Almost 50% of children presenting to GP with MCD were sent home on 1 visit: more likely to die
Pathology
Common causes investigate
with gram stain
Listeria (+)
Pneumococcus (-)
Neisseria (-)
Herpes simplex virus
Spectrum of colonisation
Gram positive bacteria that invade neutrophils
Endotoxins = inflammatory response
o Widespread vasodilation > CV
shock
Myocardial damage > septic shock
Intravascular coagulation > blocked blood
vessels
Vessel damage - haemorrhage into tissues
(e.g. petechial rash
Basically, disruption of normal CV system physiology and its role in delivering
oxygen nutrients to tissues
Evidence usually picked up by CSF but in this case using Polymerase Chain Reaction to ID DNA of
meningococcus
Uusually evidence of septicaemia
Lab work
Polymerase chain
reaction for DNA
detection
High RBC count (610/ cu mm) -
normal <5
High WBC count (4000 cells/cu mm) - normal
<5 o 2% lymphocytes, 98% polymorphs
Low BGL (0.9 mmol/L) - normal 5.8
High protein levels (5359g/L) -
normal 150-400
Clotting high (>6.0g/L) - normal 1.5-4.5
Immediate managment
Penicillin from GP
according to NICE
guidelines
Annotations:
First line of defence
Erythromyocin is used for
pneumoccus too esp. with
penicillin allergies
Empiric antibodies for suspected
pneumococcus
e.g. IV Ceftiaxone
Anti-viral e.g.
Aciclovir
for suspected viral encephalitis
Corticosteroid
e.g.
Dexamethasone
Annotations:
Rare, only used in some cases
Physical signs and symptoms
Drowsy, unrousable
Glasgow coma score 7/15
Small
haemorrhagic
lesion on foot
Evidence of septicaemia
Annotations:
blood poisoning/ toxicity resulting in deranged blood clotting and rash
Evident in advanced cases but less obvious early on
Signs and symptoms
Headache, nausea, vomiting
Photophobia
Stiff neck
Non-blanching rash
These 'spots' are a well-publicised
feature of meningococcal infections
Glass test check if the spots are blanching vs. non-blanching
Dialated temporal horns
Possible evidence of cerebral oedema
Prodrome phase in self-limiting viral illness
Lasts up to 4 hours in young children
Lasts up to 8 hours in adolescents
Symptoms from hours of onset (RED FLAG symptoms)
Fever earliest symptom across ages and most common
Sepsis features second earliest symptom and most common
Impaired mental status, meningism and
haemorrhagic rash takes longer across ages
and develops slower (also occurs in less
people)
Importance
Identifying these could reduce proportion of missed cases in first consultation by half
Recognising symptoms after 19 hours of onset, brings prognosis
forward 11 hours
Long term
Gangrene due to obstructed circulation
Severe septicaemia
Public health importance
Public health (CCDC) needs to be notified
Annotations:
Pt must have picked up bacteria from close contact
Bacteria often colonises throat but in this case
Type A
Meningitis type A (Meningitis belt) of
Africa, type B not so common Africa
Type A found in Asia far more than other types
Responsibilities of public health
officials
Follow up family o Follow up staff who performed intubation of pt. in A&E (low
risk but need to be given antibiotic cover) o Follow in flat or halls - need to
consider flatmates and any possible close contacts:
Type B
rates of type B quite steady from 1999-2009
Type B far more common
2005-2015 in England vs. type C,
Y and other regardless of age
Type B most common in children age 1-4, then <1, and then 15-19 years
New vaccine!
In infants born since 01 July 2015 o Type C particularly used to be in
teenagers/students but vaccine now o New this month, meningococcus type
ACWY vaccine in adolescents
Prevention
Friends and relatives
Parents need to get their children vaccinated A+C, ACYW or C-
conjugate, B
Contact tracing and giving antibiotic prophylaxis for close contacts
Surveillance and notifiable disease reporting
Meninges are the three membranes (the
dura mater, arachnoid, and pia mater)
that line the skull and vertebral canal and
enclose the brain and spinal