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Hong Kong Journal of Emergency Medicine

Case report: meningococcal meningitis

GPC Lee, YK Mak, CW Kam

A case of meningococcal meningitis in an adult male in March 2000 in Hong Kong is reported. The main features were fever for one day with headache, vomiting, dizziness, diffuse maculo-papular rash, and one purpuric rash on the dorsum of right hand and stable vital signs. Incidentally, there were three other unreported cases of meningococcal infection in the city during that period. It is important for emergency physicians to recognise this life-threatening condition in the initial stable phase to promptly provide the emergency management and to administer the antibiotic treatment to reduce mortality.

(Hong Kong j.emerg.med. 2001;8:108-110)

Keywords: Maculo-papular, meningitis, meningococcal, purpuric, rash

Case

A 21-year-old man presented to our A&E Department with fever for one day. On arrival, the patient's BP was 109/50, pulse rate was 115 and oral temperature was 38.1°C. He was fully conscious and clinically stable. The patient also complained of headache, vomiting for three times and severe dizziness. No rash was noted by him. He was a construction site worker and he had travelled to China a few days before his illness. Physical examination showed that there were generalised maculo-papular rash and a patch of pur pura on the dorsum of the right hand. (Figure 1) Suboccipital lymph node was negative. There was no neck rigidity. Chest, cardiac and abdominal examination did not reveal any abnormality. He was admitted to medical ward with alert for isolation and rapid investigation. Investigations showed white cell count of 29.1 with neutrophilia; raised CSF protein of 5.45 g/L

Correspondence to: Kam Chak Wah, MRCP(UK), FRCSEd, FHKAM(EM) Tuen Mun Hospital, Accident and Emergency Department, Tsing Chung Koon Road, Tuen Mun, N.T., Hong Kong Email: [email protected] Lee Ping Chung Gordon, MBBS (HK) Mak Yiu Kei, MRCP(UK), FRCSEd, FHKAM(EM)

Figure 1. Purpura on the dorsum of the right hand.

and decreased CSF glucose of 0.1 mmol/L. CSF was turbid with predominating polymorphs. Gram Stain was neg ative but culture g rew Neisseria meningitidis, which was sensitive to c e f o t a x i m e, c e f t r i a xo n e, ch l o ra m p h e n i c o l , ciprofloxacin, penicillin and rifampicin. Blood culture grew the same pathogen. He was subsequently transferred to ICU for treatment. Intravenous antibiotic including penicillin G and cefotaxime were administered. He recovered without any neurological sequelae. The staff who had close contact with the patient received post-exposure prophylactic rifampicin.

Lee et al./Case report: meningococcal meningitis

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Discussion

There are totally 12 main serogroups of Neisseria meningitidis (A, B, C, X, Y, Z, W135, 29e, H, I, K and L). Meningococcal disease occurs most commonly in the African meningitis belt (from Ethiopia in the east to Gambia in the west).1 In industrialised countries, most are caused by serogroups B or C. The incidence of meningococcal infection in the past 20 years (1980 to May 2000) in Hong Kong is shown is Figure 2. Man is the only natural host for meningococci. It is spread mainly by respirator y droplets or occasionally by sexual transmission.2 Most subjects infected with meningococci become asymptomatic carriers. 3 The ratio of carriers to cases has been reported as high as 10000:1. The ratio is very low because of several body defence mechanisms. Only piliated meningococci can adhere strongly to nasophar yng eal cells. W hen they reach the circulation, most are rapidly destroyed by antibodies and phagocytic cells.2 In case of meningococcal disease, some patients develop acute meningococcaemia whilst others develop meningitis. The mechanism is unknown, but the case fatality of acute meningococcaemia is tenfold that of meningococcal meningitis, which is generally less than 5%.4

The initial treatment for both conditions is the same. Immediate intravenous antibiotic, either penicillin G or ceftriaxone is appropriate. In suspected cases, we should administer the antibiotic at once because it is life saving. The chance of isolating the organism in blood or CSF will decrease after the antibiotic treatment, but PCR can be used in such cases with high sensitivity and specificity.5 It is essential to inform the receiving ward to arrange an isolation room for the patient because the disease is infectious. It is better not to transfer the patient to an Infectious Disease Unit (IDU) if it is far because the patient may deteriorate rapidly and close monitoring is necessary. Transfer is suitable only when the patient's condition has been stabilised after treatment Antibiotic is the main stay of treatment. After antibiotic is administered, there is a theoretical risk of Herxheimer reaction because of massive bacterial destruction and consequent release of endotoxin. However, this is rarely seen in clinical practice.2 In meningococcal meningitis, dexamethasone can be used in case of severely elevated ICP. In acute meningococcaemia, heparin has been used in case of DIC. Plasmapheresis can be employed if the patient is exposed to potentially lethal dose of endotoxin. Currently, anti-tumour necrosis factor (TNF) is under trial as it plays a central part in the pathogenesis of the clinical features of acute meningococcaemia. In case of purpura fulminans,

Figure 2. Incidence of meningococcal infection in Hong Kong (till 6th of May 2000).

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Hong Kong j. emerg. med. n Vol. 8(2)

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early replacement of protein C with heparin and haemodiafiltration have been reported to decrease the mortality and morbidity, but it is still under study. 6 For medical personnel who have contact with the patient, a face mask can provide adequate protection. If no face mask is used, only those who have close contact with the patient (mouth-tomouth resuscitation, endotracheal tube intubation or management) need chemoprophylaxis. 7 The current regime for chemoprophylaxis includes oral rifampicin 600 mg every 12 hours for 2 days, a single oral dose of ciprofloxacin 500 mg or ceftriaxone 250 mg intramuscularly if the former two are contraindicated according to the CDC (Centers for Disease Control and Prevention) recommendations.7 Concerning purpuric rash, it is important for us to think of other differential diagnosis. Haematological disease is much more common than meningococcal disease. Platelet and vascular disorders can all present with petechiae and purpuric rash. Important examples include leukaemia and immune thrombocytopaenic purpura. Besides, connective tissue disease, viral infections (e.g. Epstein-Barr virus), drugs (e.g. co-trimoxazole and steroid) and trauma can also produce purpuric rash. It is well-known that meningococcal infection is associated with purpuric rash. The cause may be vascular damage, immune-mediated platelet destr uction, abnor mal platelet function or disseminated intravascular coagulation. However,

Marzouk et al reported that purpuric rash only presented in 80% of paediatric cases. The remaining 13% had maculo-papular rash and 7% had no rash. 8 As a result, it is important for emergency physicians to be alert in cases of fever with skin rash, whether purpuric or not. It is vital for emergency physicians to detect and treat this condition early to reduce mortality.

References

1. Hart CA, Cuevas LE. Meningococcal disease in Africa. Ann Trop Med Parasitol 1997;90(7):777-85. 2. Greenwood BM. Meningococcal infection. Oxford Textbook of Medicine 3rd edition (Weatherall DJ, Ledingham JGG & Warrell DA), 1996; Vol 1. 533-44. 3. E m e l e F E , A h a n o t u C N , A n y i w o C E . Nasopharyngeal carriage of meningitis in Sokoto, Nigeria. Acta Paediatr 1999;88(3):265-9. 4. Peltola H. Early meningococcal disease: advising the public and the profession. Lancet 1993;342(8870): 509-10. 5. Suri M. Group B Meningococcal meningitis in India. Scan J Infect Dis 1994;26(6):771-3. 6. Smith OP, White B, Vaughan D, et al. Use of proteinC concentrate, heparin, & haemodiafiltration in meningococcus-induced purpura fulminans. Lancet 1997;350(9091):1590-3. 7. Centers for Disease Control. Control and prevention of meningococcal disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1997;46(RR-5):1-51. 8. Marzouk O, Thomson APJ, Sills JA, et al. Features and outcome in meningococcal disease presenting in Maculo-papular rash. Arch Dis Child 1991;66(4): 485-7.

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