Meningococcal disease remains a significant cause of morbidity and mortality in the pediatric population, and has increased in frequency in recent years, particularly among adolescents. Early disease is often mistaken for other, less serious infectious diseases. We sought to identify presenting signs and symptoms which distinguish adolescents with early meningococcal disease from children and adolescents with other infectious diseases. By a retrospective chart review, we identified 74 patients (63 available charts) presenting in the past 10 years with meningococcemia. As a control group, 5,475 consecutive Emergency Department records of children >10 years of age(11/93-11/94) were reviewed for the presence of fever and discharge diagnosis. Older children with meningococcemia were more likely to have complaints of headache and myalgia, while younger children more commonly presented with URI symptoms. More importantly, we found that fever of ≥39°C in adolescents was strongly associated with meningococcemia. Twelve (60%) of 20 adolescents with meningococcemia had this degree of fever compared to only 112 (9.1%) of 1,222 adolescents with other infectious disease diagnoses (p<.0001). In addition, 4 of the 8 adolescents with meningococcemia and temperatures of<39°C were in shock on presentation. We suggest that investigation and observation for meningococcemia in older children and adolescents with fever of >39°C is imperative even if classical features of this disease are not present.