meningococcal meningitis

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Information about meningococcal meningitis

Published on May 8, 2014

Author: nishantsagar7


A CASE OF FEVER WITH RASH: A CASE OF FEVER WITH RASH Dr Rajesh Kumar Meena 2nd Yr PG, GENERAL MEDICINE DR. S.RAJASEKARAN M.D. Professor of Medicine UNIT M7 History: History Pt. Duljang 18yr male native of orissa , Sweeper by occupation presented with fever for 1 day high grade with chills &rigor no nausea, vomiting Went to a private clinic , treated with antipyretics and antibiotics ( cefopodoxime & paracetamol ) h/o contd..: h/o contd.. Next morning his brother found him in a drowsy state h/o black colour rashes all over the body including face, tongue, hard palate & external genitalia No h/o seizures no h/o arthalgia ,abdominal pain no h/o jaundice no decreased urine output No h/o cough, sputum , breathlessness No other bleeding manifestations Past history: Past history no similar illness in the past no h/o photo sensitivity no h/o jaundice No h/o DM, SHT, TB , BA, CLD, CKD No h/o chronic drug intake No h/o dog bite No h/o recent vaccination Personal history: Personal history Not a alcoholic Not a smoker No specific addictions Not married No h/o sexual promiscuity Travel history: Travel history No h/o travel in the recent past General Examination : General Examination drowsy irritable febrile not responding to commands responding to pain by moving all 4 limbs Bilateral subconjuctival haemorrhage + lymphadenopathy + no pallor no icterus no cyanosis, no pedal edema peripheries warm Palpable purpura:face tongue hard palate,arm chest & genitalia lowerlimbs Vital signs: Vital signs Temp- 104 degree F Blood pressure – 90/60 mmHg Pulse – 112/min, regular, weak pulse SpO2 – 99% CBG ( glucometer ) -98mgs% Systemic examination: Systemic examination Examination of central nervous system drowsy , no response to command, pupil 3mm b/l equal reacting to light, Fundus - normal neck muscle rigidity + kernig s + brudzinski + Bulk of the muscles normal Tone:normal power:could not be tested DTR:present 1+ plantar:withdrawal PowerPoint Presentation: Examination of other systems within normal limits Provisional diagnosis: Provisional diagnosis Acute febrile illness Meningoencephalitis with palpable purpura Patient in hypotension Differential diagnosis 1.Meningoccocemia, 2.Other Bacterial meningitis ( STREPTOCOCCUS PNEUMONIA MENINGITIS HEMOPHILUS INFLUENZAE MENINGITIS STAPHYLOCOCCUS AUREUS MENINGITIS) 3.Rocky mountain spotted fever 4.Leucocytoclastic vasculitis [HSP,PAN,SLE,HEP B&C,HIV } 5.Disseminated Gonococcal infection Investigations - CBC : Investigations - CBC Day 1 Day 3 Day 4 Day 5 TC 21,500 7160 10,600 7600 DC P-89%; L-7%;E-4% P63%; L-36%;E-1% P-79%; L-18%;E-3% P-76%; L-22%;E-2% ESR 1 st hour 10 8 9 7 HB 9.9 12.8 10.9 11.8 PLATELETS 61,000 1 lakhs 1.1 lakhs 1.7 lakhs RFT: RFT Day 1 Day 2 Day 3 Day 4 Day 5 sugar 120 105 69 74 72 urea 48 35 29 23 29 creatinine 1.5 1.2 0.8 0.8 0.8 sodium 145 137 138 138 138 potassium 3.8 4.8 3.2 3.6 4.5 PowerPoint Presentation: Day 1 Day 2 Day3 Day 4 Day 5 T B 1.1 1.0 1.2 2 0.7 DB 0.3 - - 1 - SGOT 36 176 98 76 76 SGPT 18 94 52 37 24 SAP 96 481 141 201 118 T pro 7 6.6 6.4 6.8 7.1 ALB 4.1 3.8 3.8 3.7 4 LFT PowerPoint Presentation: MP/QBC-Negative Dengue IGM-Negative MSAT-Negative Urine c/s-no growth Blood c/s-no growth Scrub typus;IGM ; negative by elisa ICTC ;Negative HBsAg -negative by rapid HCV-Negative PowerPoint Presentation: CT brain – No mass lesion, no hydrocephalus, no edema USG ABDOMEN- no abnormality detected CSF ANALYSIS: CSF ANALYSIS CYTOLOGY/ GRAM STAIN few pus cells seen, occasional gram negative cocci seen in pairs. AFB nil Culture/ senstivity No growth after 72hours of incubation protein 162mgs% sugar 35mgs% Smear of petechial lesion: Smear of petechial lesion Direct gram stain –few pus cell with occasional gram negative cocci in pairs Other investigations: Other investigations Prothrombin time Day 1 Day 3 Day 5 Test 12.8 13.0 12.6 Control 18.7 16 13 APTT Test 36.6 30.2 31 Control 86.4 76 38 Treatment given: Treatment given Inj. Ceftriaxone 2gram i.v . BD for 7 days Inj Rantac 50mg i.v . BD Tab. Azithromycin 500mg OD Tab. Paracetamol 500mg QID i.v . fluids supportive care COURSE OF THE PATIENT IN THE HOSPITAL: COURSE OF THE PATIENT IN THE HOSPITAL Patient was intubated and put on T piece due to poor GCS Patient recovered from shock within a day with IV fluids Since patient had minor bleeding per ET tube and the PT,aPTT was high, FFP 10 units transfusion was given Patient self extubated on day 5 ,since the patients GCS improved Patient started improving.Case was notified. Patient was shifted to ward and then discharged after completing the antibiotic course DISCUSSION: DISCUSSION NEISSERIA MENINGITIDIS: NEISSERIA MENINGITIDIS BEAN SHAPED GRAM NEGATIVE , aerobic , diplococci Surrounded by an outer membrane of lipids, membrane proteins and lipopolysaccharides . At least 13 serogroups have been described :A,B,C,D,E,H,I,K,L,W-135,X,Y,Z Almost all meningococcal infections are caused by five serogroups A,B,C, 29 E or W-135 Worldwide serogroups A,B,C account for most cases Predominant in Asia and Africa are A &C PowerPoint Presentation: The relatively few reports identified suggest that the incidence of endemic meningococcal disease in India is low, but that occasional epidemics of meningococcal disease have been recorded for at least 100 years. The larger epidemics have affected mainly the cities of northern India and have almost universally been caused by meningococci belonging to serogroup A The epidemiology of meningococcal disease in India. Sinclair D ,  Preziosi MP ,  Jacob John T ,  Greenwood B . Source The South Asian Cochrane Centre, Christian Medical College, Vellore, India . PowerPoint Presentation: Albert Neisser (1855-1916) PowerPoint Presentation:   Neisseria meningiditis HOST: HOST Maternal antibodies protects for six months Subsequent colonization with neisseria meningitides induces antibodies to the infecting strain, thus reinforcing natural immunity Invasive disease occurs if no protective antibodies are mounted against the strain Those infected with the human immunodeficiency virus are probably also increased risk for sporadic meningococcal meningitis HOST AND ENVIRONMENT: HOST AND ENVIRONMENT Highest incidence- 6months to 2 yrs of age Rarely reported over 50yrs of age No gender predilection, though males account for slightly more than half of the reported cases. Increased risk with smoking ,antecedent URI, underlying chronic illnesses Low socioeconomic status Risk of invasive disease is higher in the first few days after exposure to a new strain Transmission & communicability : Transmission & communicability Direct contact and respiratory droplets Incubation period is 3-4 days with a range of 2 to 10 days This is the period of communicability Bacteria is rapidly eliminated from nasopharynx after starting antibiotics, usually within 24 hours RESERVOIR: RESERVOIR HUMANS are the only resevoirs Both cases and carriers serve as the source of infection 5- 10% adults are asymptomatic nasopharyngeal carriers during inter-epidemic periods Rise to 60- 80% in closed populations like military recruits in camps PowerPoint Presentation: Infants and young children there is slower onset of signs and symptoms with nonspecific symptoms and neck stiffness may be absent Irritability and projectile vomiting may be presenting feature Seizures occur in 40% of children with meningitis The Waterhouse – Friderichsen syndrome may develop in 10-20% of children , characterized by large petechial hemorrhages in skin &mucous membranes,fever,septic shock Even when the disease is diagnosed early and adequate therapy instituted ,5- 10% die ,typically within 24-48 hrs of onset of symptoms. Hemorrhage into the adrenal glands: Hemorrhage into the adrenal glands PURPURA FULMINANS: PURPURA FULMINANS   Purpura fulminans is a severe complication of meningococcal disease  It is characterized by the acute onset of cutaneous hemorrhage and necrosis due to vascular thrombosis and disseminated intravascular coagulopathy (DIVC) Gangrenous necrosis can follow with extension into the subcutaneous tissue and occasionally involves muscle and bone Diagnosis: Diagnosis Suspected by the clinical presentation and a L.P. showing a purulent spinal fluid CSF- increased pressure(>180 mmH20) WBC(10- 10,000 cells/µl predominantly neutrophils ) decreased glucose (<45 mg/dl) increased protein conc.(>45mg/dl) PowerPoint Presentation: Bacteriological diagnosis by gram staining of CSF Direct antigen detection using latex agglutination MANAGEMENT: MANAGEMENT Since its potentially fatal, should always be viewed as a medical emergency During epidemic Single IM dose of an oily suspension of chloramphenical have shown to be as effective as a five day course of crystalline penicillin in the treatment of meningococcal meningitis penicillin 4 million units x4 a day ceftriaxone 4g iv per day divided PowerPoint Presentation: isolate observe distract protect administer TREATMENT: TREATMENT PREVENTION AND CONTROL: PREVENTION AND CONTROL CHEMOPROPHYLAXIS: as soon as possible (ideal within 24 hrs) limited or no benefit if given more than 14 days after onset of the disease Adults – Ciprofloxacin single dose of 500 mg Rifampicin 600mg 12 hrly for two days avoided during pregnancy Ceftriaxone 250 mg IM single dose PowerPoint Presentation: Not recommended during epidemics because of multiple and prolonged sources of exposure Secondary cases comprise less than 2% of all meningococcal disease Immunization using safe and effective vaccine is only rational approach to control of meningococcal disease VACCINES: VACCINES Of the common serotypes responsible for more than 90% of meningococcal disease A, C, Y and W-135. At present two types of meningococcal vaccines are licensed; Meningococcal polysaccharide vaccines and meningococcal conjugated polysaccharide vaccine Polysaccharide vaccines: Polysaccharide vaccines Purified ,heat-stable lyophillized capsular polysaccharides Bivalent against serogroups A and C Quadrivalent against serogroups A, C, Y, W-135 Single dose – reconstituted vaccine contains 50µg of the individual polysaccharides. The dose for primary vaccination for both adults and children older than two years is 0.5 ml subcutaneous PowerPoint Presentation: Protective levels of antibody are achieved within 7-10 days Vaccination effective in control of outbreaks ands epidemics in millitary centers Carrier status is unaffected by vaccination Extremely safe , major drawback is the absence of activity against group B meningococci CONJUGATED POLYSACCHARIDE VACCINE: CONJUGATED POLYSACCHARIDE VACCINE A quadrivalent A, C, Y, W-135 conjugate vaccine has been licensed since january 2005 4µg each of A, C, Y, W-135 polyssaccharide conjugated to 48µg of diptheria toxoid . Nasopharyngeal carriage rates also be decreased reducing bacterial trasmission RECOMMENDATIONS FOR USE OF MENINGOCOCCAL VACCINE: RECOMMENDATIONS FOR USE OF MENINGOCOCCAL VACCINE Routine vaccination is reccommended for certain high risk groups, including persons who have complement component deficiencies and who have functional or anatomic asplenia Travelers above 18 months of age going to an areas experiencing an epidemic or to areas with high rate of endemic disease. Revaccination may be indicated for persons at high risk for infection particularly for children who are vaccinated when less than 4 yrs of age such children should be considered for revaccination after 2-3 yrs if they remain at high risk LEUKOCYTOCLASTIC VASCULITIS: LEUKOCYTOCLASTIC VASCULITIS Leukocytoclastic vasculitis (LCV), also known as hypersensitivity vasculitis and hypersensitivity angiitis , is a histopathologic term commonly used to denote a small-vessel vasculitis Between one third and one half of the cases of cutaneous vasculitis are idiopathic, and the remainder have various identifiable causes. The most common drugs that can cause cutaneous vasculitis are antibiotics, particularly beta- lactam drugs, nonsteroidal anti-inflammatory drugs, and diuretics TAKE HOME MESSAGE: TAKE HOME MESSAGE 1.. EVERY CASE OF FEVER WITH PALPABLE RASH, MENINGOCOCCEMIA SHOULD BE THE 1 ST DIFFERENTIAL DIAGNOSIS THAT SHOULD COME TO MIND AND TREATMENT SHOULD BE STARTED TARGETING MENINGOCOCCUS WHILE TRYING TO INVESTIGATE FOR THE CAUSE THANK YOU !!!: THANK YOU !!! THANK YOU

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