Meningococcemia

Naval Forces for

Southern Luzon
Rawis, Legazpi City
January 21, 2005

Cmdr. Modesto T. Kapuno, PN (Res)

Medical Officer V, City Health Office
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.
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
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
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.
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.
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)
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.
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.)
GRAM STAIN OF SPINAL FLUID
What are the signs and symptoms
of Meningococcemia?
•fever
may or may not have signs of
stiff neck
meningitis such as:
convulsion, in some  stiff neck,  convulsion,
delirium  delirium,  altered
altered mental status mental status,  vomiting
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
Clinical Presentation
> 2 Years :and small infants:
Newborns
• High fever,
•Classic headache,
symptoms and stiff
may be
neck. or difficult to detect.
absent
• Other
•In symptoms
babies include
under one year nausea,
of
vomiting,
age, the softdiscomfort looking
spot on the top ofinto
bright
the headlights, confusion,
(fontanel) and
may bulge
sleepiness.
upward.
•Infant may only appear slow or
inactive, or be irritable, have
vomiting, or be feeding poorly.
How doesis meningococcal
Infection disease
spread by direct contact with spread?
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.
 Who is considered
A close a close
contact is someone whocontact
is likely toof a
have
had direct contact withdisease?
meningococcal 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
 What happens when someone is a
close contact?
Close
In mostcontacts of a case
cases, classes, of meningococcal
school-related disease
or work-
may be activities
related given an antibiotic to protect
will continue them.
as planned.
Classmateson
Depending or the
co-workers of an infected
circumstances, person are
public health
not considered
officials to be closethat
may recommend contacts unless they
close contacts have
receive
had direct contact
antibiotics, vaccine,with secretions
or both from
in order the mouth or
to prevent
nose of thecases
additional sick person.
of meningococcal disease.
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.
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.
How does one prevent
• Wash hands frequently with soap and water.
meningococcemia?
• 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.
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.
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.
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.
VACCINE & TOXOID

• Polyvalent capsular antigens - Groups A and C

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
Immunity to Meningococcus
Lab Tests

• Catalase = Positive
• Oxidase = Positive
• Sugar utilization = glucose & maltose
• Latex agglutination of CSF for rapid diagnosis
• DNA testing
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
Algorithm – Fever and Petechiae
Riordan FAI,Arch Dis Child 2001;85 172-175
Evaluation of Purpura
Purpura – Diagnostic Consideration
• Platelet Disorders
• Coagulation Factor Deficiency
• Vascular Factors
– Congenital
• Hereditary Telangectasia
• Ehrlos Danlos
– Acquired
• Infectious
• HSP
• Mechanical
• Psychogenic
• Abuse
 Case Study
• An 18-month-old infant is seen in the
emergency room with a temperature of 105oF,
purpuric rash, and opisthotonos.
Fulminant Meningococcemia

• Most common in Winter and early Spring

• Extreme cases progress to sepsis
• Effects more than 2500 people/year
– Half are <2
– While many individuals harbor the bacteria in
their nose, throat and digestive tract, only a
tiny portion develop the disease
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.
Thank
You…