We report an infant case of meningococcal W meningitis presenting within 24 hours of receiving group B meningococcal vaccine (4CMenB), illustrating the dilemma clinicians face in interpreting advice for management of post-immunisation fever and the NICE Fever Guidelines, and highlighting the need for sustained vigilance for bacterial infections in infants with post-4CMenB fever.A 2-month old female infant arrived by ambulance to the local Emergency Department in April 2017 suffering from right-sided focal limb seizures and fever of 39°C, within 24 hours of receiving her 2-month immunisations (including 4CMenB).The seizure terminated with two doses of intravenous lorazepam and suspected sepsis was treated with immediate intravenous antibiotics. Investigations revelealed a normal cranial CT scan; elevated C-reactive protein (263.5 mg/L [0-5]); normal full blood count; normal liver function tests and serum electrolytes.Urine and blood cultures were negative. Cerebrospinal fluid (CSF) obtained 36 hours after antibiotics showed raised white blood cells (1000x10 6 /L), red blood cells (1921x10 6 /L), protein (1750 mg/L [0 -400)], and a low glucose <0.3
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BackgroundDifferentiating infants with adverse events following immunisation (AEFIs) or invasive bacterial infection (IBI) is a significant clinical challenge. Young infants post vaccination are therefore often admitted to the hospital for parenteral antibiotics to avoid missing rare cases of IBI.MethodsDuring a service evaluation project, we conducted a single-centre retrospective observational study of infants with IBI, urinary tract infection (UTI) or AEFI from two previously published cohorts. All patients presented to hospital in Oxfordshire, UK, between 2011 and 2018, spanning the introduction of the capsular group-B meningococcal vaccine (4CMenB) into routine immunisation schedules. Data collection from paper and electronic notes were unblinded. Clinical features, including National Institute for Health and Care Excellence (NICE) ‘traffic light’ risk of severe illness and laboratory tests performed on presentation, were described, and comparisons made using regression models, adjusting for age and sex. We also compared biochemical results on presentation to those of well infants post vaccination, with and without 4CMenB regimens.ResultsThe study included 232 infants: 40 with IBI, 97 with probable AEFI, 24 with possible AEFI, 27 with UTI and 44 post vaccination ‘well’ infants. C-reactive protein (CRP) was the only discriminatory blood marker, with CRP values above 83 mg/L only observed in infants with IBI or UTI. NICE risk stratification was significantly different between groups but still missed cases of IBI, and classification as intermediate risk was non-differential. Fever was more common in probable AEFI cases, while seizures and rashes were equally frequent. Diarrhoea and clinician-reported irritability or rigours were all more common in IBI.ConclusionsClinical features on presentation may aid risk stratification but cannot reliably differentiate IBI from AEFI in infants presenting to the emergency department. Blood results are generally unhelpful due to post vaccination inflammatory responses, particularly in children receiving 4CMenB vaccination. Improved biomarkers and clinical prediction tools are required to aid management in febrile infants post vaccination.
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