Kembara Xtra - Medicine - Meningococcal Disease
Neisseria meningitidis, a blood-borne pathogen, is the cause of meningococcemia. Bacteremia without meningitis causes the patient to become critically unwell and may cause hypotension as well as skin symptoms such rashes, petechiae, and ecchymosis. Symptoms of bacteremia with meningitis include myalgias, nausea, vomiting, headache, and a fast onset of fever. The disease advances quickly (within hours). Hypotension and skin changes could be observed. - Discrete lesions with a diameter of 1 to 2 mm that are characteristic of a petechial rash typically develop on the trunk and lower body and are seen in more than 50% of patients when they first show. - Up to 25% of instances of meningococcal illness result in purpura fulminans, a serious consequence. It is distinguished by the sudden onset of cutaneous bleeding and necrosis brought on by disseminated intravascular coagulopathy and vascular thrombosis. Incidence There is a 13% mortality rate. - Serious consequences, such as deafness, neurological impairments, or limb loss as a result of peripheral ischemia, affect 11–19% of survivors. Peak incidence occurs in the first year of life; 35-40% of cases occur in children under the age of five. The disease is seasonal, peaking in December/January. Atypical clinical presentations include stomach symptoms, septic arthritis, and bacteremic pneumonia. Adolescence is when there is a second peak. There were 350 cases of meningococcal illness reported in 2017 (the most recent CDC data), translating to an incidence rate of 0.18 cases per 100,000 people (1). - Most prevalent in teenagers and young adults, then infants under one year old, Pathophysiology and Etiology Fastidious, aerobic, gram-negative diplococcus N. meningitidis has at least 13 different serotypes. The outer coat of N. meningitidis secretes an endotoxin that causes illness. Humans are the only known reservoir for N. meningitidis, and the major serogroups in the US are B, C, Y, and W- 135. Bacterial virulence factors cause invasive illness. Serogroup B is the main cause of meningococcemia in children under the age of one. The majority of cases of meningococcal illness in the US are caused by serogroup C. Major serogroups in the world include A, B, C, Y, and W-135. Serogroup Y is the main cause of meningococcemia in the elderly. - The main disease-causing agent in sub-Saharan Africa's "meningitis belt" is W-135. Genetics The inheritance pattern for late complement component deficiency is autosomal recessive. Risk Elements Age: 3 months to 1 year; Late complement component deficit (C5, C6, C7, C8, or C9); Asplenia; Close quarters (e.g., home connections; childcare facilities; dorms; military barracks); and Exposure to active (and/or passive) tobacco smoke Prevention There are now two vaccinations approved for use in the US. There are antigens for serogroups A, C, Y, and W-135 in each. Both offer protection from serotype B, which accounts for one-third of infections in the United States (3). - Meningococcal polysaccharide vaccine (MPSV-4) is advised for anyone under the age of 55 who are at increased risk. Brief protection period: 1 to 3 years for patients under the age of 5, and 3 to 5 years for adults and adolescents.○ frequently used for patients needing short-term protection, such as those going to endemic locations, college freshman, and those experiencing community outbreaks - MenACWY, the meningococcal conjugate vaccination The routine immunization of all youngsters between the ages of 11 and 18 is advised. Immunization is advised for those aged 2 to 55 who have a higher risk of contracting meningococcal illness. A personal history of Guillain-Barré syndrome is a relative contraindication for the MCV-4 immunization because the MCV-4 vaccine has been linked to the Guillain-Barré syndrome. Two serogroup B meningococcal (MenB) vaccines have received FDA approval. The first is a three-dose sequence called MenB-FHbp. The second is a 2-dose sequence called MenB-4C. Both vaccines have been given the go-ahead for usage in patients 10 to 25 years old. People under the age of 10 who have anatomical or functional asplenia, persistent complement component deficits, or both should receive the MenB vaccination. Antibody levels that are protective are reached 7 to 10 days following the first immunization. CDC international travel advisory: Saudi Arabia's government mandates vaccination for Hajj pilgrims over the age of two. Travelers to the "meningitis belt" of sub-Saharan Africa should receive the vaccine. Symptoms of the diagnosis Acute nonsuppurative sore throat, chills, nausea, vomiting, headache, myalgias, and/or fever. - Pharyngitis could be confused for the bacterial infection known as strep throat. - The severity of the "flu," which also has a wintertime peak occurrence, can be mistaken for myalgia. Mental state changes, diminished focus, stiff neck, and convulsions Determine potential exposures. ● Other clinical assessment Tachycardia, hypotension, and fever Neurologic: coma, seizure, nuchal stiffness, focal neurologic symptoms - Seizures and focal neurologic abnormalities are more frequently observed in patients with Streptococcus pneumoniae or Haemophilus influenzae. Cardiopulmonary: galloping, rales, and other symptoms of heart failure with pulmonary edema Dermatologic: purpura, petechiae, ecchymosis, and maculopapular rash The onset of specific meningitis symptoms, such as bulging fontanelles, photophobia, and stiff necks, might take between 12 and 15 hours (4). Late meningitis symptoms, such as unconsciousness, delirium, or seizures, appear after 15 hours in infants under 1 year old and 24 hours in larger kids. Differential Diagnosis: Rocky Mountain Spotted Fever, Gonococcemia, Acute Bacterial Endocarditis, Hemolytic Uremic Syndrome, Gonococcal Arthritis Dermatitis Syndrome, Influenza Results from the Laboratory Caution The gold standard for determining if a person has a systemic meningococcal infection is the isolation of N. meningitidis from a sterile location (blood or CSF). After taking an antibiotic, blood and/or CSF cultures may become negative in two hours. Initial Tests (Lab, Imaging) Culture (of blood, CSF, or another sterile site) is required for a final diagnosis. Leukocytosis (left shift; toxic granulation) or leukopenia, thrombocytopenia on CBC with differential Lactic acidosis, procalcitonin, which is frequently high in cases of bacterial meningitis, coagulation tests, low fibrinogen, and elevated fibrin degradation products Blood cultures are positive in 50–60% of cases for N. meningitidis in blood cultures. CSF: Extremely murky; elevated WBCs with a predominance of polymorphonuclear cells - Positive for N. meningitidis antigen (MAT or PCR) - Gram stain indicating gram-negative diplococci - Glucose-to-blood glucose ratio 0.4 - Protein >45 mg/dL - 80–90% of cases have a positive CSF culture. Head CT before lumbar puncture (LP) if space-occupying lesions are a concern or if there are localized abnormalities on a neurologic examination Interpretation of Tests Meningeal exudates, polymorphonuclear infiltration of the meninges, hemorrhage of the adrenal glands, and disseminated intravascular coagulation (DIC). management in the lead As soon as meningococcal meningitis is detected, start taking antibiotics. - Treatment empirics are based on age. Cefotaxime 0 to 7 days: 50 mg/kg q12h 8 to 28 days: 50 mg/kg q8h Preterm to 1 month: ampicillin plus cefotaxime or ampicillin plus gentamicin Ampicillin >2,000 g 0 to 7 days: 50 mg/kg q8h 8 to 28 days: 50 mg/kg q6h 2,000 g 0 to 7 days: 50 mg/kg q12h 8 to 28 days: 50 mg/kg q8h 1 month to 50 years: cefotaxime or ceftriaxone plus vancomycin If severe penicillin allergy: chloramphenicol Effective if the isolate has a penicillin MIC of less than 0.1 g/mL Penicillin can be utilized if the isolate has a penicillin MIC of less than 0.1 g/mL. A third-generation cephalosporin is preferable for isolates with a penicillin MIC of 0.1 to 1.0 g/mL. Penicillin G: 4 million units IV every four hours (pediatric dose: 0.25 mU/kg/day IV divided every six hours). OR 2 g IV q4h of ampicillin (pediatric dose: 200 to 300 mg/kg/day IV divided every 6 hours). Treatment time: seven days Indications for Dexamethasone In some adults, pneumococcal meningitis is known or suspected. Children with suspected bacterial meningitis who have H. influenzae type B meningitis are frequently treated with dexamethasone while waiting for the results of microbiologic tests. - Once the diagnosis of meningococcal meningitis has been made, dexamethasone should be stopped since it has not been proven to be beneficial in treating the condition. - Dosing Starting 10 to 20 minutes before or with the first dose of antibiotic, provide IV 0.15 mg/kg/dose every six hours to infants and children older than six weeks. Chemoprophylaxis - Significance Close contacts include those who are in close proximity to the patient for an extended period of time (>8 hours), are less than 3 feet away from the patient, or are directly exposed to the patient's oral secretions between one week prior to the onset of symptoms and up to 24 hours following the start of adequate antibiotic therapy (2). Close connections at nurseries, daycare centers, nursing homes, dorms, military barracks, prisons, and other closed institutional settings are a few examples. No chemoprophylaxis is advised for inadvertent contacts, such as the majority of healthcare professionals, unless they are exposed to respiratory secretions. - Timing: 24 hours after case identification is ideal. Chemoprophylaxis shouldn't be given if it has been more than 14 days since exposure. - Prevention programs. Because ciprofloxacin-resistant, -lactamase-producing N. meningitidis serogroup Y cases are increasing in the United States (1), the CDC advises taking into account antimicrobial susceptibility testing on meningococcal isolates to guide prophylaxis decisions if a case of meningococcal disease caused by ciprofloxacin-resistant strains has occurred in that state within the previous two years. Rif Adults should take 250 mg IM once day; children under 15 should take 125 mg IM once daily. Rifampin (meningococcal prophylaxis) Adult: 600 mg IV or PO q12h for 2 days Pediatric: 10 mg/kg/day in divided doses Infants and children: 20 mg/kg/day in divided doses (max 600 mg/dose) Pediatric: 10 mg/kg/day in divided doses Adults: 500 mg PO as a single dosage of ciprofloxacin Precautions: Modify medicine dosage in patients with severe renal impairment. Vaccination: For household contacts (if the case is from a vaccinepreventable serogroup). Next Line Meningitis treatment options include ceftriaxone 2 g IV q12h (pediatric dose: 80 to 100 mg/kg/day split q12-24h) or chloramphenicol 1 g IV every 6 hours (pediatric dose: 75 to 100 mg/kg/day divided q6h). Large outbreaks have been treated with a single dosage of long-acting chloramphenicol. In one randomized controlled trial, single-dose ceftriaxone had equivalent efficacy. Ceftriaxone should not be administered to patients who have previously experienced allergic reactions to penicillin (such as hypotension, laryngeal edema, wheezing, or hives). - Aplastic anemia may be induced by chloramphenicol. Referral Potential issues include seizure activity and DIC. Acute respiratory distress syndrome, multisystem organ failure, renal failure, and failure of the adrenal glands Admission If meningitis is suspected, start taking antibiotics (corticosteroids) and get a lab result as away. 24 hours of droplet isolation following the commencement of antibiotics IV fluids: Replace volume as necessary; substantial quantities of crystalloid may be needed in cases of septic shock. Education of Patients Inform your family and close friends about the danger of meningococcal infection. Overall mortality is predicted to be 13%. Young age, hypotension, thrombocytopenia, impaired mental status, and leukopenia are factors linked to a poor prognosis. Complications Neurologic: sensorineural hearing loss, cranial nerve palsy, seizures; Acute tubular necrosis; Obstructive hydrocephalus; Subdural effusions; Acute adrenal hemorrhage; Waterhouse-Friderichsen syndrome; DIC.
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