Department of Infectious Diseases

1. MENINGOCOCCAL MENINGITIS Department of Infectious Diseases (Shi Hong)

2. Meningococcal meningitis HIGH ●early diagnosis ● modern therapy ● supportive measure Morbidity mortality Morbidity mortality rate low LOGO Meningococcal meningitis

3. A case Beijing Center for Disease Control and Prevention (CDC) January 11, 2007 ◆The patient was a 14-year-old male student. ◆ The onset of this case started quickly with high fever(39°C) and headache. ◆ Other clinical symptoms included nausea, vomiting, stiff neck and confusion. ◆ There was little petechiate rash emerged on the patient’s four limbs. ◆ The Kernig’s sign was positive and Brudzinski’s sign was negative. ◆ The numbers of white cell in the blood and cerebrospinal fluid (CSF) were 3.6×1010/L and 1.7×109/L, respectively. LOGO What was the most likely diagnosis

4. Definition Meningococcal meningitis : ★Neisseria meningitides ★ Respiratory tract ★ Purulent meningitis (an acute inflammation of the membranes that cover the brain and spinal cord) LOGO Meningococcal meningitis

5. Etiology ◆ gram-negative coccus ◆ Neisseria species ◆ 13 serogroups ◆ groups A, B, C What causes Meningococcal meningitis LOGO

6. Epidemiology Sources of infection: carriers and patients Infectious period : between late incubation period and acute phase, no more than 10 days of onset LOGO Meningococcal meningitis

7. Epidemiology • Routes of transmission ⑴ Respiratory tract: ⑵ Close contact: cough/sneeze bosoming/kiss/breast-feed LOGO Meningococcal meningitis

8. Epidemiology Susceptibility ☆Everybody without specific immunity ★6 months to 2 years of age. Epidemical features ◇the common season : in the winter and early spring (November to May in next year) The peak incidence is in March to April LOGO Who is at risk?

9. Pathogenesis • Immunity＞bacterial quantity and virulence • A. bacteria eliminated. • B. benign nasopharyngeal carriage • or upper respiratory tract infection • →→cured • C. temporal meningococemia • →→cured LOGO Meningococcal meningitis

10. Pathogenesis • Immunity<bacterial quantity and virulence • A. meningococcal septicemia. • B. meningococcal meningitis. • C. meningococcal arthritis and pericarditis LOGO Meningococcal meningitis

11. Pathogenesis Immunity<bacterial quantity and virulence A. meningococcal septicemia endothelial cells ▼Petechia ▼infectious shock ▼acidosis, ▼DIC ▼multiorgans failure invade release endotoxin LOGO Meningococcal meningitis

12. Pathogenesis Immunity＜bacterial quantity and virulence B. meningococcal meningitis Neisseria meningitides the mucosal barrier the bloodstream the central nervous system increased intracranial pressure convulsion, coma, herniation CSF turbid, sometimes circular obstacle of cerebrospinal fluid and hydrocephalus LOGO Meningococcal meningitis

13. Clinical manifestations petechia in the skin (Meningococcal meningitis) LOGO What are the signs and symptoms

14. Clinical manifestations • Incubation period: generally 2 to 3 days (Range is 1 to 10 days) • Four types: ⒈Meningococcal meningitis(Moderate type) ⒉ Fulminate type（shock type, Meningoencephalitic type) 3. Mixed type （Meningococcemia- meningitis） 4. Mild type (Mild acute meningococcemia) LOGO What are the signs and symptoms

15. Clinical manifestations Prodromal period Septic period Septic period Meningitic period Meningitic period ▲ an abrupt onset ▲ chills high fever ▲ Headache ▲ Petechias ▲ purpuras ▲Splenomegaly ▲intracranialpressure ▲ headache ▲vomiting ▲restlessness ▲Stiff neck ▲Kernig (+) ▲brudziski (+) Convalescent period ▲gradually disappears, ▲recovers to normal. LOGO Meningococcal meningitis

16. Clinical manifestations LOGO Meningococcal meningitis

17. Clinical manifestations LOGO Meningococcal meningitis

18. Laboratory examination • ⒈ Routine laboratory studies of blood: platelet count(DIC) WBC>20×109/L Polymorphonuclear leukocyte LOGO Meningococcal meningitis

19. Laboratory examination Lumbar puncture: CSF LOGO Meningococcal meningitis

20. Laboratory examination ⒉ Cerebrospinal fluid examination (an important method to establish diagnosis) : ● pressure ● glucose ● WBC ● sodium ● proteinchloride turbid >1000×106/L LOGO Meningococcal meningitis

21. Laboratory examination • ⒊ Bacteriological examination (an important method to definitive diagnosis) : Smear: skin lesions spun sediment of CSF Bacterial culture of blood and CSF LOGO Meningococcal meningitis

22. Laboratory examination Figure :  Neisseria meningitidis Gram-stain of a pure culture LOGO Meningococcal meningitis

23. Diagnosis ⒈ Epidemic season, age and epidemic situations. ⒉ Clinical features. ⒊Manifestations of severe form in sepsis and meningoencephalitis ⒋Increased leukocytes and polymorphonuclear leukocytes predominantly in peripheral blood. ⒌ Increased intracranial pressure and purulent changes in CSF. ⒍ Positive results in bacteriological examination. LOGO Meningococcal meningitis

24. Differential diagnosis ⒈Purulent meningitis caused by other purulent bacteria. ⑴ Streptococcus pneumonia meningitis, ⑵ Haemophilus influenzae meningitis, ⑶ Staphylococcus aureus meningitis. ＆(no overt season,no petechae or purpura) ⒉ Meningeal tuberculosis. ＆(the history, no petechae or purpura,Bacillus tuberculosis) ⒊ Sepsis (Shock type) ＆ (other causative bacteria in blood cultures) LOGO How to diagnose Meningococcal meningitis

25. A case Beijing Center for Disease Control and Prevention (CDC) January 11, 2007 ◆The patient was a 14-year-old male student. ◆ The onset of this case started quickly with high fever(39°C) and headache. ◆ Other clinical symptoms included nausea, vomiting, stiff neck and confusion. ◆ There was little petechiate rash emerged on the patient’s four limbs. ◆ The Kernig’s sign was positive and Brudzinski’s sign was negative. ◆ The numbers of white cell in the blood and cerebrospinal fluid (CSF) were 3.6×1010/L and 1.7×109/L, respectively. LOGO What was the most likely diagnosis

26. 1 3 2 what do we still do for definitive diagnosis? what’s the most likely diagnosis? How to treat this young patient? Problems LOGO To analyze the case

27. 1 2 3 General treatment ①Isolation hospitalization: ②Careful monitor nursing. ③Prevent complication. ④Maintain the balances of fluid and electrolytes • Etiological treatment • ① Antibacterial activity. • ②Concentration in CSF. • ③ Resistance to drugs • Penicillin G • （200~400u/kg/day) • B.Chloromycetin • C.Cephalosporis Other treatment ● High fever: anti-pyretic (physical chemical) measures. ● Increased intracranial pressure: 20 % mannitol (0.5g/kg~2g/kg) Treatment LOGO

28. Fulminate type ⑴ Shock type ①Etiology treatment: . Penicillin G ② Shock should be corrected promptly: a. Volume expanded. b. Metabolic acidosis corrected. c. Vasoactive drugs. d. Adrenal corticosteroids. e. Important organs protected ⑵ Meningococcemia-meningitis type ① Effective antibacterial drugs. Penicillin G. ②Alleviate cerebral edema Mannitol and 50 per cent Glucose. ③ Adrenal corticosteroids: Dexamethasone ④ Treatment in respiratory failure: lobeline, coramine ⑤High fever and seizure: Sedatives: wintermine phenergan Treatment LOGO Meningococcal meningitis

29. Good poor poor early diagnosed appropriately treated Fulminate meningo-coccemia in the extremes of age Prognosis LOGO Meningococcal meningitis

30. for 3 days after the symptoms disappeared, generally no less 7 days after the onset Protection of the susceptible population isolate Protect Protection of the susceptible population Close contacts: observed medically for 7 days. Protect observe meningococcal vaccines, Chemoprophylaxis To go to the crowd places should be avoided during the epidemic Administer Disrupt Prevention LOGO Meningococcal meningitis

31. Multiple choice 1.A diagnosis of meningococcal infection requires the following to be present: a) Headache b) Neck stiffness c) Photophobia d) vomiting e) Pyrexia LOGO Meningococcal meningitis

32. Multiple choice • 2. Meningococci: ( which one is right?) a) Are most often harmless commensals colonising the nasopharynx b) Are carried by some adolescents who show no signs of disease c) Are transmitted by aerosol d) Are usually transmitted with minimal contact e) Cause infection most frequently in teenagers LOGO Meningococcal meningitis

33. Summarization ⒈ Definition Meningococcal meningitis is an acute purulent meningitis caused by meningococci ⒉ Transmission route occurs through respiratory tract. ⒊ The incidence of meningococcal meningitis The incidence of meningococcal meningitis is the first in purulent meningitis among children. LOGO Meningococcal meningitis

34. Summarization ⒋ Clinical characteristics ⑴ high fever rapidly; ⑵ severe headache; ⑶ vomiting frequently; ⑷ petechiae and purpura in the skin; ⑸ meningeal irritations; ⑹ infectious shock and injuries in brain parenchyma occurred in severe cases and often result in death. LOGO Meningococcal meningitis

35. Summarization • What is meningitis? What is encephalitis?What causes meningitis and encephalitis?Who is at risk for encephalitis and meningitis?How are these disorders transmitted?What are the signs and symptoms?How are meningitis and encephalitis diagnosed?How are these infections treated?Can meningitis and encephalitis be prevented?What is the prognosis for these infections?. LOGO Meningococcal meningitis

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38. Features of meningococcal meningitis in infants ⒈ Causes of atypical symptoms are that the crania and fontanelle are not still closed and the central nervous system is not well developed. ⒉ The features of clinical manifestations ⑴ Respiratory symptoms always presents with cough. ⑵ Gastroenteric symptoms Refusal to take food, vomiting and diarrhea are common gastroenteric symptoms. ⑶ Increased intracranial pressure includes irritability, shrill, seizures and fullness of the fontanelle. ⑷ Meningeal irritation always is not overt LOGO Meningococcal meningitis

39. Features of menigococcal meningitis in the old ⒈ The causes of high incidence in fulminate type In the old the immunity is lower, properdin deficiency and sensitive to endotoxin. ⒉ Clinical manifestations ⑴ Symptoms of upper respiratory tract are commonly presented in the old. ⑵ Mental obtundation is overt. ⑶ Petechia and purpura are more common. ⒊ Complications and prognosis usually can be seen with high mortality. ⒋ Leukocytes Leukopenia is often seen due to lower human body’ reaction LOGO Meningococcal meningitis