meningococcal infections

•Meningococcal nasopharyngitis•Meningococcemia•Meningitis

Charan TejasviML-510

Neisseria meningitidis (meningococcus)

gm (-) diplococcus usually found within PMN leucocytes

found only in man

13 serogroups by surface capsular polysaccharide

A, B, C, W135 and Y- frequent isolates from patients with meningococcal disease

Other groups isolated from carriers

Meningococcal Infections

Common in temperate and tropical climates

carriage rates: healthy children 2-5% military personnel (epidemics) 90%

transmitted via contact with respiratory secretions

Meningococcal Infections

Disease may occur following exposure to carriers or infected patients within the family, day care and military camps

occurs most frequent:(< 5 yrs old ) peak attack rate : 6-12 months old

2nd peak attack rate: 15-19 y/o of age

Meningococci colonize the nasopharynx penetrate mucosal surface transported by leukocytes to blood stream hematogenous dissemination localizes: heart, CNS, skin, mucous and serous membranes adrenals

Release of IL and TNF

hypotension multi-organ system failure

Diffusevasculitis

*Complement activation

DIC

H’ge and necrosis in any organ bleeding into adrenals in patients with septicemia and shock

Waterhouse- Friderichsen syndrome

Clinic. The incubation period is from 2 to 10 days (usually 4-6 days).

Clinical classification:Localized forms (acute

nasopharyngitis)Generalized forms

(meningococcemia, meningitis)Rare form (endocarditis, arthritis,

pneumonia, iridocyclitis)

spectrum range from asx’c colonization to fulminant sepsis

1. Bacteremia without sepsis 2. Meningococcemia (sepsis) without

meningitis

3. Meningitis with or without meningococcemia

Manifested a moderate and short-term (1-3 days)

increase in temperature, mild symptoms of intoxication rhinopharyngitis (nasal congestion,

flushing, dryness, swelling of the posterior pharyngeal wall with hyperplasia of lymphoid follicles affected mucosa "dry", sometimes bluish).

From acute viral disease meningococcal nasopharyngitis different is that the mucous membrane of the soft and hard palate, and tonsils are not impaired or only slightly hyperaemic, but major changes are located on the back of the throat.

Nasopharyngitis preceded meningococcemia at an average of 78% of patients.

Meningococcemia is inherently meningococcal sepsis, which, like other septic conditions, appears febrile fever and severe intoxication syndrome with manifestations of multiple organ pathology.

The most important diagnostic symptom is a “RASH”.

after 5-15 hours of onset single or multiple polymorphic

elements ranging in size from 2.1 mm to 5 cm or more in diameter and has a hemorrhagic character.

asymmetrically, mainly on the skin of the thighs and buttocks, at least - on the trunk and face.

Eruptions have different colors - red, brown, yellowish-green. In the center of the elements of necrotizing rash. Most often appear large star-shaped form of hemorrhagic lesions with dense infiltrated the base and necrosis in the center.

Initially with pharyngitis, fever, myalgias, arthralgias, headache, and GI complaints within hours--> (+) petechial, purpuric (purpura fulminanas)

( slate gray satellite shaped ) or morbilliform lesions with hypotension, DIC, acidosis,

adrenal h’ge, renal/heart failure, coma

If fulminant--> rapidly progressive purpura, relentless shock, adrenal H’ge, extensive

hematogenous dissemination unresponsive

to therapy

if with meningitis, (most common clinical manifestation) indistinguishable from those

2° to other bacteria

(+) petechial < 12° prior to admission (+) hypotension absence of meningitis WBC < 10,000/mm3 ESR < 10 mm/hr.

Interpretation: (+) 3 or > features: 90% mortality > 2 features; 9% mortality

Rapid progression of petechia to ecchymoses or purpura Wakefulness skin perfusion respiratory distress thrombocytopenia advanced age

Seen in children and adults

low grade fever, non toxic appearance, arthralgias, headache , rash,

(+) blood culture

mean duration of illness: 6-8 weeks

Waxing and waning sx purulent arthritis acute non suppurative polyarthritis erythema nodosum URI subacute endocarditis

assoc with C5 deficiency

Chronic Meningococcemia

1. Maintain a high index of suspicion (fever, petechial rash, abn mental status)

2. Gm stain of petechial scrapings CSF buffy coat of blood; gm (-) diplococci

3. Culture of blood, CSF, petechial scraping, synovial

fluid, sputum and other body fluids

4. Antigen detection tests (CSF, urine, serum) CIE, latex agglutination, lack adequate sensitivity and specificity

Aq Penicillin G 250,000 -300,000 u/k/day IV 6 div doses x 7 days Alternatives : Cefotaxime 200 mg/k/d Ceftriazone 100-150 mg/k/day

If allergic to B-lactams : Chloramphenicol 75-100 mg/kg d

ISOLATION: RESPIRATORY isolation until 24° after effective antibiotics

Chemoprophylaxis

for all household, school or day care contacts ASAP or within 24° from diagnosis of 1° case

NOT ROUTINELY recommended for medical personnel EXCEPT those with INTIMATE exposure (mouth to mouth resuscitation, intubation, suctioning)

Chemoprophylaxis DOC: Rifampicin 10 mg/kg (max 600 mg) q

12° x 2 days

other drugs: Ceftriaxone Ciprofloxacin

meningococcal vaccine can be used with chemoprophylaxis since 2° cases may occur several weeks later

Vaccines available monovalent A bivalent A and C quadrivalent A, C, Y, W135

no effective vaccine against serogroup B

not routinely recommended

Recommended: 1. children > 2 yrs.

2. In high risk grps.

(+) functional /anatomic asplenia,

(+) terminal complement component defect +

as adjunct to chemoprophylaxis

For Meningitis: deafness ataxia Sz blindness paresis of CN 3,4,6,7, hemi or quadriparesis obstructive hydrocephalus

Complications

For Meningococcemia: Adrenal H’ge, arthritis, myocarditis, pericarditis, pneumonia, lung abscess, peritonitis, renal infarcts, DIC, peripheral neuropathy

Vasculitis - 2° bacterial infection tissue necrosis gangrene skin loss