# A 38-year-old client with atypical hemolytic uremic syndrome received the first urgent dose of eculizumab 6 days ago, before meningococcal vaccination could be completed 2 weeks in advance. Meningococcal ACWY and B vaccines were given the same day, and oral penicillin prophylaxis was prescribed. The client missed 2 prophylaxis doses because of nausea. Today the client reports chills, headache, and severe leg aches that began 3 hours ago. Temperature is 39.2°C (102.6°F), heart rate 118/min, blood pressure 98/60 mm Hg (baseline 132/80 mm Hg), and respiratory rate 22/min. A few nonblanching petechiae are present on both lower legs; the neck is supple. Platelet count is 188,000/mm3 (42,000/mm3 on admission), LDH is falling, and creatinine has improved from 3.1 to 1.6 mg/dL. The deltoid injection sites are not red or swollen. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617370&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## Question

A 38-year-old client with atypical hemolytic uremic syndrome received the first urgent dose of eculizumab 6 days ago, before meningococcal vaccination could be completed 2 weeks in advance. Meningococcal ACWY and B vaccines were given the same day, and oral penicillin prophylaxis was prescribed. The client missed 2 prophylaxis doses because of nausea. Today the client reports chills, headache, and severe leg aches that began 3 hours ago. Temperature is 39.2°C (102.6°F), heart rate 118/min, blood pressure 98/60 mm Hg (baseline 132/80 mm Hg), and respiratory rate 22/min. A few nonblanching petechiae are present on both lower legs; the neck is supple. Platelet count is 188,000/mm3 (42,000/mm3 on admission), LDH is falling, and creatinine has improved from 3.1 to 1.6 mg/dL. The deltoid injection sites are not red or swollen. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Condition

Select 1
Influenza
Recurrent aHUS thrombotic microangiopathy
Post-vaccination febrile reaction
Invasive meningococcal infection

Actions to take

Select 2
Hold the next scheduled eculizumab infusion
Give acetaminophen and recheck temperature in 1 hour
Give prescribed IV ceftriaxone after blood cultures
Prepare for plasma exchange per hematology protocol
Notify the provider and start Droplet Precautions

Parameters to monitor

Select 2
Blood pressure and heart rate
Platelet count and LDH
Induration at the vaccine injection sites
Extent of petechial or purpuric rash
Cough and nasal congestion

## Explanation

Complement inhibition with eculizumab greatly increases the risk of rapid, life-threatening meningococcal infection, and vaccination does not remove that risk, especially in the first 2 weeks. Fever, myalgia, falling blood pressure, and new petechiae with a rising platelet count point to meningococcemia rather than aHUS relapse. The nurse escalates immediately, starts Droplet Precautions, and gives empiric IV antibiotics after cultures, then trends hemodynamics and rash spread.

## In-depth explanation

Quick answer
Invasive meningococcal infection. Actions: give prescribed IV ceftriaxone after blood cultures; notify the provider and start Droplet Precautions. Monitor: blood pressure with heart rate, and the extent of the petechial or purpuric rash.

Why this is correct
Eculizumab blocks terminal complement, which is the main defense against Neisseria meningitidis. The boxed warning states that infections can become life-threatening rapidly and that vaccinated clients remain at risk. This client was vaccinated only 6 days ago and missed prophylaxis. Fever, severe myalgia, tachycardia, blood pressure 34 mm Hg below baseline, and nonblanching petechiae are early meningococcemia. The platelet count and LDH are improving, which argues against an aHUS relapse as the cause of the petechiae.

Easy analogy or mental picture
Eculizumab is like switching off a building's alarm system to stop a false fire alarm (aHUS): it works, but a real burglar (meningococcus) can now walk in, so any sign of an intruder means calling security at once.

Memory hook
Complement off, meningococcus on: fever plus petechiae on eculizumab = cultures, ceftriaxone, call now.

NCLEX decision rule
In a client on a drug with a boxed infection warning, treat a new fever with hemodynamic change as the boxed-warning complication until proven otherwise; do not attribute it to a benign cause first.

Why the other choices are wrong
Influenza shares fever and myalgia but not nonblanching petechiae or relative hypotension, and cough is not the parameter that tracks meningococcemia. A post-vaccination reaction appears within 1 to 2 days and shows local injection-site changes; neither is present, so acetaminophen with a recheck delays sepsis care. aHUS relapse is tempting because of petechiae, but platelets and LDH are improving, so plasma exchange and a platelet/LDH trend target the wrong problem. Holding the next eculizumab infusion is not the immediate action and interrupting therapy risks TMA relapse; that decision belongs to the prescriber after the infection is treated.

References
1DailyMed — SOLIRIS (eculizumab) prescribing informationBoxed warning: life-threatening meningococcal infection despite vaccination; immediate evaluation of early signs.

## Clinical scenario

Scenario
Six days after urgent eculizumab with same-day meningococcal vaccination and missed prophylaxis doses, a client with aHUS develops fever, headache, myalgia, relative hypotension, and new petechiae while hematologic markers are improving.

## Key concepts

- **Complement inhibitor** — A drug such as eculizumab that blocks complement protein C5 and impairs defense against Neisseria species.
- **Meningococcemia** — Bloodstream infection with Neisseria meningitidis that can cause petechial rash, shock, and death within hours.
- **REMS** — A Risk Evaluation and Mitigation Strategy that requires counseling and a patient safety card for eculizumab.

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