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MENINGITIS
Meningococcal MeningitisDr.T.V.Rao MD
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Introduction
Bacterial meningitis is an inflammation of
the leptomeninges, usually causing by
bacterial infection. Bacterial meningitis may present acutely
(symptoms evolving rapidly over 1-24
hours), sub acutely (symptoms evolvingover 1-7days), or chronically (symptoms
evolving over more than 1 week).
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In Meningitis Meninges are infected
and Inflamed
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Etiology
Causative organisms vary with patient age, with
three bacteria accounting for over three-quarters
of all cases:
Neisseria meningitidis (Meninococcus)
Haemophilus influenza (if very young andunvaccinated)
Streptococcus pneumoniae ( pneumococcus)
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Etiologygram-negative CoccusNeisseria species13 serogroupsgroups A, B, C
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Etiology
Other organisms
Neonates and infants at age 2-3
months Escherichia coli
B-hemolytic streptococci
Staphylococcus aureus
Staphylococcus epidermidis
Listeria MonocytogenesDr.T.V.Rao MD 6
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Knowing about Meningococcal
Disease Meningococcal disease is an acute, potentially
severe illness caused by the bacterium
Neisseria meningitidis. Illness believed to be
meningococcal disease was first reported in
the 16th century. The first definitive
description of the disease was by Vieusseux in
Switzerland in 1805. The bacterium was firstidentified in the spinal fluid of patients by
Weichselbaum in 1887.
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Characteristics of N. meningitides
N. meningitidis, or Meninococcus, is an
aerobic, gram-negative diplodocus, closely
related to N. gonorrhea, and to several
nonpathogenic Neisseria species, such as N.
lactamica. The outer membrane contains
several protein structures that enable the
bacteria to interact with the host cells as wellas perform other functions.
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Transmission of Meninococcus
Transmission
Primary mode is
by respiratorydroplet spread
or by direct
contact.
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Pathogenicity
Meningococci are transmitted by droplet
aerosol or secretions from the
nasopharynx of colonized persons. Thebacteria attach to and multiply on the
mucosal cells of the nasopharynx. In a
small proportion (less than 1%) ofcolonized persons, the organism
penetrates the mucosal cells and enters
the bloodstream Dr.T.V.Rao MD 10
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Pathogenesis
A offending bacterium from blood invades theleptomeninges.
Bacterial toxics and Inflammatory mediators are
released.
Bacterial toxics
Lipopolysaccharide, LPS
Teichoic acid
Peptidoglycan
Inflammatory mediators
Tumor necrosis factor, TNF
Interleukin-1, IL-1
Prostaglandin E2, PGE2
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Pathogenesis
The outer membrane is surrounded by a
polysaccharide capsule that is necessary
for pathogenicity because it helps thebacteria resist phagocytosis and
complement-mediated lysis. The outer
membrane proteins and the capsularpolysaccharide make up the main surface
antigens of the organism.
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Serotyping of Meninococcus
Meningococci are
classified by using
serologic methods
based on the structureof the polysaccharide
capsule. Thirteen
antigenically and
chemically distinctpolysaccharide capsules
have been described.
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Different Serotypes and Epidemiology
Almost all invasive disease is caused by
one of five serogroups: A, B, C, Y, and W-
135. The relative importance of eachserogroups depends on geographic
location, as well as other factors, such as
age. For instance, serogroups A is a majorcause of disease in sub-Saharan Africa
but is rarely isolated in the United States.
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Systemic Spread of Meningococcal
Infections
The bacteria spread by way of the blood
to many organs. In about 50% of
bacteremia persons, the organismcrosses the bloodbrain barrier into the
cerebrospinal fluid and causes purulent
meningitis. An antecedent upperrespiratory infection may be a
contributing factor
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N. meningitidisHabitat: human nasopharynx (10-
25%)
Similar to N. gonorrhea but lessexacting ?
Can grow in BA, Chocolate agar
without selective media from CSF ?
Id. CHO utilization: acid from glucose
& maltose. Dr.T.V.Rao MD 16
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Meninges and spinal cord
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How patients present withMeningitis
Meningitis ( inflammation of membranecovering brain) :
Headache
Photophobia (pain on looking at bright
lights)
Stiff Neck
Convulsion
Vomiting
Septicemia (blood poisoning):
Rash (pinpricks + bruises)
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Clinical manifestation
Clinical manifestation of CNS
Increased intracranial pressure
Headache
Projectile vomiting Hypertension
Bradycardia
Bulging fontanel
Cranial sutures diastasis Coma
Decerebrate rigidity
Cerebral hernia
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Clinical manifestation
Clinical manifestation of CNS
Conscious disturbance
Drowsiness Clouding of consciousness
Coma
Psychiatricsymptom
Irritation
Dysphoria
dullness
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Dr.T.V.Rao MD
Clinical manifestations
Meningococcal meningitis
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
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MENINGOCOCCAL INFECTION
Neisseria meningitidis: gram
negative intracellular
diplococci.
Groups A, B, C, W135 and Y.
Septicaemia, meningitis or
bacteraemia.
Incubation period of 2 to 7
days.
Spread by droplets from
asymptomatic carriers.
Case fatality of 10% (meningitis)and 20% (septicaemia).
Affects young children
predominately
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Diagnosis
Isolation of the organism
from CSF or blood.
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Laboratory Findings
Other bacterial
test
Blood cultivation
Film preparation of skin
petechiae and purpura
Secretion culture of local
lesion
Imageology examination
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Pathogenicity
Meningococcal meningitis, as a spreadfrom nasopharynx blood stream
meninges in susceptible hosts.
Direct spread to meninges
Rash
Adrenal hemorrhage (Waterhouse-Friderchsen syndrome)
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Dr.T.V.Rao MD
Clinical manifestations
Meningococcal meningitis 26
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Death from Waterhouse-Friderichsen
syndrome
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Meningococcemia
Bloodstream infection
May occur with or without meningitis
Clinical findings fever
petechial or purpuric rash
hypotension
multiorgan failure
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Clinical examination and
Important Signs
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Diagnosing by Isolation and
identification of Meninococcus
Invasive meningococcal disease is typically
diagnosed by isolation ofN. meningitidis
from a normally sterile site. However,
sensitivity of bacterial culture may be low,
particularly when performed after initiation of
antibiotic therapy. A Gram stain of
cerebrospinal fluid showing gram-negativediplococci strongly suggests meningococcal
meningitis.
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Diagnosis
Diagnostic methods
A careful evaluation of history
A careful evaluation of infant
s signs andsymptoms
A careful evaluation of information on
longitudinal changes in vital signs andlaboratory indicators
Rout examination of cerebrospinal fluid (CSF)
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Laboratory Findings
Especial examination of CSF
Specific bacterial antigen test
Countercurrent immuno-electrophoresis
Latex agglutination
Immunoflorescent test
Neisseria meningitidis (Meninococcus)
Haemophilus influenza
Streptococcus pneumoniae ( pneumococcus)
Group B streptococcusDr.T.V.Rao MD 32
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Lumbar puncture for CSF
Examination
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INVESTIGATION
1. Blood culture (sp)
2. Naso-pharyngeal
swab (both)
3. Lumbar puncture(mg)
4. PCR serum (sp)
5. PCR CSF (mg)6. Serology
7. Bleb aspirate (sp)
8. Skin scrapings (sp) Dr.T.V.Rao MD 34
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Dr.T.V.Rao MD
Laboratory examination of CSF
Cerebrospinal fluid examination
(an important method to establish diagnosis) :
pressure glucose
WBC sodium
protein chloride
M
turbid
>1000106/L
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Dr.T.V.Rao MD
Diagnosis with Combination of Factors
Epidemic season, age and epidemic situations.
Clinical features.Manifestations of severe form in sepsis and
meningoencephalitis
Increased leukocytes and polymorph nuclear
leukocytes predominantly in peripheral blood.
Increased intracranial pressure and purulent changes
in CSF.
Positive results in bacteriological examination.
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USUAL MANAGEMENT OF SUSPECTED CASE
Isolation
Released once they have had their antibiotictreatment for 48 hours
Intravenous Fluids
Often ill and pyrexiaAntibiotics
Cefotaxime (+ Ciprofloxacin or rifampicin).Will be given former for first 24-48 hours even
if diagnosis uncertain.Intensive care
Not unusual - unfortunately
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Epidemiology
Occurrence Meningococcal disease occurs worldwide in
both endemic and epidemic form.
Reservoir
Humans are the only natural reservoir of
Meninococcus. As many as 10% of adolescents
and adults are asymptomatic transient carriersofN. meningitidis, most strains of which are
not pathogenic (i.e., strains that are not
groupable). Dr.T.V.Rao MD 38
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Antibiotic Therapy
Course of treatment
7 days for meningococcal infection
1014 days for H influenza or S pneumoniaeinfection
More than 21 days for S aureus or E coli infection
1421 days for other organisms
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PREVENTION: CHEMOPROPHYLAXIS
Gets rid of bacteria from carriers (and cases)
Does not prevent infection
Given to those who, in 7 days before symptoms:
* Lived in same house* Kissed case on lips
* Gave mouth to mouth
resuscitation.Options: Ciprofloxacin, Rifampicin, Ceftriaxone.
Can be given up to 28 days after contact with case
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PREVENTION:
VACCINATION IN RESPONSE TO CASE
Available for groups A, C, W135 or Y.Only used once group is confirmed
Given to same group who receivechemoprophylaxis.
Different vaccines used: conjugate groupC or ACW135Y polysaccharide vaccines.
Limited immunity from polysaccharide
vaccine: lifelong from conjugate vaccineNow there is vaccine available forgroup B
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GROUP B VACCINESSome countries (NewZealand, Cuba, Norway,and Chile) developedvaccines against localstrains of B meningococcithat use strain-specific outer
membrane vesicle proteinrather than capsularpolysaccharide.
Polyvalent serogroups Bvaccine that contains
multiple bacterial surfaceproteins believed to befound in mostmeningococcal B strainsresponsible for the disease
globally being developed Dr.T.V.Rao MD 42
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Prognosis
Appropriate antibiotic therapy reduces the
mortality rate for bacterial meningitis in
children, but mortality remain high.
Overall mortality in the developed
countries ranges between 5% and 30%.
50 percent of the survivors have somesequelae of the disease.
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Public Health Importance
Challenges:-Educating public
-Timely reporting and records keeping
-Updating information daily.-Alleviating public anxiety and concerns
-Collaborating with health partners
Opportunities:-Educating public
-Communication
-Strengthening partnerships
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PUBLIC HEALTH RESPONSE: CASE DEFINITIONS
CONFIRMED: antibiotics +/- vaccine
Clinical diagnosis of meningitis or septicaemia
Confirmed microbiologically as due to Neisseria meningitidis
PROBABLE: antibiotics +/- vaccine
Clinical diagnosis of meningitis or septicaemia
Not microbiologically confirmedPublic Health Practitioner, in consultation with clinician,considers meningococcal infection most likely cause
POSSIBLE: no antibiotics or vaccine
Public Health Practitioner, in consultation with clinicianconsiders diagnoses other than meningococcal disease atleast as likely
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Programme Created by Dr.T.V.Rao MD for
Medical and Health care workers in the
Developing World
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