4 Meningococcal Meningitis

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Department of Infectious Diseases

(Shi Hong)

MENINGOCOCCAL

MENINGITIS

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Meningococcal meningitis


Morbidity mortality

rate

Morbidity

mortality

● early diagnosis

● modern

therapy

● supportive

measure

HIGH

low


A case Beijing Center for Disease Control and Prevention (CDC) January 11, 2007

◆ The patient was a 14-year-old male student. ◆ The onset of this case started quickly with high fever(39°C)

and headache. ◆ Other clinical symptoms included nausea, vomiting, stiff

neck and confusion. ◆ There was little petechiate rash emerged on the patient’s

four limbs. ◆ The Kernig’s sign was positive and Brudzinski’s sign was

negative. ◆ The numbers of white cell in the blood and cerebrospinal

fluid (CSF) were 3.6×1010/L and 1.7×109/L, respectively.

What was the most likely diagnosis


DefinitionMeningococcal meningitis :

★ Neisseria meningitides

★ Respiratory tract

★ Purulent meningitis (an acute inflammation of the membranes that

cover the brain and spinal cord)



Etiology◆ gram-negative coccus

◆ Neisseria species

◆ 13 serogroups

◆ groups A, B, C

What causes Meningococcal meningitis


Epidemiology

Sources of infection: carriers and patients

Infectious period : between late incubation period and acute phase, no more than 10 days of onset



Epidemiology Routes of transmission

⑴ Respiratory tract: ⑵ Close contact:

cough/sneeze bosoming/kiss/breast-feed



Epidemiology

Susceptibility☆ Everybody without specific immunity★ 6 months to 2 years of age.

Epidemical features◇ the common season : in the winter and early spring (November to May in next year) The peak incidence is in March to April

Who is at risk?


Pathogenesis

Immunity ＞ bacterial quantity and virulence

A. bacteria eliminated. B. benign nasopharyngeal carriage or upper respiratory tract infection →→cured C. temporal meningococemia →→cured



Pathogenesis

Immunity<bacterial quantity and virulence

A. meningococcal septicemia. B. meningococcal meningitis. C. meningococcal arthritis and pericarditis



Pathogenesis

Immunity<bacterial quantity and virulence

A. meningococcal septicemia


endothelial cells

endotoxin

▼Petechia▼infectious shock▼acidosis, ▼DIC ▼multiorgans failure

invade

release


Pathogenesis Immunity ＜ bacterial quantity and virulence B. meningococcal meningitis

Neisseria meningitides

the mucosal barrier the bloodstream

the central nervous system

increased intracranial pressure

convulsion, coma, herniation

CSF turbid, sometimes circular

obstacle of cerebrospinal fluid and hydrocephalus



Clinical manifestations

What are the signs and symptoms

petechia in the skin (Meningococcal meningitis)



Incubation period: generally 2 to 3 days

(Range is 1 to 10 days)

Four types: ⒈ Meningococcal meningitis (Moderate type)

⒉ Fulminate type （ shock type, Meningoencephalitic type)

3. Mixed type （ Meningococcemia- meningitis ） 4. Mild type (Mild acute meningococcemia)

What are the signs and symptoms




Septic period▲ an abrupt onset

▲ chills high fever

▲ Headache

▲ Petechias

▲ purpuras

▲Splenomegaly

Meningitic period

▲ intracranial pressure ▲ headache▲ vomiting ▲ restlessness▲ Stiff neck

▲ Kernig (+)▲ brudziski (+)

▲ gradually disappears,

▲ recovers to normal.

Prodromal period

Septic period Meningitic period

Convalescent period








Laboratory examination

⒈ Routine laboratory studies of blood:


WBC>20×109/L Polymorphonuclearleukocyte

platelet count(DIC)



Lumbar puncture:


CSF



⒉ Cerebrospinal fluid examination (an important method to establish diagnosis) :

● pressure ● glucose ● WBC ● sodium ● protein chloride


turbid

>1000×106/L



⒊ Bacteriological examination (an important method to definitive diagnosis) :


Smear: skin lesions

spun sediment of CSF

Bacterial culture

of blood and CSF




Figure : Neisseria meningitidis Gram-stain of a pure culture


Diagnosis

⒈ Epidemic season, age and epidemic situations.

⒉ Clinical features.

⒊Manifestations of severe form in sepsis and meningoencephalitis

⒋Increased leukocytes and polymorphonuclear leukocytes predominantly in peripheral blood.

⒌ Increased intracranial pressure and purulent changes in CSF.

⒍ Positive results in bacteriological examination.



Differential diagnosis

⒈ Purulent meningitis caused by other purulent bacteria. ⑴ Streptococcus pneumonia meningitis, ⑵ Haemophilus influenzae meningitis, ⑶ Staphylococcus aureus meningitis. ＆ (no overt season,no petechae or purpura) ⒉ Meningeal tuberculosis. ＆ (the history, no petechae or purpura,Bacillus tuberculosis) ⒊ Sepsis (Shock type) ＆ (other causative bacteria in blood cultures)

How to diagnose Meningococcal meningitis


A case Beijing Center for Disease Control and Prevention (CDC) January 11, 2007

◆ The patient was a 14-year-old male student. ◆ The onset of this case started quickly with high fever(39°C)

and headache. ◆ Other clinical symptoms included nausea, vomiting, stiff

neck and confusion. ◆ There was little petechiate rash emerged on the patient’s

four limbs. ◆ The Kernig’s sign was positive and Brudzinski’s sign was

negative. ◆ The numbers of white cell in the blood and cerebrospinal

fluid (CSF) were 3.6×1010/L and 1.7×109/L, respectively.

What was the most likely diagnosis


Problems

what’s the most likely diagnosis?1

what do we still do for definitive diagnosis?

2

How to treat this young patient?3

To analyze the case


Treatment1

General treatment①Isolation hospitalization: ②Careful monitor nursing. ③Prevent complication.④Maintain the balances of fluid and electrolytes

2

Etiological treatment① Antibacterial

activity.②Concentration

in CSF.③ Resistance to

drugs A. Penicillin G（ 200~400u/kg/day)

B.ChloromycetinC.Cephalosporis

3

Other treatment ● High fever: anti-pyretic(physical chemical) measures. ● Increased intracranial pressure:20 % mannitol(0.5g/kg~2g/kg)


Treatment

⑴ Shock type ①Etiology treatment: . Penicillin G

② Shock should be corrected promptly:a. Volume expanded.b. Metabolic acidosis corrected.c. Vasoactive drugs. d. Adrenal corticosteroids. e. Important organs protected

Fulminate type

⑵ Meningococcemia-meningitis type

① Effective antibacterial drugs.Penicillin G.②Alleviate cerebral edema Mannitol and 50 per cent Glucose.

③ Adrenal corticosteroids: Dexamethasone

④ Treatment in respiratory failure: lobeline, coramine ⑤High fever and seizure: Sedatives: wintermine phenergan



Prognosis

Fulminate meningo-coccemia

early diagnosed

appropriately

treated

in the extremes of age

Good poor poor



Prevention

ProtectProtection of the susceptible population

ProtectProtection of the susceptible population

Administermeningococcal vaccines, Chemoprophylaxis

isolatefor 3 days after the symptoms disappeared, generally no less 7 days after the onset

observeClose contacts:observed medically for 7 days.

DisruptTo go to the crowd places should be avoided during the epidemic



Multiple choice

1. A diagnosis of meningococcal infection

requires the following to be present:

a) Headache b) Neck stiffness c) Photophobia d) vomiting e) Pyrexia



Multiple choice

2. Meningococci: ( which one is right?)

a) Are most often harmless commensals colonising the nasopharynx

b) Are carried by some adolescents who show no signs of disease

c) Are transmitted by aerosol

d) Are usually transmitted with minimal contact

e) Cause infection most frequently in teenagers



Summarization

⒈ Definition Meningococcal meningitis is an acute purulent meningitis

caused by meningococci

⒉ Transmission route occurs through respiratory tract.

⒊ The incidence of meningococcal meningitis The incidence of meningococcal meningitis is the first in

purulent meningitis among children.



Summarization

⒋ Clinical characteristics ⑴ high fever rapidly;

⑵ severe headache;

⑶ vomiting frequently;

⑷ petechiae and purpura in the skin;

⑸ meningeal irritations;

⑹ infectious shock and injuries in brain parenchyma occurred in severe cases and often result in death.



Summarization

What is meningitis? What is encephalitis?

What causes meningitis and encephalitis?

Who is at risk for encephalitis and meningitis?

How are these disorders transmitted?

What are the signs and symptoms?

How are meningitis and encephalitis diagnosed?

How are these infections treated?

Can meningitis and encephalitis be prevented?

What is the prognosis for these infections? .


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Features of meningococcal meningitis in infants

⒈ Causes of atypical symptoms are that the crania and fontanelle are not still closed and the

central nervous system is not well developed. ⒉ The features of clinical manifestations ⑴ Respiratory symptoms

always presents with cough. ⑵ Gastroenteric symptoms

Refusal to take food, vomiting and diarrhea are common gastroenteric symptoms.

⑶ Increased intracranial pressure includes irritability, shrill, seizures and fullness of the

fontanelle. ⑷ Meningeal irritation

always is not overt



Features of menigococcal meningitis in the old

⒈ The causes of high incidence in fulminate type In the old the immunity is lower, properdin deficiency and

sensitive to endotoxin. ⒉ Clinical manifestations

⑴ Symptoms of upper respiratory tract are commonly presented in the old.

⑵ Mental obtundation is overt.

⑶ Petechia and purpura are more common.

⒊ Complications and prognosis usually can be seen with high mortality.

⒋ Leukocytes Leukopenia is often seen due to lower human body’ reaction


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4 Meningococcal Meningitis