Meningococcal Meningitis

Case Presentation Meningococcal Septicaemia and Meningitis : 

Case Presentation Meningococcal Septicaemia and Meningitis By Louise MacWhirter 4 th Year Medical Student

Objectives : 

Objectives Case presentation of JPB History Examination Differential Diagnosis Management Progression Meningococcal Septicaemia and Meningitis Definitions Epidemiology Neisseria Meningitidis ( meningococcus) Key problems Pathophysiology Signs and symptoms Recent guidelines- diagnosis and management Prognosis and complications

Case: 

Case 26.10.2011 JPB 2 yr old boy with Mother and Father PC: Presented to A&E at 13.15 hrs by ambulance with a non-blanching rash, fever, drowsiness and a provisional diagnosis of meningococcal septicaemia made by the walk-in centre. HPC: Vomited: 23.30pm on 25.10.11 Mother thought he was starting with a ‘ bug ’ During night: Twitchy Jumpy Poor sleep Temperature : 38.7 degrees No rash Morning: - Further vomiting (bile) - One red mark on left lateral chest wall – 10.30 am - Not interested in eating or drinking 11am: Attended walk in centre Further non-blanching purpuric rash developed No neck pain/stiffness, no photophobia, stiffness Dazed and unaware Pale Floppy Not very responsive and weak Decreased urine Given IM benzylpenicillin Ambulance to Ormskirk A&E Prior: Generally well, no recent illness

Further History: 

Further History PMH: Pregnancy normal Born term Normal vaginal delivery Normal development Immunisations- up to date Capillary haemangioma- on right cheek – under Alder Hey PSH: Nil DH: Nil, NKDA FH: Nobody else ill Nil other family conditions Diabetes- on mothers side SH : Lives at home with mother, father and dog Not in nursery Attends playgroup- not been for past few weeks Mother: at College Father: unemployed No smoking in house Happy home- no social service concerns No recent travel ROS : Nil of note

Examination Findings : 

Examination Findings A&E- 13.15 hr, 26.10.11: - Temp: 38.6 -HR: 173 BPM - Resp: 38 - BP: 89/55 - Pupils: 2mm and equal - Capillary refill: 4 seconds - Heart sounds: I+II+O -Lungs clear - Abdomen soft, non tender - Liver edge: 3cm A: Maintaining airway B: Sats 100% on 15L of 02 C: capillary refill time centrally: 3-4secs D: drowsy, responding to pain- GCS: 12? Non-blanching rash extensively over chest Weight : 12kg

Differential diagnosis : 

Differential diagnosis - Meningococcal septicaemia +/- meningitis - Henoch -Schonlein Purpura (HSP) - Systemic lupus erythematous - Drug induced: Steroids and sulphonamides - Impaired platelet production- leukaemia - Coagulation defects: DIC - ITP

Initial management- Stabilisation : 

Initial management- Stabilisation - IV access (2x IV cannulas) - IV ceftriaxone (960mg) - IV fluid bolus: 2x 20ml/kg (240ml per bolus) - IV Human albumin solution: 240ml - Anaesthetist on standby - Public health informed - Prophylaxis for parents- Rifampicin, 600mg BD PO for 2 days - No Lumbar puncture

1st Investigations: 

1 st Investigations - Clotting, Blood gas, Ca2+, lactate and sepsis screen requested- Calcium: 1.96 mmol/L MCV: 72.8fl MPV: 6.7fl Neutrophil: 9.0 Lymphocyte: 1.1 Clotting: APTT ratio 1.15 pH: 7.36 PO2: 4.4kPa CRP: 69.6mg/L CXR: Clear

Progression : 

Progression By 19.30 – 26.10.11 - Been moved to paediatric ward on 15 minute observations Giggling and responsive with mum Sats: 95-98% on air HR: 147 BPM BP: 101/55 Respiratory rate: 30 BPM IV antibiotics continued Maintenance Fluids: 0.45% saline and 5% dextrose and 10mmol/l KCL added

Day 3: 

Day 3 Day 3: Feeling much better, eating, drinking, wetting nappies, playing and increased concentration. Not irritable to light, no complaints of neck pain, no vomiting. On examination: sat comfortably. Responsive to the environment and good concentration. No obvious pain. Rash is fading. Chest and heart normal. Abdomen soft and non-tender . IV antibiotics: ceftriaxone IV dexamethasone- 1.8mg QDS Paracetamol: QDS 180mg Apyrexial

Lumbar puncture : 

Lumbar puncture Turbid/cloudy colour CSF glucose: 5.2 mmol/L CSF protein: 0.6 g/L Total white cell count: 7528 10 6 /L Polymorphs-95% Lymphocytes: 95% Red cell count: 405 Microscopy: Gram –ve cocci (very scanty) Blood PCR: Group B meningococcal

Day 7 : 

Day 7 7 day course of antibiotics finished Discharged home Hearing test and follow-up in clinic for long-term complications 2.11.11: - Brief trip back to hospital ‘ wobbly on feet ’ - reassured after review and re-discharged.

Meningococcal septicaemia and Meningitis: 

Meningococcal septicaemia and Meningitis

Definitions : 

Definitions Meningococcal Disease: Infection by Neisseria Meningitidis. Cause of: Septicaemia Meningitis Combination of both Other presentations: arthritis etc Meningitis: Is inflammation and irritation of the meninges. Meningococcus most common, but just one cause.

Neisseria Meningitidis : 

Neisseria Meningitidis Gram negative diplococcus Different groups- 13+ Group B and C most common in UK C- decreased since Meningitis C vaccine programme introduced B- no vaccine Asymptomatic colonisation in nasopharynx Transmitted: droplets, direct contacts- requires frequent and prolonged contact Symptoms- occur within 1-14 days of acquisition

Key problems : 

Key problems Vague – non- specific symptoms Classic signs present late- increased severity

: 

Epidemiology: Mainly a pathogen of children and young adults Highest rate: 1- 5 yr olds Most common in winter 2000 ppl affected in the UK/yr Risk factors: Crowded environments Smoking Inhalation of dusty air Prior viral infections

Pathophysiology   : 

Pathophysiology Meningitis : Bacterial infection (usually) after bacteraemia Host response- causes damage Inflammatory mediators, activated leucocytes Endothelial damage: causing cerebral oedema, raised ICP and decreased cerebral flow Septicaemia: Host response Release of inflammatory cytokines Coagulation cascade, prostaglandins and NO Vasodilation Increased capillary permeability Shift of fluid to intravascular compartment Hypotension

Symptoms and signs : 

Symptoms and signs - Fever - Headache - Photophobia - Lethargy - Poor feeding/ vomiting - Irritable - Hypotonia - Drowsiness - Loss of consciousness - Seizures -Purpuric rash- non blanching, irregular in size, present anywhere on the body, necrotic centre. Neck stiffness - Positive Brudzinskis/ Kernigs sign - Signs of shock- tachycardia, prolonged capillary refill time, oliguria, Cold peripheries, leg pain and hypotension - Focal neurological signs -Papilloedema - Bulging fontanelle in infants - Unusual cry - Opisthotonus/ decerebrate posturing - Muscle and joint pains - Unusual skin colour

NICE guidance 2010 Bacterial Meningitis and Meningococcal septicaemia: Management of bacterial meningitis and meningococcal septicaemia in children and young people less than 16 years in primary and secondary care. : 

NICE guidance 2010 Bacterial Meningitis and Meningococcal septicaemia: Management of bacterial meningitis and meningococcal septicaemia in children and young people less than 16 years in primary and secondary care.

Diagnosis and management: 

Diagnosis and management

Lumbar puncture : 

Lumbar puncture Diagnosis of meningitis Changes: turbid, increased polymorphs, increased protein, decreased/ normal glucose Organisms identified through PCR, microscopy and culture CI: Cardiorespiratory instability Focal neurological signs Raised ICP: Coma, high BP, low HR, Papilloedema, abnormal doll ’ s eyes, unequal, dilated or poorly responsive pupils Coagulopathy/ thrombocytopenia Local infection at site of lumbar puncture If prevents antibiotics being started

Prognosis and complications: 

Prognosis and complications Complications: - DIC - cerebral oedema and increased cerebral pressure - Hearing loss - Cranial nerve palsies - Seizures and epilepsy - Hydrocephalus - Cerebral abscess and subdural effusion - Neurological and developmental problems- least of 3 main causes of meningitis - Water- house- Friederichsen syndrome (haemorrhagic adrenalitis) Prognosis: -Meningococcal meningitis: 5% mortality - Septicaemia: 18-50%

Summary: 

Summary - Meningococcal septicaemia and meningitis are life-threatening. - vague symptoms - However, with a quick response as shown by the team in both primary and secondary care in this case outcomes can be much more favourable.

References : 

References NICE guidance 2010: Bacterial Meningitis and Meningococcal septicaemia: Management of bacterial meningitis and meningococcal septicaemia in children and young people less than 16 years in primary and secondary care. Patient UK: Meningococcal Disease Lissauer and Clayden. Illustrated textbook of paediatrics Oxford Handbook of clinical specialties

Thank you : 

Thank you