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| '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' | | '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' |
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| {{DiseaseDisorder infobox | | | {{DiseaseDisorder infobox | |
| Name = {{PAGENAME}} | | | Name = {{PAGENAME}} | |
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| DiseasesDB = 8847 | | | DiseasesDB = 8847 | |
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| {{Meningococcemia}} | | {{Meningococcemia}} |
| {{CMG}}; '''Associate Editor(s)-In-Chief:''' {{CZ}} | | {{CMG}}; '''Associate Editor(s)-In-Chief:''' {{CZ}} |
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| '''''Synonyms and related keywords:''''' meningococcal infections, epidemic cerebrospinal fever, Waterhouse-Friderichsen syndrome, meningitis, meningococci, fulminant meningococcemia, acute meningococcemia, meningococcemia, meningococcal meningitis, bacterial meningitis, meningococcal disease, Neisseria meningitidis, N meningitidis, chronic meningococcemia | | '''''Synonyms and related keywords:''''' meningococcal infections, epidemic cerebrospinal fever, Waterhouse-Friderichsen syndrome, meningitis, meningococci, fulminant meningococcemia, acute meningococcemia, meningococcemia, meningococcal meningitis, bacterial meningitis, meningococcal disease, Neisseria meningitidis, N meningitidis, chronic meningococcemia |
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| == Overview == | | ==[[Meningococcemia overview|Overview]]== |
| '''Meningococcemia''' is the presence of ''[[Neisseria meningitidis]]'' (also known as '''meningococcus'''), a severe bacterical infection, in the blood stream. It is demonstrated by [[blood culture]]. The [[disease]] is hard to identify as it can appear in several different forms, depending on which part of the body the [[bacteria]] invade. '''Neisseria meningitides''' is a gram-negative diplococcus. The bacteria is known to cause [[meningitis]], [[septicaemia]], [[pneumonia]], and even rarely [[urethritis]].
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| Most cases of meningococcal meningitis occur in children. Early recognition and treatment of anyone exposed to [[meningococcus]] is extremely important to prevent serious illness or death. In cases of serious infection, sufferers may have to have limbs amputated as infected flesh dies off and may otherwise spread [[gangrene]].
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| == Epidemiology and Demographics ==
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| * Case rate is 1-2 per 100,000 in the US in 1980. More recently, there are approximately 2,500 cases of meningococcal infections per year in the United States.
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| * Since the introduction of ''Haemophilus influenzae'' type b vaccine in 1990 for infants the majority of cases of bacterial meningitis have been in adults; historically 45-87% of cases have been in children.
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| * Second most common cause of community-acquired adult bacterial meningitis after pneumococcus.
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| * In West African countries during 1996-1997 there were 213,658 cases and 21,830 deaths due to menigococcal disease.
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| == Risk Factors == | |
| * Episodic epidemic nature of meningococcal meningitis particularly among young children and military recruits was known since the 18th century.
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| * Epidemics occur generally among poorest groups where crowding and lack of sanitation are common.
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| == Pathophysiology & Etiology==
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| * Transmission through respiratory secretions from a nasopharyngeal carrier case-patient.
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| * Shock is due to lipooligosaccharide which is a potent toxin. This toxin initiates release of inflammatory cytokines, reactive oxygen radicals, prostaglandins, arachidonic acid, complement activated products, platelet aggregating factor, and perhaps nitric oxide.
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| == Molecular Biology ==
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| * The polysaccharide capsule is the basis of the serogroup typing system.
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| * 13 Serotypes are described based on capsular polysaccharide: A, B, C, D, X, Y, Z, E, W-135, H, I, K, and L.
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| * Serogroup A usually with epidemics in less developed nations and an attack rate of as high as 500 cases per 100,000 population.
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| * Serogroup B usually in developed nations with attack rate of 50-100 cases per 100,000 population.
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| * Serogroup C usually in both developed and less developed populations and an attack rate of up to 500 per 100,000 population.
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| == Natural History ==
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| * Before antibiotics the case fatality rate was over 50%, particularly dangerous in infants and elderly (84% and 72% respectively). Now it is often as low as 8% in major medical centers.
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| == Diagnosis ==
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| ===One of Four Scenarios is Often Present===
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| #Bacteremia without sepsis. Admission for upper respiratory illness or viral exanthem. Positive blood cultures for ''Neisseria meningitides''.
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| #Meningococcemia without meningitis. Septic patient with leukocytosis, skin rashes, generalized malaise, weakness, headache, and hypotension on admission or shortly after.
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| #Meningitis with or without meningococcemia. Patients with headache, fever, meningeal signs and cloudy spinal fluid. No pathologic reflexes.
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| #Meningoencephalitic presentation. Profoundly obtunded with meningeal signs and septic spinal fluid. Altered reflexes (either absent or rarely hyperactive). Pathologic reflexes are often present.
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| === General Symptoms === | | ==[[Meningococcemia classification|Classification]]== |
| According to [http://www.meningitis.org/symptoms research], these are typical symptoms of infection. Not all of these symptoms will appear, and not necessarily in this order. Every child with purpuric [[rash]] and high [[fever]] should be treated as meningococcemia - until proven otherwise.
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| *Rash, pinpoint red spots ([[petechiae]])
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| *High [[fever]]
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| *Severe [[headache]]
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| *Severe [[malaise]]
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| *[[Nausea]] and [[vomiting]]
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| *Stiff neck
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| *Sensitivity to light (photophobia)
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| *Mental status changes
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| *[[Headache]], [[confusion]], and stiff neck occurred as symptoms in less than half of 53 patient in one series by Carpenter and Petersdorf.
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| *Patient may complain of significant [[myalgia]]s.
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| ===HUSSEIN AND SHAFRAN CANADIAN REVIEW OF BACTERIAL MENINGITIS=== | | ==[[Meningococcemia historical perspective|Historical Perspective]]== |
| {|
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| |-style="background:silver; color:black"
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| | '''Fever >= 37.7 degrees Celsius''' || '''97%'''
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| |-style="background:silver; color:black"
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| | '''Nucal Rigidity''' || '''87%'''
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| |- style="background:silver; color:black"
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| | '''Headache''' || '''66%'''
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| |-style="background:silver; color:black"
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| | '''Denied Headache''' || '''16%'''
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| |-style="background:silver; color:black"
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| | '''Nausea/Vomiting''' || '''55%'''
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| |-style="background:silver; color:black"
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| | '''Confusion''' || '''56%'''
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| |-style="background:silver; color:black"
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| | '''Decreased Consciousness''' || '''51%'''
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| |-style="background:silver; color:black"
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| | '''Focal Neurologic Deficits''' || '''23%'''
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| |-style="background:silver; color:black"
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| | '''Seizure''' || '''29%'''
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| |}
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| == Physical Examination == | | ==[[Meningococcemia pathophysiology|Pathophysiology]]== |
| *[[Fever]]
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| *Not infrequently [[hypotension]] and [[shock]]
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| ===Skin=== | | ==[[Meningococcemia epidemiology and demographics|Epidemiology & Demographics]]== |
| * Petechial [[rash]] manifesting as discrete lesions 1-2 mm in diameter frequently on the trunk and lower portions of the body.
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| * Petechial regions can coalesce and form larger lesions that appear ecchymotic.
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| * A rash may appear that mimics a viral exanthem, particularly [[rubella]]. Not purpuric and non-pruritis and is transient, generally not lasting more than 2 days and is frequently gone hours after first observation.
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| === Eyes === | | ==[[Meningococcemia epidemiology and demographics|Risk Factors]]== |
| * Palpebral and [[ocular]] [[conjunctiva]]l [[petechia]].
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| === Heart === | | ==[[Meningococcemia screening|Screening]]== |
| * [[Congestive heart failure]], [[myocarditis]], [[pericarditis]] may be present
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| === Lungs === | | ==[[Meningococcemia causes|Causes]]== |
| [[Rales]] may be present, consolidation may be present if [[pneumonia]] is present | |
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| === Neurologic === | | ==[[Meningococcemia differential diagnosis|Differentiating Meningococcemia from other Diseases]]== |
| Nuchal rigidity and seizures may be present
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| == Laboratory Findings == | | ==[[Meningococcemia natural history|Natural History, Complications & Prognosis]]== |
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| === Electrolyte and Biomarker Studies === | | ==Diagnosis== |
| * [[Blood culture]]s were positive in 41.4% of 400 cultures in one series of patients with [[meningococcal disease]].
| | [[Meningococcemia history and symptoms|History & Symptoms]] | [[Meningococcemia physical examination|Physical Examination]] | [[Meningococcemia staging|Staging]] | [[Meningococcemia laboratory tests|Lab Tests]] | [[Meningococcemia electrocardiogram|Electrocardiogram]] | [[Meningococcemia chest x ray|Chest X Ray]] | [[Meningococcemia CT|CT]] | [[Meningococcemia MRI|MRI]] | [[Meningococcemia echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Meningococcemia other imaging findings|Other Imaging Findings]] | [[Meningococcemia other diagnostic studies|Other Diagnostic Studies]] |
| * [[Cerebrospinal fluid]] (CSF) culture and gram stain were positive in 94% of patients in the same series.
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| * The ability to culture the [[meningococcus]] from [[CSF]] will not be substantially reduced if the cultures are obtained within one hour of antibiotic administration.
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| * One series revealed a median [[leukocyte]] count of approximately 1200 in [[CSF]] (range 10 to 65,000/mm). Approximately 75% had a [[CSF]] [[glucose]] level less than 40 mg/100 mL. [[CSF]] [[protein]] ranged from 25 to over 800 mg/100 mL with a median value of 150 mg/100 mL.
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| * [[Polymerase chain reaction]] ([[PCR]]) has been shown in a study with 54 samples to be 91% sensitive and specific, particularly useful when cultures may be negative due to prior antibiotic administration.
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| * Latex agglutination can detect A, B, C, Y, and W-135 though the sensitivity of detecting serogroup B is low.
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| ===HUSSEIN AND SHAFRAN CANADIAN REVIEW OF BACTERIAL MENINGITIS===
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| {|
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| |-style="background:silver; color:black"
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| | '''Cloudy CSF''' || '''78%'''
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| |- style="background:silver; color:black"
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| | '''CSF >= 1000 WBC/mm3''' || '''56%'''
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| |- style="background:silver; color:black"
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| | '''CSF >= 10,000 WBC/mm3''' || '''14%'''
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| |-style="background:silver; color:black"
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| | '''CSF Neutrophil predominance''' || '''90%'''
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| |-style="background:silver; color:black"
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| | '''CSF Glucose =< 50 mg/deL''' || '''70%
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| |-style="background:silver; color:black"
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| | '''CSF Protein > 200 mg/dL''' || '''66%'''
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| |-style="background:silver; color:black"
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| | '''Gram Stain without bacteria''' || '''53%'''
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| |-style="background:silver; color:black"
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| | '''Gram Stain Neg --> Culture Pos''' || '''47%'''
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| |}
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| ==Treatment== | | ==Treatment== |
| | | [[Meningococcemia medical therapy|Medical Therapy]] | [[Meningococcemia surgery|Surgery]] | [[Meningococcemia primary prevention|Primary Prevention]] | [[Meningococcemia secondary prevention|Secondary Prevention]] |
| === Acute Pharmacotherapies ===
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| * [[Cephalosporin]] CSF penetration: [[cefuroxime]] 11-14 %; [[ceftriaxone]] 1.5-7%, [[cefotaxime]] 4-54%, and [[ceftazidime]] 14%.
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| * [[Ceftriaxone]] CSF half life approximately 5 hours.
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| * Potential antibiotics include [[cephalosporin]]s, [[penicillin]], and [[chloramphenicol]].
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| * Therapy may be as brief as 10 to 14 days in fully sensitive organisms.
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| * Steroid use particularly in [[purpura fulminans]] and [[adrenal hemorrhage]] ([[Waterhouse-Friderichsen syndrome]]) is controversial.
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| ===Prophylaxis===
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| * [[Rifampin]] 600 mg PO q12h x 4 doses total or alternatively [[ciprofloxacin]] 500 mg PO x 1 in patients over 18 who cannot tolerate [[rifampin]]
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| == Risk Stratification and Prognosis==
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| * Current vaccines have polysaccharides of groups A, C, Y, and W-135. No vaccine available presently for group B disease since the polysaccharide is not sufficiently immunogenic to produce a reliable antibody response in humans to be effective.
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| * Rates of meningococcus in US college students as a whole 0.7 per 100,000.
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| * Rates of meningococcus in US persons aged 18-23 not in college 1.5 per 100,000.
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| * Rates of freshmen living in dormitories 4.6 per 100,000.
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| * Rates for college students in UK 13.2 per 100,000 versus those not in college of 5.5 per 100,000.
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| ==Prevention==
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| The most important form of prevention is a vaccine against ''[[Neisseria meningitidis]]''. Different countries have different strains of the bacteria and therefore use different vaccines. Five serogroups, A, B, C, Y and W135 are responsible for virtually all cases of the disease in humans. Vaccines are currently available against four of the five strains, and a vaccine against the B strain is in development. Menactra and Menomune are two commonly used vaccines. Unfortunately, there is currently no evidence that any of the current vaccines offer significant protection beyond three years.
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| Additionally, basic [[hygiene]] measures, such as '''hand washing''' and '''not sharing drinking cups''', can reduce the incidence of infection by limiting exposure.
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| When a case is confirmed, all close contacts with the infected person can be offered [[antibiotics]] to reduce the likelihood of the infection spreading to other people.
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| ==Related chapters== | | ==Related chapters== |
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| [[Category:Disease]] | | [[Category:Disease]] |
| [[Category:Infectious disease]] | | [[Category:Infectious disease]] |
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| [[Category:Bacterial diseases]] | | [[Category:Bacterial diseases]] |
| [[Category:Overview complete]] | | [[Category:Overview complete]] |