Download - Meningococcal septicaemia
Canterbury Health Laboratories
Meningococcal septicaemia
Rachel C Hutton, PhDMedical Laboratory Scientist
Canterbury Health Laboratories
Diagnosis Meningococcus
• Disease• Transmissio
n• Symptoms• Diagnosis• Treatment• Prevention
• Case Study
Canterbury Health LaboratoriesMeningococcal Disease
• Contagious bacterial disease
• Neisseria meningitidis– Fastidious aerobe– Gram Negative Diplococci (GNDC)– 12 serogroups
• 6 can cause epidemic (A, B, C, W135, X, Y) (WHO)
• Humans only natural carriers
• Meningitis• Meningococcemia• Pneumonia• Arthritis• Urethritis
Canterbury Health LaboratoriesTransmission
– Exchange of respiratory/throat secretions
– Cough/sneeze
– Close contact – household members
– 10% population are carriers (nose/throat)
– Carriers are crucial to disease transmission
Canterbury Health LaboratoriesSymptoms
• Meningitis– Nausea– Vomiting– Photophobia– Altered mental status
• Meningococcemia– Fatigue– Vomiting– Cold hands and feet– Cold chills– Severe aches or pain– Rapid breathing– Diarrhoea– Petechial rash (dark purple)
Source: CDC online
Canterbury Health LaboratoriesDisease
• 5-10% of patients die within 24-48H
• Meningitidis– Brain damage– Hearing loss– Learning disability
• Septicaemia– Haemorrhagic rash– Rapid circulatory collapse
Canterbury Health LaboratoriesDiagnosis
• Clinical Examination
• Gram Stain
• Culture
• Agglutination
• PCR
• MALDI-TOF
– Susceptibility testing– Serogroups
Canterbury Health LaboratoriesTreatment & Prevention
• Medical Emergency
• Antibiotics immediately ( after LP/Blood)– Penicillin– Ampicillin– Chloramphenicol– Ceftriaxone
• Vaccination– Polysaccharide
• Bivalent (A&C), Trivalent (A,C,W), Tetravalent (A,C,Y,W135)– Outer Membrane Protein (OML)
– Group B– Conjugate Vaccines
• Tetravalent (A,C,Y,W135)
Canterbury Health Laboratories
CASE STUDY:MENINGOCOCCAL DISEASE
Case Study: Meningococcal disease
Canterbury Health Laboratories
Case Study:Meningococcal disease
Day
Event Tests/Results Treatment
0 Presents to GP Diagnosed as EBVNo bloods
None – sent home
Canterbury Health Laboratories
Day
Event Tests/Results Treatment
0 Presents to GP Diagnosed as EBVNo bloods
None – sent home
1 Found by mother
Unresponsive Ambulance called
Ambulance GCS 8/15 (E2V2M4)Skin cool & mottledRash (Non-blanching erythematous confluent)HR 76BP not palpableAirway patient – sat not recorded (NR)
IV ceftriaxone
Canterbury Health Laboratories
Day Event Tests/Results Treatment
1 ED GCS 9/15CT head Scan = No pathological changes
IV DexamethasoneIV fluidsAdrenalin
ICU LP not performed due to coagulopathyLow BPBlood tests-INR 3.1-No evidence of DIC-Raised blood glucose
IV VancomycinIV Acyclovar2 u FFPNoradrenalin
Insulin infusion
Serology EBV IgG PositiveEBV IgM NegativeEBV EBNA Positive
Evidence of PAST infection with EBV
Microbiology Blood Cultures = Negative-Blood, Arterial, CVC
IV Acyclovar StoppedIV Dexamethasone Stopped
Canterbury Health Laboratories
Day Event Tests/Results Treatment
1 ED GCS 9/15CT head Scan = No pathological changes
IV DexamethasoneIV fluidsAdrenalin
ICU LP not performed due to coagulopathyLow BPBlood tests-INR 3.1-No evidence of DIC-Raised blood glucose
IV VancomycinIV Acyclovar2 u FFPNoradrenalin
Insulin infusion
Serology EBV IgG PositiveEBV IgM NegativeEBV EBNA Positive
Evidence of PAST infection with EBV
Primary diagnosis = meningococcal meningitis
Blood Cultures = Negative-Blood, Arterial, CVCEDTA – N. meningitidis PCR = Positive
IV Acyclovar StoppedIV Dexamethasone Stopped
Canterbury Health Laboratories
Day Event Tests/Results Treatment
2 Extubated Continued improvementMild headache & photophobia
3 Transferred to Ward
Ceftriaxone 2g Q12HTEDS
7 Discharged
Canterbury Health Laboratories
This is not the end of the story…
Canterbury Health LaboratoriesDiagnosis Arthritis
Day Event Tests/Results Treatments
9 Increasing unwellPainful knee + elbowLines present L hand + R groin
Admitted to orthopaedic ward
CRP 102WCC elevatedPyreticR Knee = swollen, effusion, good ROMGroin = visible scab from line, no erythema, tender, able to weight bare
Wash out elbow + knee (under GA)IV ceftriaxoneIV flucloxacillin
12 Washout L elbow CRP 32Full ROM Hip & KneeLimitation at extremes of left elbow extension
R hip joint aspirated & washed out
N. meningitidis DNA detected
18 Discharged
Canterbury Health LaboratoriesBlood Tests: Trends
WBCNeutrophils
Platelets
INR Fibrinogen
Canterbury Health Laboratories
CRP
pH Blood Base Excess
Canterbury Health Laboratories
EDTA N. meningitidis DNA detected
Canterbury Health Laboratories
Samples Sent to Microbiology
Day Sample Results
9 L Elbow Aspirate BC bottle NG
9 L Elbow Aspirate PottleAnti co-ag tube
NOSWBC 175600 x106/L– predom polynucleated
RBC 12700 x106
No CrystalsNG
9 R Knee Aspirate BC bottle GPCNG
9 R Knee Aspirate PottleAnti co-ag tube
Occasional GPCWBC 5950 x106/L– predom polynucleated
RBC 1520 x106/LNo CrystalsNG16S rRNA PCR: Bacterial DNA not detected
10 R Knee Aspirate Syringe NOSScanty leucocytesNG
12 Hip Aspirate PottleAnti co-ag tube
NOSWBC 51650 x106/L – predom polynuecleatedRBC 2800 x106/L
N. meningitidis PCR = Detected
Canterbury Health LaboratoriesThe Value of PCR
Day Sample Results
9 L Elbow Aspirate BC bottle NG
9 L Elbow Aspirate PottleAnti co-ag tube
NOSWBC 175600 x106/L– predom polynucleated
RBC 12700 x106
No CrystalsNG
9 R Knee Aspirate BC bottle GPCNG
9 R Knee Aspirate PottleAnti co-ag tube
Occasional GPCWBC 5950 x106/L– predom polynucleated
RBC 1520 x106/LNo CrystalsNG16S rRNA PCR: Bacterial DNA not detected
10 R Knee Aspirate Syringe NOSScanty leucocytesNG
12 Hip Aspirate PottleAnti co-ag tube
NOSWBC 51650 x106/L – predom polynuecleatedRBC 2800 x106/L
N. meningitidis PCR = Detected
Canterbury Health LaboratoriesRequest Forms
Canterbury Health Laboratories
Canterbury Health Laboratories
The Value of PCR
Day 12: Hip Aspirate
Test Add N. meningitidis PCR
Result = Positive
Canterbury Health LaboratoriesMeningococcal Burdon
Canterbury Health LaboratoriesMeningococcal Burden
• Meningococcal disease causes life-threatening meningitis and sepsis conditions
• Patient's health can change from good to mortally ill within hours
• As the antibiotics kill the bacteria, they release more toxin. It can take several days for the toxin to be neutralized from the body
• Despite antibiotic therapy ~ 1/10 will die
• ~ 1/10 survivors will lose a limb, loose their hearing or suffer permanent brain damage
Canterbury Health LaboratoriesThank you
• Dr Sophie Wen• Jen Fahey• Elaine Keith• CHL
