Meningococcemia

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Meningococcemia
Naval Forces for Southern Luzon Rawis, Legazpi
City January 21, 2005
Cmdr. Modesto T. Kapuno, PN (Res) Medical Officer
V, City Health Office
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What is Meningococcal infection? 
Meningococcal infection is brought by bacteria
Neisseria meningitides. The most common form of
disease due to meningococcal infection is
meningitis and the less common is Meningococcemia.
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NEISSERIA MENINGITIDIS(MENINGOCOCCUS)

• Gram Stain - Negative
• Anaerobic - CO2 enhances growth
• Extracellular
• Features - diplococci - coffee bean or
  kidney bean appearance
• Colonies - small, transparent on chocolate agar

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Cont.

• Non-motile
• Capsule Glycocalyx - polysaccharide
• Exotoxins - NONE
• Endotoxin - Lipooligosaccharide (LOS)
• Produces and sheds excessive amounts of LOS
  endotoxin as membrane fragments into the
  extracellular space
• Stimulates release of cytokines TNF alpha IL-1
  which can lead to hypotension septic shock

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Meningococcal Disease

• Incubation Period
• The incubation period is variable, 2-10 days, but
  usually 3-4 days
• Infectious Period
• An infected person is infectious as long as
  meningococci are present in nasal and oral
  secretions or until 24 hours after initiation of
  effective antibiotic treatment.

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 What is Meningococcemia?
Meningococcemia is a clinical form brought about
by spread of the bacteria to bloodstream causing
severe signs and symptoms.   The most
devastating form of meningococcemia is fulminant
meningococcemia which consists of hemorrhagic
rashes drop in blood pressure and circulating
shock leading to death.
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Case Definition

• Clinical Description
• Meningococcal disease manifests most commonly as
  meningitis and/or meningococcemia that may
  progress rapidly to purpura fulminans, shock, and
  death. However, other manifestations might be
  observed.
• Laboratory criteria for diagnosis
• Isolation of Neisseria meningitidis from a
  normally sterile site (e.g., blood or
  cerebrospinal fluid (CSF) or, less commonly,
  joint, pleural, or pericardial fluid)

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Case Definition

• Case Classification
• Probable a case with a positive antigen test in
• cerebrospinal fluid or clinical purpura fulminans
  
• in the absence of a positive blood culture.
• Confirmed a clinically compatible case that is
• laboratory confirmed.

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Epidemiology

• Reservoir
• Humans are the only known reservoir of
  Neisseria Meningitidis.
• Mode of Transmission
• Person to person through droplets of
  respiratory or throat secretions.
• Close and prolonged contact e.g., (kissing,
  sneezing and coughing on someone, living in close
  quarters or dormitories (military recruits,
  students), sharing eating or drinking utensils,
  etc.)

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GRAM STAIN OF SPINAL FLUID
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 What are the signs and symptoms of
Meningococcemia? 

• fever
• stiff neck
• convulsion, in some
• delirium
• altered mental status
• vomiting
• cough, sore throat, other respiratory symptoms
• pinpoint rashes then become wider and appear like
  bruises starting on the legs and arms
• large map like bruise-like patches
• severe skin lesions may lead to gangrene
• unstable vital signs

may or may not have signs of meningitis such as
? stiff neck, ? convulsion, ? delirium, ?
altered mental status, ? vomiting
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Clinical Presentation

• gt 2 Years
• High fever, headache, and stiff neck.
• Other symptoms include nausea, vomiting,
  discomfort looking into bright lights, confusion,
  and sleepiness.

• Newborns and small infants
• Classic symptoms may be absent or difficult to
  detect.
• In babies under one year of age, the soft spot on
  the top of the head (fontanel) may bulge upward.
• Infant may only appear slow or inactive, or be
  irritable, have vomiting, or be feeding poorly.

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How does meningococcal disease spread? 
Infection is spread by direct contact with
discharges from the nose and throat which contain
the bacteria.  Although meningococcal bacteria
are common, they are extremely delicate outside
of the body and are not very contagious.  The
bacteria spread from an infected carrier to
another person through close, direct physical
contact and through coughing, and sneezing,
kissing. It can also spread through saliva (spit)
when sharing items such as food or drinks, cups,
utensils and drinking straws. In general, people
should not share anything that has been in their
mouth. Exposure to cigarette smoke increases the
risk of spread of meningococci, as well as other
bacteria.
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Who is considered a close contact of a
meningococcal disease?

• A close contact is someone who is likely to have
  had direct contact with saliva or mucous from the
  nose or throat of an infected person.
• those who live in the same house
• those who have kissed the infected person
• those who share a bed
• children in the same childcare center or nursery
  because they
• frequently put objects into their mouths
• those who share drinks, cigarettes, food, drinks,
  water, glasses,
• cups, musical instruments with mouthpieces,
• or anything else that has been in the mouth of
  the infected person

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 What happens when someone is a close contact? 

• Close contacts of a case of meningococcal disease
  may be given an antibiotic to protect them.
• Classmates or co-workers of an infected person
  are not considered to be close contacts unless
  they have had direct contact with secretions from
  the mouth or nose of the sick person.
• Those who are close contacts of the infected
  person do not pose a risk to others and may
  continue to attend school or work.
• Siblings and other family members of close
  contacts do not require preventive treatment.

• In most cases, classes, school-related or work-
  related activities will continue as planned.
• Depending on the circumstances, public health
  officials may recommend that close contacts
  receive antibiotics, vaccine, or both in order to
  prevent additional cases of meningococcal
  disease.

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Can meningococcemia and meningitis be treated?
Penicillin kills meningococcal bacteria that
have invaded the body. Early recognition of
meningococcal infection and prompt treatment with
penicillin greatly improves chances of
survival. Prophylaxis is reserved for those who
have intimate contact with the patient household
members, boyfriend/girlfriend, sexual partners,
hospital personnel who did suctioning of
secretions and/or mouth resuscitation. Rifampicin
is the drug of choice and may be given to both
children and adults.
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How does one prevent meningococcemia? 

• Wash hands frequently with soap and water.
• Avoid close contact with meningococcemia
  patients.
• Increase resistance by having healthy diet,
  regular exercise, adequate rest and sleep, no
  alcohol and cigarette smoking.
• Maintain clean environment/surroundings
• Don't share utensils, cups, water bottles,
  lipstick, cigarettes and other water bottles,
  dishes, glasses, cups, lipstick, musical
  instruments with mouthpieces, mouth guards, or
  anything else that has been in the mouth of the
  infected person
• Avoid crowded places.

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Diagnosis
Diagnosis is confirmed by demonstration of the
bacteria in a gram-stained smear of the
cerebro-spinal fluid (CSF) and the isolation of
the bacteria from the CSF blood.
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Occurrence
The disease is usually sporadic (cases occur
alone or may affect household members with
intimate contact). Although primarily a disease
of children, it may occur among adults especially
in conditions of forced overcrowding such as
institutions, jails and barracks. It occurs more
in males than females.
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Public Health Significance?

• Leading cause of bacterial meningitis in children
  and young adults in the U.S
• 2,400 to 3,000 cases each year in U.S.
• 5 to 10 of patients die, typically within 24-48
  hours of onset of symptoms.
• 10 to 20 of survivors of bacterial meningitis
  may result in brain damage, permanent hearing
  loss, learning disability or other serious
  sequelae.
• Meningococcal septicemia - rapid circulatory
  collapse.

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VACCINE TOXOID

• Polyvalent capsular antigens - Groups A and C

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HOST DEFENSE IMMUNITY

• Circulating antibodies to capsule and activation
  of complement are important
• PMNs abound in CSF
• Antibodies can cross-react to other strains
• Previous infection and vaccination confer long
  lasting immunity
• Endotoxin stimulates cytokines TNF alpha and
  IL-1 which may mediate shock

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Immunity to Meningococcus
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Lab Tests

• Catalase Positive
• Oxidase Positive
• Sugar utilization glucose maltose
• Latex agglutination of CSF for rapid diagnosis
• DNA testing

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Public Health Actions

• Upon receiving a report of invasive meningococcal
  
• disease
• 1. Determine if reported case is probable or
• confirmed.
• 2. Assure that isolates are forwarded to the
  Office of Laboratory Services for serogrouping.
• 3. Determine if contacts need prophylaxis.
• 4. Recommend prophylaxis if indicated.
• 5. Complete appropriate report form(s).
• 6. Send completed forms to IDEP

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Algorithm Fever and PetechiaeRiordan FAI,Arch
Dis Child 200185 172-175
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Evaluation of Purpura
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Purpura Diagnostic Consideration

• Platelet Disorders
• Coagulation Factor Deficiency
• Vascular Factors
• Congenital
• Hereditary Telangectasia
• Ehrlos Danlos
• Acquired
• Infectious
• HSP
• Mechanical
• Psychogenic
• Abuse

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Case Study

• An 18-month-old infant is seen in the emergency
  room with a temperature of 105oF, purpuric rash,
  and opisthotonos.

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Fulminant Meningococcemia

• Most common in Winter and early Spring
• Extreme cases progress to sepsis
• Effects more than 2500 people/year
• Half are lt2
• While many individuals harbor the bacteria in
  their nose, throat and digestive tract, only a
  tiny portion develop the disease

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Fulminant Meningococcemia

• Rare cases of treatment failure infected with N
  meningitidis that are moderately resistant to
  penicillin, a third generation cephalosporin is
  indicated for patients in whom penicillin appears
  to be ineffective.

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Thank You