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