Meningococcal serogroup W ST-11 causing meningitis, endogenous endophthalmitis, and septic arthritis in a child

Invasive meningococcal disease (IMD) remains a major global health concern because of its epidemic potential, unpredictable presentation, and rapid progression. Although IMD classically presents as meningitis, meningococcemia, or both, Neisseria meningitidis can also cause extra-meningeal manifestations. Serogroup W (MenW), particularly the hyperinvasive ST-11 lineage, has increasingly been associated with atypical and invasive clinical phenotypes. We report an 11-year-old previously healthy boy with IMD due to MenW ST-11 who developed the exceptional triad of meningitis, endogenous endophthalmitis, and septic arthritis.

An 11-year-old boy residing in a school dormitory presented with fever, rhinorrhea, cough, generalized erythematous rash, and conjunctival redness. Because of altered consciousness and seizures, he was transferred to the pediatric intensive care unit after receiving initial antibiotic therapy. He had not received meningococcal vaccines. On admission, he was lethargic, with anisocoria, marked right conjunctival hyperemia, neck stiffness, and a diffuse non-blanching petechial and purpuric rash. Cerebrospinal fluid (CSF) analysis was consistent with purulent meningitis; Gram stain showed rare Gram-negative diplococci, and CSF PCR identified N. meningitidis serogroup W, ST-11. Ophthalmologic examination confirmed severe endogenous endophthalmitis with hypopyon, and vitreous PCR also detected N. meningitidis. Because of clinical non-response with progressive ocular and neurologic involvement, therapy was escalated to meropenem. On hospital day 7, acute right knee swelling developed, and synovial fluid PCR confirmed MenW. At 6-week follow-up, the patient had normal vision, normal hearing, no neurologic deficits, and no joint sequelae.

Meningococcal endophthalmitis is rare and usually associated with poor visual outcomes; only one adult MenW case has been reported previously. This case demonstrates that MenW ST-11 can cause aggressive multisystem IMD in children and underscores the importance of molecular diagnosis, early multidisciplinary care, and MenACWY vaccination.