title: A fatal case of streptococcal and meningococcal meningitis in a 2-years-old child occurring as Waterhouse-Friderichsen Syndrome.
abstract: We report a fatal case of streptococcal and meningococcal meningitis in a previously healthy 2-year-old child, a simultaneous co-infection of both pathogens that is poorly reported in the reviewed literature. The lack of a clinical diagnosis in addition to the medico-legal aspects arising from possible professional liability for the emergency service doctor who had failed to recognize the child's symptoms led to a forensic autopsy within 48 h after the death. After external and internal examination, Waterhouse-Friderichsen Syndrome (WFS) was suspected. Consequently, cerebrospinal fluid, whole blood, nasal and pharyngeal swab and pleural liquid samples were selected and collected for microbiological studies. All tested samples resulted Neisseria meningitidis DNA and Streptococcus pneumoniae DNA positive. The NM genotyping Real-Time PCR resulted positive for NM serotype C. Microscopic histological study confirmed these findings. We underline that when a patient presents fever and petechiae (50-60% of patients), WFS must be considered, even when the patient has a non-toxic appearance. Due to its rapid progression and often devastating consequences, therapy should be started as soon as WFS is suspected. Emphasis should also be placed on the importance of public education programs and on broadening protection against meningitis through new vaccines. In such cases, from a forensic point of view, there is a strong need for a robust, multidisciplinary approach in order to reach the correct post-mortem diagnosis.
authors.affiliation: Department of Legal and Forensic Medicine, University of Genoa, S. Martino Hospital, Via De Toni 12, 16132 Genova, Italy. francesco.ventura@unige.it
authors.forename: Francesco
authors.initials: F
authors.lastname: Ventura
authors.forename: Alessandro
authors.initials: A
authors.lastname: Bonsignore
authors.forename: Federica
authors.initials: F
authors.lastname: Portunato
authors.forename: Giulio Fraternali
authors.initials: GF
authors.lastname: Orcioni
authors.forename: Oliviero E
authors.initials: OE
authors.lastname: Varnier
authors.forename: Francesco
authors.initials: F
authors.lastname: De Stefano
mesh_terms: D000311:Adrenal Glands / Q000473:pathology; D001921:Brain / Q000473:pathology; D001929:Brain Edema / Q000473:pathology; D002675:Child, Preschool; D060085:Coinfection / Q000175:diagnosis*; D004269:DNA, Bacterial / Q000302:isolation & purification; D003951:Diagnostic Errors; D017809:Fatal Outcome; D005260:Female; D049429:Forensic Pathology; D006801:Humans; D008168:Lung / Q000473:pathology; D008297:Male; D008318:Malpractice; D008585:Meningitis, Meningococcal / Q000175:diagnosis*; D008586:Meningitis, Pneumococcal / Q000175:diagnosis*; D038542:Neisseria meningitidis, Serogroup C / Q000235:genetics; D011693:Purpura / Q000473:pathology; D013296:Streptococcus pneumoniae / Q000235:genetics; D014884:Waterhouse-Friderichsen Syndrome / Q000175:diagnosis*
chemical_list: D004269:DNA, Bacterial
keywords: Fatal streptococcal-meningococcal co-infection; Meningitis; Professional liability profiles; Waterhouse–Friderichsen Syndrome