Meningococcal Infections

Meningococcal infections follow a fairly standard pattern development from an insignificant nasopharyngitis , the organism directly produces a bacteremia.
The systemic infection may be:
1. Passed unnoticed
2. May appear as an acute septicemia or a fulminating meningococcemia
3. May develop into meningitis or may be very insidious.
4. Chronic disorder that persists for months of the years.

The incidence of endemic meningococcal disease during the last 13 years ranges from 1 to 5 per 100,000 in developed countries, and from 10-25 per 100,000 in developing countries. During epidemics the incidence of meningococcal disease approaches 1000 per 1,000,000. There are approximately 2,600 cases of bacterial meningitis per year in the United States, and on average 333,000 cases in developing countries. The case fatality rate ranges between 10 and 20%

The clinical manifestations of meningococcal disease can be quite varied, ranging from transient fever and bacteremia to fulminant disease with death ensuing within hours of the onset of clinical symptoms.

Acute Meningcoccemia
It usually starts as a nasopharyngitis followed by sudden onset of high fever with chills, nausea, vomiting, malaise and headache. Patechial, purpuric or ecchymmotic hemorrhages scattered all over the entire body surface appear.

Histollogically, the skin lesions are the result of acute vasculitis in the minute vessels followed by supporative necrosis and hemorrhage into the dermal connective tissue.

It is marked perivascular cuffing of neutrophils and macrophages with lymphocytes are seen. Organisms can be identified within the walls of the vessels which are frequently thrombosed.

The adrenal lesions start as bleeding into the medulla which extends to the cortex. The combination of meningococcemia and adrenal medullary hemorrhage is now as the water house friederichsen syndrome. It is the rapid development of the petechiae to purporic and echymotic spots in association with shock.

Meningococcal Meningitis
Meningococcal meningitis is a consequence of bacteria entering the cerebrospinal fluid (CSF) and irritating the meninges - the membranes that line the brain and spinal cord. It may be ushered in by a short predromal period but often is sudden in onset and appears to coincide with the first symptoms of infection. It is characterized in older infants and children by:
1. Sudden onset of high fever, convulsion, nausea, vomiting, and intense headache.
2. Characteristics ssign of meningeal irritation are stiffneck, opisthotonus (aching of the back ; neck bowed), kernig’s sign (resistance to full extension of leg at knee when hip is flexed), Brudzinski’s sign (flexion of both hips and knees when neck is possibly flexed)
3. Delirium, stupor and coma in more severe infection
4. Petechial or purporic rashes – which may precede or accompany the meningitis provide a clue as to the causative agent.
5. Signs of increased intracranial pressure – bulging of the fontanel, positive Macewen sign, choked disk.
6. The appearance of convulsions or purpura – give an indication as to the nature of the disease.

Prophylaxis:
Rifampicin – 5-10mg/kg every 12 hours
Mynocycline – 4mg/kg every 12 hours for 5 doses
Meningococcal Polysaccharide Vaccine – has not been shown to give clear out effectively, restricted availability also limits general use.

Treatment
Penicillin – drug of choice
Chloramphenicol

Nursing Interventions:
1. Side boards and restraints may be necessary to keep the patient in bed.
2. Many of these patients are extremely irritable and delirious. It is necessary to give nursing care despite the protest of the patient.
3. For febrile patients, these may be reduced and controlled by alcohol fan, tepid sponge bath (TSB) or rectal flushing.
4. The temperature should not be reduced to quickly since the danger of shock is always present.

Bacterial Meningitides
Meningitis is an infection of the fluid in the spinal cord and the fluid that surrounds the brain. Meningitis is usually caused by an infection with a virus or a bacterium. Knowing whether meningitis is caused by a virus or a bacterium is important because of differences in the seriousness of the illness and the treatment needed.

VIRAL MENINGITIS is usually relatively mild. It clears up within a week or two without specific treatment. Viral meningitis is also called aseptic meningitis.

BACTERIAL MENINGITIS is much more serious. It can cause severe disease that can result in brain damage and even death.

Bacterial meningitis is most commonly caused by one of three types of bacteria: Haemophilus influenzae type b (Hib), Neisseria meningitidis, and Streptococcus pneumoniae.

Incubation Period:
Variable, the extreme limits being set at from 1-10 days. Usually, it is from 3-6 days.

Mode of Transmission:
By respiratory droplets via passage through the nasopharyngeal mucosa by direct invasion via otitis media, upper respiratory tract and head otitis injury.

Period of Communicability:
For 24 hours after the start of effectively antibiotic treatment

Bacterial meningitis is found worldwide. The bacteria often live harmlessly in a person's mouth and throat. In rare instances, however, they can break through the body's immune defenses and travel to the fluid surrounding the brain and spinal cord. There they begin to multiply quickly. Soon, the thin membrane that covers the brain and spinal cord (meninges) becomes swollen and inflamed, leading to the classic symptoms of meningitis.

Clinical Manifestation:
1. Human cases and carriers are source of infection; transmission is by contact or droplet infection.
2. Meningococcus may localized in the brain, skin or joint synovia.
3. The disesase occurse in winter and spring months; epidemic are most apt to occur when people live in crowded quarters.

Prevention:
• Vaccines -- There are vaccines against Hib, some strains of Neisseria meningitidis, and many types of Streptococcus pneumoniae.

The vaccines against Hib are very safe and highly effective. By age 6 months of age, every infant should receive at least three doses of an Hib vaccine. A fourth dose (booster) should be given to children between 12 and 18 months of age.

The vaccine against Neisseria meningitidis (meningococcal vaccine) is not routinely used in civilians in the United States and is relatively ineffective in children under age 2 years. The vaccine is sometimes used to control outbreaks of some types of meningococcal meningitis in the United States. New meningococcal vaccines are under development.

The vaccine against Streptococcal pneumoniae (pneumococcal vaccine) is not effective in persons under age 2 years but is recommended for all persons over age 65 and younger persons with certain medical problems. New pneumococcal vaccines are under development.
• Disease reporting -- Cases of bacterial meningitis should be reported to state or local health authorities so that they can follow and treat close contacts of patients and recognize outbreaks.
• Treatment of close contacts -- People who are identified as close contacts of a person with meningitis caused by Neisseria meningitidis can be given antibiotics to prevent them from getting the disease. Antibiotics for contacts of a person with Hib disease are no longer recommended if all contacts 4 years of age or younger are fully vaccinated.
• Travel precautions -- Although large epidemics of bacterial meningitis do not occur in the United States, some countries experience large, periodic epidemics of meningococcal disease. Overseas travelers should check to see if meningococcal vaccine is recommended for their destination. Travelers should receive the vaccine at least 1 week before departure, if possible.