of endotoxin, but first the nature of the physiologic disturbance of the circulation will be examined.

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