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1 Department of Infectious 
Diseases, General Hospital 
Celje, Celje, Slovenia
2 National Institute of 
Public Health, Regional 
Unit Celje, Celje, Slovenia
3 Department of Public 
Health Microbiology, 
Centre for Medical 
Microbiology, National 
Laboratory of Health, 
Environment and Food, 
Ljubljana, Slovenia
Correspondence/
Korespondenca:
Miha Simoniti, e: miha.
simoniti@gmail.com
Key words:
meningococcus; serogroup 
B; cluster; bone and joint 
infections
Ključne besede:
meningokok; skupina B; 
skupek; okužbe kosti in 
sklepov
eng slo element
en article-lang
10.6016/ZdravVestn.3042 doi
24.2.2020 date-received
19.1.2021 date-accepted
Infections Infekcije discipline
Short scientific article Klinični primer article-type
First case of interconnected clusters of prima-
ry meningococcal arthritis and meningococ-
cal meningitis due to Neisseria meningitidis 
serogroup B in Slovenia
Prvi primer povezanih skupkov primarnega 
meningokoknega artritisa in meningokoknega 
meningitisa zaradi Neisserie meningitidis skupine 
B v Sloveniji
article-title
First case of interconnected clusters of inva-
sive meningococcal disease in Slovenia
Prvi primer povezanih skupkov invazivnih menin-
gokoknih bolezni v Sloveniji alt-title
meningococcus, serogroup B, cluster, bone 
and joint infections
meningokok, skupina B, skupek, okužbe kosti in 
sklepov kwd-group
The authors declare that there are no conflicts 
of interest present.
Avtorji so izjavili, da ne obstajajo nobeni 
konkurenčni interesi. conflict
year volume first month last month first page last page
2021 90 5 6 266 274
name surname aff email
Miha Simoniti 1 miha.simoniti@gmail.com
name surname aff
Tanja Selič Kurinčič 1
Alenka Trop Skaza 2
Ines Kebler 2
Metka Paragi 3
Tamara Kastrin 3
eng slo aff-id
Department of Infectious 
Diseases, General Hospital Celje, 
Celje, Slovenia
Splošna bolnišnica Celje, 
Oddelek za infekcijske bolezni in 
febrilna stanja, Celje, Slovenija
1
National Institute of Public 
Health, Regional Unit Celje, 
Celje, Slovenia
Nacionalni inštitut za javno 
zdravje, Območna enota Celje, 
Celje, Slovenija
2
Department of Public 
Health Microbiology, Centre 
for Medical Microbiology, 
National Laboratory of Health, 
Environment and Food, 
Ljubljana, Slovenia
Nacionalni laboratorij za zdravje, 
okolje in hrano, Oddelek za 
javnozdravstveno mikrobiologijo, 
Ljubljana, Slovenija
3
First case of interconnected clusters of 
primary meningococcal arthritis and 
meningococcal meningitis due to Neisseria 
meningitidis serogroup B in Slovenia
Prvi primer povezanih skupkov primarnega meningokoknega 
artritisa in meningokoknega meningitisa zaradi Neisserie 
meningitidis skupine B v Sloveniji
Miha Simoniti,1 Tanja Selič Kurinčič,1 Alenka Trop Skaza,2 Ines Kebler,2 Metka Paragi,3 
Tamara Kastrin3
Abstract
In this report, we describe a case of interconnected clusters of invasive meningococcal disease 
due to Neisseria meningitidis serogroup B:P1.22,14:F5-1(ST-269) in young adults – a boyfriend 
and a girlfriend. The male was diagnosed with primary meningococcal septic arthritis of the right 
knee and the female was diagnosed with meningococcal meningitis with meningococcemia a 
few hours later. Both were hospitalized at the General Hospital Celje and treated with ceftriax-
one, but with different outcomes; the female recovered completely, while the male will probably 
have long-term sequelae of septic arthritis.
Izvleček
V članku opisujemo primer povezanega skupka invazivne meningokokne bolezni zaradi povzro-
čitelja Neisseria meningitidis serološke skupine B:P1.22,14:F5-1(ST-269) pri mladih odraslih (fant 
in dekle). Pri moškem smo ugotavljali primarni meningokokni septični artritis desnega kolena in 
pri ženski meningokokni meningitis z meningokokcemijo z začetkom nekaj ur kasneje. Oba sta 
bila hospitalizirana v Splošni bolnišnici Celje in zdravljena s ceftriaksonom, a z različnima izido-
ma. Ženska je popolnoma ozdravela, medtem ko bo imel moški najverjetneje trajne posledice 
zaradi septičnega artritisa.
Cite as/Citirajte kot: Simoniti M, Selič Kurinčič T, Trop Skaza A, Kebler I, Paragi M, Kastri T. First case of 
interconnected clusters of primary meningococcal arthritis and meningococcal meningitis due to Neisseria 
meningitidis serogroup B in Slovenia. Zdrav Vestn. 2021;90(5–6):266–74.
DOI: https://doi.org/10.6016/ZdravVestn.3042
Copyright (c) 2021 Slovenian Medical Journal. This work is licensed under a
Creative Commons Attribution-NonCommercial 4.0 International License.
Slovenian
Medical
Journal
267
SHORT SCIENTIFIC ARTICLE
First case of interconnected clusters of invasive meningococcal disease in Slovenia
1 Introduction
Neisseria meningitidis (the menin-
gococcus) is the cause of invasive me-
ningococcal disease, ranging from mild 
bacteraemia to devastating purulent 
meningitis, sepsis, pneumonia and oth-
er, less common forms such as meningo-
coccal arthritis (1). In 2017, 3,221 con-
firmed cases of invasive meningococcal 
disease (IMD), including 282 deaths, 
were reported in 30 EU/EEA Member 
States. Serogroup B caused 51% of cas-
es overall and was the dominating sero-
group in all age groups below 65 years 
(2). We present a cluster of two cases of 
invasive meningococcal disease – arthri-
tis and meningococcaemia with menin-
gitis. Both cases were caused by Neisseria 
meningitidis serogroup B and our cluster 
is the first to be reported in Slovenia.
2 Case reports
On 11 December 2018, a 23-year-old 
previously healthy male was examined 
in the Surgical Emergency Room of the 
General Hospital Celje because of swell-
ing of his right knee that had occurred 
suddenly two days earlier; he could not 
remember any trauma that might have 
caused it. He had become febrile on 8 
December 2018, a day before the knee 
swelling occurred, and reported about 
a rash on his torso. He had a headache 
which spontaneously resolved with-
out intervention. However, during the 
medical examination, the focus was only 
on the knee and there was no mention of 
a febrile illness. The surgeon described 
a significant circular swelling of the 
knee with positive ballottement and no 
signs of inflammation such as redness or 
heat. The surgeon ordered an X-ray that 
showed no signs of skeletal trauma, and 
performed a puncture to obtain a fluid 
sample that was then sent for culture to 
the microbiology laboratory.
On 13 December 2018, he was con-
tacted to return to the hospital as the 
Gram stain of the joint fluid showed 
Gram-negative diplococci and the 
culture grew Neisseria meningitidis. 
He was immediately admitted to the 
Orthopaedics Ward. The epidemiolo-
gist of the National Institute of Public 
Health, Regional Unit Celje, was notified 
about the patient. An infectious disease 
specialist was called in for consultation 
and examined the patient: a petechial 
rash could be seen on his limbs, but the 
patient did not present with meningeal 
symptoms. Laboratory testing revealed 
moderately elevated CRP and mildly ele-
vated procalcitonin without leukocytosis 
(Table 1). The rest of the findings were 
within normal limits, including coagula-
tion studies; laboratory testing was not 
repeated until 7 days later, after which 
inflammatory parameters had normal-
ized. After blood cultures were drawn, 
the patient started antibiotic therapy 
Table 1: Laboratory testing results of the male patient.
Variable Reference range On admission
White blood cell count (per mm3) 4,000 – 10,000 8,100
Platelet count (per mm3) 150,000 – 350,000 290,000
CRP (mg/L) <5 87.0
Procalcitonin <0.5 1.2
Received: 24. 2. 2020
Accepted: 19. 1. 2021
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with ceftriaxone 2g/12h. A synovecto-
my was performed in the patient on 13 
December 2018.
Susceptibility testing of Neisseria 
meningitidis from the synovial fluid 
showed excellent susceptibility to all 
tested antibiotics. Blood cultures drawn 
prior to the start of antibiotic therapy 
were negative for bacterial growth, as 
was the synovial sample taken during 
the surgery.
The subsequent course and hospital-
ization were uneventful. The patient was 
afebrile and he developed no new symp-
toms. However, symptoms concerning 
his right knee abated only slowly and in-
completely, with pain and poor mobility 
persisting despite physical and analgesic 
therapy. He received parenteral ceftri-
axone for 14 days and on 27 December 
2018 he was switched to oral ciproflox-
acin therapy (750 mg twice daily). He 
was discharged from the hospital on 31 
December 2018. After completing the 
three-week antibiotic course, the patient 
came in for a check-up. Due to persistent 
poor mobility of the right knee and on-
ly 20 degree flexion, the patient was re-
ferred to balneorehabilitation at a ther-
mal spa.
After 6 months of follow-up no sig-
nificant improvement of symptoms had 
been achieved with loss of mobility per-
sisting, especially with flexion.
On 12 December 2018, the first pa-
tient’s girlfriend, a previously healthy 
23-year-old woman, fell ill with a sore 
throat, a temperature of up to 40 de-
grees Celsius, and generalized mus-
cle and joint pain. Her right ankle and 
left wrist were particularly painful, but 
without any signs of arthritis. On 13 
December 2018, she noticed a red rash 
spreading over her whole body. She did 
not have a headache. She was examined 
in the Infectious Diseases Emergency 
Room at the General Hospital Celje on 
13 December 2018. By that time, it had 
already been confirmed that her boy-
friend was ill with meningococcal septic 
arthritis. She was tachycardic, hyper-
tensive and febrile. Petechial haemor-
rhage was noticed on her body. There 
was mild pharyngitis without tonsilli-
tis, and the rest of the examination was 
unremarkable. Laboratory testing re-
vealed a normal total leukocyte count 
with left shift and mildly elevated CRP, 
moderately elevated procalcitonin and 
creatinine (Table 2). Blood cultures 
were drawn and treatment with ceftri-
axone 2g/12h started immediately af-
terwards. Laboratory testing 18 hours 
after admission showed a significant 
increase in inflammatory parameters 
and near-normalization of kidney func-
tion. The rest of the parameters tested, 
including hepatic enzymes, were with-
in normal limits, including on admis-
sion . On 14 December 2018, a lumbar 
puncture was performed. Cerebrospinal 
fluid (CSF) was macroscopically cloudy 
and colourless. White blood cell count 
was 5205 leukocytes per mm3 with neu-
trophilic predominance, glucose was 
2.51  mmol/L, and protein 1.51 g/L. A 
CSF sample was sent for microbiologic 
analysis – PCR Filmarray was positive 
for N. meningitidis, Gram stain showed 
damaged Gram-negative diplococci and 
culture was negative for bacterial growth 
– the lumbar puncture was performed 
after antibiotic therapy had commenced. 
Blood cultures also grew N. meningitidis. 
The regional epidemiologist was notified 
about this patient as well. Susceptibility 
testing of N. meningitidis from blood 
cultures showed excellent susceptibility 
to all tested antibiotics.
The subsequent clinical course was 
mostly uneventful as the patient be-
came afebrile soon, with the repeated 
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SHORT SCIENTIFIC ARTICLE
First case of interconnected clusters of invasive meningococcal disease in Slovenia
laboratory testing showing a significant 
decrease in inflammatory parameter lev-
els. Arthralgia had resolved completely 
by 22 December 2018, when the patient 
was discharged from the hospital after 
having been treated for 10 days with cef-
triaxone. At home, she continued taking 
oral penicillin for 4 more days. By the 
first check-up on 16 January 2019, the 
patient had recovered completely.
In both cases, the isolates were N. 
meningitidis serogroup B. The isolates 
were serotyped by slide agglutination and 
the results were confirmed with molec-
ular capsule typing by RT-PCR (3). The 
genome sequences of the isolates were 
determined on an Illumina MiSeq plat-
form. Whole genome sequence (WGS) 
data were collected, de novo assembled 
and submitted for the automated anno-
tation and analysis to the PubMLST/
Neisseria website, BIGSdb (4).
Both isolates were ST-269, ST-269 com-
plex, with the finetype B:P1.22,14:F5-1.
Table 2: Laboratory testing results of the female patient.
Variable Reference range On admission 18 hours after 
admission
White blood cell count (per mm3) 4,000 – 10,000 8,900 10,500
Differential count (%)
Neutrophils 40-75 80 61
Band forms <4 12 15
Lymphocytes 20-50 6 19
Monocytes 2-10 2 4
Basophils 0-1 0 0
Eosinophils <6 0 0
Platelet count (per mm3) 150,000 – 350,000 200 180
CRP (mg/L) <5 87.0 183.4
Procalcitonin <0.5 4.0 8.0
Creatinine (µmol/L) 44-80 130 102
2.1 Epidemiological investigation
On 13 December 2018, the epide-
miologist at the National Institute of 
Public Health, Regional Unit Celje, was 
informed of the isolation of N. menin-
gitidis from the punctate of the male’s 
knee, and also of the suspicion of me-
ningococcal meningitis in the male’s 
girlfriend a few hours later.
In accordance with invasive me-
ningococcal disease intervention al-
gorithm we identified 9 close contacts. 
Four contacts were family members – 3 
adults and 1 child. All family members 
received antibiotic prophylaxis with ci-
profloxacin – the adults received a sin-
gle 500 mg dose, and the child received 
a single 250 mg dose. The other close 
contacts were friends with whom the 
patients had interacted on 8 December. 
They also received a single 500 mg dose 
of ciprofloxacin (5,6).
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3 Discussion
Unusually, the patient with arthritis 
did not completely recover despite the 
adequate and even prolonged antibiot-
ic and surgical therapy, perhaps due to 
a delay in starting treatment. Prompt 
recognition and treatment of the clini-
cal syndrome and rapid epidemiological 
investigation and start of chemoprophy-
laxis are key to preventing progression 
of the disease in index cases and pre-
venting further spread of the invasive 
disease in close contacts.
In Europe, the incidence rate of con-
firmed cases of invasive meningococ-
cal disease is similar to that in Slovenia 
(0.5/100,000 inhabitants) (Table 3) (7). 
In 2017, the overall incidence for inva-
sive meningococcal disease in Europe 
was 0.6/100,000 inhabitants. The clinical 
presentation was known for 1641 cases 
(51%). Meningitis or both meningitis 
and meningococcemia was reported in 
937 cases (57%), meningococcemia on-
ly in 604 (37%), pneumonia in 19 (1%) 
and ‘other’ in 81 cases (5%) (2). As part 
of the national surveillance system of 
invasive bacterial infections in Slovenia, 
all invasive isolates of  N. meningiti-
dis are collected at the Department for 
Public Health Microbiology, National 
Laboratory of Health, Environment and 
Food in Ljubljana, where they are typed 
and the antibiotic susceptibility is deter-
mined (7).
In 2017, 8 isolates of N. meningiti-
dis were received at the Department for 
Table 3: Reported cases and incidence rate of invasive meningococcal diseases. Referenced 
after Sočan M, et al. (7).
Year 2013 2014 2015 2016 2017
Number of reported cases 11 8 20 7 11
Cases/100,000 0.5 0.4 1.0 0.3 0.5
Public Health Microbiology, National 
Laboratory of Health, Environment and 
Food in Ljubljana, out of 11 that were 
reported in total in that year; the other 
3 were not sent to the reference labora-
tory and were thus not analysed further. 
Out of these, six were isolated in chil-
dren (under the age of 15 years) and two 
in the adult patient group (>15 years of 
age). The sample from which they were 
isolated was in five cases blood, in two 
cases blood and CSF at the same time, 
and in one case CSF. The referring di-
agnosis was known to the laboratory in 
five cases; in four cases it was meningitis 
and in one case sepsis; in the rest, the 
clinical diagnosis was not made avail-
able to the laboratory. In six cases, we 
demonstrated the serogroup B and in 
two cases the serogroup C (7).
In 2018, 19 cases of invasive me-
ningococcal disease were confirmed 
by the Department for Public Health 
Microbiology, National Laboratory 
of Health, Environment and Food in 
Ljubljana (Figure 1) (8). Eighteen cas-
es were laboratory-confirmed, and one 
was a potential case without laboratory 
confirmation. In three cases, this was 
demonstrated only by the molecular RT-
PCR method from the patient’s blood. 
Fifteen isolates of N. meningitidis were 
cultivated. In the age group of children 
under the age of 15 years the laboratory 
received six isolates of N. meningitides 
and in one additional case N. meningiti-
dis serogroup C was demonstrated only 
by RT-PCR. In three cases the sample 
271
SHORT SCIENTIFIC ARTICLE
First case of interconnected clusters of invasive meningococcal disease in Slovenia
was CSF, in two it was blood, and in 
two cases blood and a CSF sample at 
the same time. The clinical diagnosis 
was known to the laboratory only in one 
case - meningitis. In the adult patient 
group (>15 years of age) the laboratory 
received 11 samples, two of which were 
demonstrated only molecularly. In nine 
cases the sample was blood, in one case 
it was blood and CSF at the same time, 
and in one case meningococcus was 
isolated from the knee puncture. The 
clinical diagnosis was known to the lab-
oratory in six cases, in three cases there 
was meningitis and in two sepsis, in one 
case it was pneumonia and in one case 
it was septic arthritis. In eight cases we 
demonstrated N. meningitidis serogroup 
B, in seven cases N. meningitidis sero-
group C, in two cases N. meningitidis 
serogroup Y, and in one case serogroup 
was not determined (Figure 1). Other 
serogroups of meningococcal disease 
are very rare in Slovenia (M. Paragi 
Personal Communication 4. 2. 2019; 
8,9).
At this point it should be noted that 
the laboratory does not always receive 
information about the patient and their 
Figure 1: Invasive meningococcal disease: serogroup identification in 2018. Referenced after 
(8).
Serogroup B Serogroup C Serogroup Y Serogroup not determined
3.5
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2.5
2
1.5
1
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Feb
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clinical information in the referral doc-
ument along with samples for microbi-
ological analysis; this accounts for the 
lack of clinical diagnosis in several of 
the isolates mentioned in the text.
A cluster in the field of epidemiol-
ogy means an aggregation of cases of a 
disease or another health-related con-
dition; in our case, it refers to two pa-
tients, close contacts to each other, de-
veloping the same infectious disease in a 
short period of time. The highest risk of 
transmission of invasive meningococcal 
disease is to people who live in the same 
household as a case of meningococcal 
disease; in such cases, the absolute risk 
of developing a second case of invasive 
meningococcal disease within 30 days 
is 1 in 300 if chemoprophylaxis is not 
administered. This risk is the highest 
in the first 7 days and then falls rapidly 
(9,10,11,12). Chemoprophylaxis should 
be administered to close contacts that 
were in contact with the index patient 
during the 7 days before symptoms ap-
pear and for the first 24 hours from the 
start of antibiotic treatment. The pur-
pose of chemoprophylaxis is to reduce 
the incidence of invasive meningococcal 
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disease among close contacts by elimi-
nating established or newly acquired 
carriage of N. meningitidis that could 
cause invasive disease. In our case, cip-
rofloxacin chemoprophylaxis was given 
to all close contacts (5).
In 2017, 7 out of 8 isolates were sus-
ceptible to penicillin, as were the iso-
lates from our patients (7). They were 
both treated with ceftriaxone instead 
of the more appropriate penicillin. The 
decision to treat with ceftriaxone and 
administer ciprofloxacin prophylax-
is could be explained by easier use and 
convenient dosing, even though such 
decisions are not strictly medically cor-
rect; a single daily dose of ceftriaxone 
and a single dose of prophylactic cip-
rofloxacin instead of multiple doses of 
penicillin daily and two days of rifampi-
cin prophylaxis. The authors do not con-
done such behaviour and recommend 
that medically appropriate instead of 
more convenient antibiotics be used for 
invasive meningococcal as well as other 
bacterial infections.
Our patients were treated as follows: 
the female patient with meningococce-
mia and meningitis for 14 days (10 days 
of parenteral ceftriaxone and 4 days of 
oral penicillin), and the male patient 
with arthritis for 21 days (14 days of 
parenteral ceftriaxone and 7 days of oral 
ciprofloxacin). The duration of treat-
ment for the female patient was longer 
than that suggested by guidelines for the 
treatment of meningococcal meningi-
tis, which is 5-7 days (13). The duration 
of treatment for meningococcal arthri-
tis has not yet been established; 21-day 
treatment is recommended for septic 
arthritis caused by common microor-
ganisms, such as Staphylococcus aureus, 
but is probably excessive in the case of 
meningococcal joint infections; in a 
large series, 4-7 days of treatment were 
enough for cure (14).
Septic arthritis is an acute bacterial 
infection of synovial joints. It is an in-
fectious disease that requires early di-
agnosis and prompt treatment with a 
combination of antibiotics and surgical 
drainage. In Slovenia, the most com-
monly affected joint is the knee (48.9%), 
followed by the shoulder, wrist, and an-
kle. The most common cause of septic 
arthritis is Staphylococcus aureus, fol-
lowed by streptococci; Gram-negative 
organisms are causative in 21% of cases, 
and of these, N. meningitidis is report-
ed very rarely - in approximately 1% of 
all cases of septic arthritis (14,15). The 
frequency of arthritis secondary to me-
ningococcal disease is variable, but the 
latest series reported a prevalence of 
2% to 12.5% (14,16). In experimental 
models of bacterial arthritis, cartilage 
destruction starts after only eight hours 
of joint infection. The administration 
of antibiotics 24 hours after the infec-
tion causes significant joint destruction 
with an overall loss of collagen of up to 
37%. Although there have been no for-
mal long-term studies carried out, long-
term outcomes after primary meningo-
coccal arthritis appear to be favourable. 
In contrast to literature reporting no 
major sequelae after meningococcal ar-
thritis, our patient did suffer from com-
plications and sequelae in the form of 
loss of knee mobility (17,18,19).
The presented male patient with an 
atypical clinical course started treat-
ment with antibiotics and surgery 3 days 
after the first onset of symptoms. Based 
on the published data for overall prog-
nosis of septic arthritis with late treat-
ment, irreversible joint destruction can 
be expected (18).
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First case of interconnected clusters of invasive meningococcal disease in Slovenia
4 Conclusion
We confirmed the first cluster of inva-
sive meningococcal disease in Slovenia. 
Meningococcal arthritis is a very rare 
disease that can be overlooked if the pa-
tient’s case history is incomplete. Prompt 
diagnosis and combination treatment 
with antibiotics and surgical drainage 
are crucial to prevent irreversible joint 
destruction. A brief description of the 
clinical picture with the sample sent for 
microbiological analysis would also be 
of great help to the microbiology labora-
tory responsible for identifying the caus-
ative microorganism.
References
1. Bennet JE, Dolin R, Blaser MJ. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious 
Diseases. 9th ed. Philadelphia (PA): Elsevier/Saunders; 2020. pp. 2585-607.
2. European Centre for Disease Prevention and Control. Invasive meningococcal disease: suveillance report: 
annual epidemiological report for 2017. Solna: ECDC; 2019 [cited 21 April 2019]. Available from: https://
www.ecdc.europa.eu/sites/default/files/documents/AER_for_2017-invasive-meningococcal-disease.pdf.
3. Castillo D, Harcourt B, Hatcher C, Jackson M, Katz L, Mair R, et al. Laboratory methods for the diagnosis of 
meningitis casued by Neisseria meningitides, Streptocococcus pneumoniae, and Haemophilus influenzae. 
2nd ed. Geneva: World Health Organization; 2011 [cited 2019 Feb 5]. Available from: https://www.cdc.gov/
meningitis/lab-manual/full-manual.pdf.
4. Jolley KA, Maiden MC. BIGSdb: scalable analysis of bacterial genome variation at the population level. 
BMC Bioinformatics. 2010;11(1):595. DOI: 10.1186/1471-2105-11-595 PMID: 21143983
5. Grgič Vitek M, Učakar V. Invazivna meningokokna bolezen: algoritem ukrepanja: posodobljeno maj 2015. 
Ljubljana: Nacionalni inštitut za javno zdravje; 2017 [cited 2019 Feb 5]. Available from: https://www.nijz.si/
sites/www.nijz.si/files/publikacije-datoteke/algoritem_meningo_posodobljen_2015_04_05_2015.pdf.
6. European Centre for Disease Prevention and Control. Public health management of sporadic cases 
of invasive meningococcal disease and their contacts. Solna: ECDC; 2010 [cited 2019 Feb 5]. Available 
from: https://www.ecdc.europa.eu/sites/default/files/media/en/publications/Publications/1010_GUI_
Meningococcal_guidance.pdf.
7. Sočan M, Frelih T, Klavs I, Grilc E, Grgič Vitek M, Učakar V. Epidemiološko spremljanje nalezljivih bolezni v 
Sloveniji v letu 2018. Ljubljana: Nacionalni inštitut za javno zdravje; 2018 [cited 2019 Feb 5]. Available from: 
https://www.nijz.si/sites/www.nijz.si/files/uploaded/epidemiolosko_spremljanje_nalezljivih_bolezni_v_
sloveniji_v_letu_2018.pdf.
8. Tedenski pregled dogodkov, nalezljive bolezni 4/2019 = Weekly report, Communcable diseases 4/2019. 
Ljubljana: Nacionalni inštitut za javno zdravje; 2019.
9. Trop Skaza A, Selič Kurinčič T, Beškovnik L, Paragi M, Božanić V. First case of meningococcal meningitis 
due to Neisseria meningitidis serogroup Z′ in Slovenia, December 2010. Euro Surveill. 2011;16(6):2-4. DOI: 
10.2807/ese.16.06.19786-en PMID: 21329646
10. Hastings L, Stuart J, Andrews N, Begg N. A retrospective survey of clusters of meningococcal disease in 
England and Wales, 1993 to 1995: estimated risks of further cases in household and educational settings. 
Commun Dis Rep CDR Rev. 1997;7(13):R195-200. PMID: 9447784
11. De Wals P, Hertoghe L, Borlée-Grimée I, De Maeyer-Cleempoel S, Reginster-Haneuse G, Dachy A, et al. 
Meningococcal disease in Belgium. Secondary attack rate among household, day-care nursery and pre-
elementary school contacts. J Infect. 1981;3(1):53-61. DOI: 10.1016/S0163-4453(81)80009-6 PMID: 7185953
Inform consent of the patient
Both patients gave informed consent 
for the publication of their cases.
Acknowledgement
This publication made use of the 
Neisseria Multi Locus Sequence Typing 
website (https://pubmlst.org/neisseria/) 
sited at the University of Oxford (Jolley et 
al. Wellcome Open Res2018, 3:124 [ver-
sion 1; referees: 2 approved]). The de-
velopment of this site has been funded 
by the Wellcome Trust and European 
Union.
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12. Zangwill KM, Schuchat A, Riedo FX, Pinner RW, Koo DT, Reeves MW, et al. School-based clusters of 
meningococcal disease in the United States. Descriptive epidemiology and a case-control analysis. JAMA. 
1997;277(5):389-95. DOI: 10.1001/jama.1997.03540290041030 PMID: 9010171
13. Čižman M, Beović B. Kako predpisujemo protimikrobna zdravila v bolnišnicah. 2., dopolnjena izd. 
Ljubljana: Sekcija za protimikrobno zdravljenje Slovenskega zdravniškega društva; 2013.
14. Cabellos C, Nolla JM, Verdaguer R, Pelegrin I, Ribera A, Ariza J, et al. Arthritis related to systemic 
meningococcal disease: 34 years’ experience. Eur J Clin Microbiol Infect Dis. 2012;31(10):2661-6. DOI: 
10.1007/s10096-012-1610-1 PMID: 22476361
15. Ross JJ, Saltzman CL, Carling P, Shapiro DS. Pneumococcal septic arthritis: review of 190 cases. Clin Infect 
Dis. 2003;36(3):319-27. DOI: 10.1086/345954 PMID: 12539074
16. Weisfelt M, van de Beek D, Spanjaard L, de Gans J. Arthritis in adults with community-acquired bacterial 
meningitis: a prospective cohort study. BMC Infect Dis. 2006;6(1):64. DOI: 10.1186/1471-2334-6-64 PMID: 
16571115
17. Furlan Lotrič S, Volkar Meglic J, Kolšek M, Bogovič P. Characteristics of patients with septic arthritis in 
Slovenia. Orthop Proc. 2015;97-B:62.
18. Boyle C, Howard T, Griffith D, Cowie J. Primary meningococcal septic arthritis with multiple native joint 
involvement. BMJ Case Rep. 2018;2018. DOI: 10.1136/bcr-2017-223197 PMID: 29739760
19. Smith RL, Schurman DJ, Kajiyama G, Mell M, Gilkerson E. The effect of antibiotics on the destruction 
of cartilage in experimental infectious arthritis. J Bone Joint Surg Am. 1987;69(7):1063-8. DOI: 
10.2106/00004623-198769070-00015 PMID: 3654698