pg1 Report on Etiology, Epidiology, pathogenesis, the treatment principles of the meningococcal infections. Pachymeningitis –rare mostly due to extention of inflammation from the bones of the skull. Eg from chronic suppurative otitis media or compound fracture of the skull) (1) Etiology 1)Bacteria E.coli,B,Hemolitic Strep.(gr.B),Listeria monocytogenicmostly in neonates H.influenza, N,meningitidis, strep. Pneumoneae, M.tuberculosiskids <14yrs N.meningitides,Strep. Pneumoneaeadults Strep. Pneumoneae, Listeria monocytogens,M.tuberculosis,gr” “organisms elderly & immunocompromised 2)Virus1.enterovirus groupcoxsackie, echo, polio 2.mumps 3.Herpes simplex, H.zoster, V. zoster, EBV 4. HIV 5. Arbo V. (tick borne encephalitis) 3)Fungi 1.Cryptococcus 2. candida 4)SpirochaetsLeptospyra, treponema, Borellia5)Malignant cells 6)Blood, following subarachnoidal hemorrhage7)systemic dis. –LED 8)Drugs 9) Protozoamalaria(cerebral or P. falsiparum) Toxoplasmosis 10) Poisoning(Pb, Hg) 5,6,7,8,10non infectious causes ( 2)Mode of transmission 1. Blood streamdue to septicemia or metastasis from infection in heart, lung, resp.tract 2. Direct spread – from septic foci in skullsinusitis, otitis media: From septic foci in spine –osteitis,potts dis.: From trauma Lumbar puncture, penetrating wound. (3)Meningitis (a)Pathology BacterialPia, arachnoid is conjested w/ polymorphonuclear LeucocytesPus formation organised to form adhesionsleading to cranial N. lesions, hydrocephalus, cerebral edema(inTbc, brain is covered in a viscous, greygreen exudates, numerous tubercles found on the meninges) Viral there is predominantly Lymphocytic, inflammatory reaction in the CSF w/out the formation of puss or adhesions. There is no cerebral edema, hydrocephalus(unless viral encephalitis develops.) (b)clinical features – Intense malaise, fever, rigors, severe headaches, photophobia, vomiting, patient is irritable, often preffers to lie still, petechial rash, decr. Appetite Signs – Stiff neck, positive Kernig’s sign appears w/in a few hours, upper Brudzinskiwhen flexing neckflexion of leg, lower Brudzinsliwhen flexing 1 legflexion of other leg, nistagmus In uncomplicated meningitis, consiousness is not impared, although pt. May be delirious w/ high fever, papillo edema may occur, drowsyness maybe (c)complications –1. CNS hydrocephalus, deafness , cranial N. lesions 2. Heart pericarditis, endocarditis 3. Jointsarthritis (meningismusstate of irritation in Meningesclinics are the same, but CSF is normaleg:in severe intoxication) (d) Specific varieties of Meningitis – 1. Viral Meningitisalmost always benign,self limiting condition, lasting 410days. Consists of fever,headache(frontal & retro orbital) Meningeal irritation present , but sever meningeal irritation,. Evidencesuch as Kernig’s, Brudzinzski’s are absent, but neck stiffness positive.fever maybe with myalgia, malaise, anorexia,nausea, vomiting,mild degree of lethargy or drowsiness can be present. Photophobia, pain on moving eyes. 2.Tuberculous meningitis TBc causes chroninc meningitis w/ headache, lassitude , anorexia, & vomiting meningitic signs may appear only after some weeks., drowsiness, focal signs & seizures may occur. 3.Malignant Meningitis Malignant cells sometimes causes a subacute or chroninc meningitis process. Meningitis, cranial N. palsy , para paresis & root lesions are seen often in complex pattern. CSFincreased. Cells, incr. Prot. & often low glucose Treatmentintrathecal cytotoxic agents . Prognosis is poor.
pg2 4.Meningococcal Meningitis (acute bac. Meningitis) caused by N. meningitides A, B, C groups.: Gr. A & C –epidemics, gr Bsporadic It’s virulence is attributed to the polisaccharide capsule, wich resists phagocytosis & the lipo polysaccharide endotoxin complex which is responsible for it’s clinical toxicity, transmission by droplets or by direct contact. I.P : 1 week. Humans are the only known reservoir, not stable in environmental optimal temp.37oC, season is Spring. PathogenesisSpread by droplet infectionfrom naso pharyngeal colonization b/c of it’s humidity, & increased CO2 tension & specific receptor subst. Synthesized by naso pharynx to which they adherenaso pharyngeal cell invasionblood streem invasion transverses across bl. Brain barr. Enters CSF causes Meningitis Clinical Features4 major clinical syndromes due to meningo cocci 1.Meningococcaemia –Associated w/ fever (spiking fever), headache, chills ,myalgia, arthralgia, malaise, tachycardia, tachypnoea,purpuric or petechial rash(skin manifestations occur early) Dg: i )bl. Culture ii)culture from scraping petechia, purpura. In 30%50% of cases,there is meningococcaemia w/out meningitis. 2.Fulminent meningococcaemia(waterhouseFriderichsen syndr.) Occurs in about 10% of pts.in whom there is high level of circulating toxins, Characterised by n extremely rappid downhill clinical cource, with extensive hemorrhage into the skin, petechia enlarged rapidly aswell, hypotention(can be due to adrenal hemorrhage Addisonian crisis hypotension) shock ,coma ,deathw/in a few hours from the onset of sympt. DIC may complicate the clinical picture further.Hemmor. into Adrenal gl. Mey or mey not occur., w/out treatment, 100% mortality. 3.Meningococcal MeningitisPresent w/ fever, nausea, vomiting, headache, photo phobia, altered consiousness, neck rigiditiy,etc.(same signs & sympt. As written b/4 under meningitis) 4.Chronic meningococcaemia.Rare, intermittent fever,macculopapular rash, Arthralgia,splenomegally,bl.culture is positive during bacteraemic episodes. Forms that can be identified clinically i)Local forms – 1. Nasopharyngitis, 2.carriers,3.pneumonias, ii)Generalised forms1.meningococcaemia,2.Meningitis 1.Nasopharyngitisclinicssore throat,subfebrile temp., light intoxication,running nose.Objectiveslocal lymphadenopathy 2.Pneumoneaclinicsunilateral lobular pneumonea w/high temp. & cough . 3.Mwningococcaemia & 4.Meningitis (3.& 4. clinics stated above & B/4) Complicationsafter Pneumoniaabscess & pleuritis: after meningitisbrain edema, micro abscesses in all the organs & brain .DIC, kidney damage w/ kidney failure or insufficiencytoxic shock Diagnosis1)epidemiologyhistory of sinusitis, otitis,tonsillitis, TBc,lumbar puncture(c/I for Lumb. Punc. incr.i/c pressure, bleeding diathesis,cardiorespiratory compromise,infectionskin at the site) 2)clinicssymptoms & classical signs. 3)C.T.to exclude SAH or i/cranial mass. 4. CSF , Bl.,petechial or joint aspirates examination. 5.Bloodroutine tests(eg;Bl. Glucose) 6. 3 bac cultures from nasopharynx, from blood, from CSF & bacterioscopy(eg;CSF gram staining gr ““ coci, meningococcus) 7.Urine analysis, LDH , ASSAT, ALLAT, CPK. 8. Detect the cause of infectionskull, sinus, spine Xray. Normal viral Bac. Tbc Malignant (1)colour Crystal clear Clear or turbid Turbid or Turbid or cloudy purulent viscous (2)amount 50150ml (3)Pressure 60150mm/H ↑ ↑ ↑ ↑ 2O (4)mononuclear 05/mm3 10100/mm3 550/mm3 100300/mm C(lympho) 80%Lym.20%Ne 80%Neu. 3 u 20%Lym (5)PMN nil nil 2003000/m 0200/mm3 ↑
(6)Prot (7) Glucose
5080mg/dl( >1/2 of bl. Glucose) (2.54.2mmol /l)
5080mg/dl(>1/2 of bl. Glucose) (2.54.2)can be ↓ mumps, fungal
↓ (<1/2 of bl. ↓ (< 1/3 of Gluc.) bl. Glucose) (<2mmol/l) (<2mmol/l)
pg3 Treatment: 1.bed rest . 2. isolation. 3. symptomaticvit, antipyretics,analgesics, for convulsionsDiazepams,rehydration, disintoxication,diuretics. 4. etiologicalI)Benzyl penicillin 2.4 mil U /i/v / 6h. ii) Cefotaxime (3rd gen) 24g/i/v can be used too(b/c of resistance) iii)if allergic to penicillin Cloramphenicol 75100mg/Kg/day . iv) Steroidsfor children w/ meningococcal meningitis (Dexamethazone) v) TBc – Rifampicine, Isoniazide, Pyrazinamide is the combination. vi) Local/nasopharyngitisAmoxicillin, Doxaciclin (56 days) 5.PreventionPolyvalent vaccines against recurrent pneumococcal meningitis & for some strains of meningococci. Rifampicine prophylaxis is given to contacts & family members. DD of Meningitis According to etiological agents, which can lead to meningitis are D/D Main D/d in Latvia is tick borne encephalitis in which there are 3 stages i ) fever(37 days)apyrexia(20) days ii)Meningo encephalitisiii)Paralytic stage in meningo encephalitis stage there are meningial as well as encephalitis signs. Mental characteristics are encephalitis clinicsnervousness, tremor, halusinations, aggressiveness, memoty loss, to differentiate between Meningitis & encephalitis, can use clinics, if only encephalitisCSF normal findings & in later stages in encephalitisMRI, C.T. abnormalities positive. & if only Meningitisno MRI , C.T. abnormalities. If Leptospirosis, MeningitisEncephalitis, if not treated. Local infectionscausing neck stiffness eg; cervical lymph nodes,tetanus (CSF normal in both these conditions) Concept about Aseptic Meningitis febrile, meningeal inflammation, characterized by CSF mono nuclear pleocytosis,normal glucose, mild elevation of prot. & an absence of Bac. On examination & culture. Can be due to i) infectivevirus(echo, coccackie.HSV, VZV,HIV,Measles)partly treated bact. Meningitis, fungi,atypical TB, syphilis, Lyme dis, Leptospyrosis, Lysteria, after SAH, after infections (Measles, small pox, Rubella, Varicella) ii)Non infectiveMeningeal infiltration of malignant cells(Leukemia, Lymphoma), chemical meningitis(intrathecal drugs, contrast,LP, contaminants), drugs(NSAID like Ibuprofen,Trimethoprim), Sarcoidosis,SLE, Parameningeal Diseaseeg;sinusitis(chronic) or otitis, brain tumor.
Report on Etiology, Epidiology, pathogenesis, the treatment principles of the meningococcal infections. Report prepared by 1. Dr. Sajid Mahmood, MD (EU), Accident & Emergency Department, NHS Royal infirmary Liverpool United Kingdom. 2. Dr. Adnan Akram, MD (EU), Department of Infectious Diseases. University Hospital Riga Latvia. 3. Dr. Aftab Ahmed, MD (EU), Infection Control Department, Kaunas Medical University Clinic. Lithuania. Contact: publications [at] infekcijas.eu