A Bit of a Headache
Robert Adam
Charlie Bircher
Rashida Ganiji
Introduction Miss B
22 year old
Ethnic origin Guiana / Trinidad
2nd Year university student
History taken from mother in A&E on 5/11/03
PC
Headache
Neck stiffness
Photophobia
Puertic Rash
HPC
For the 2 weeks prior to presenting in A&E Miss X had been suffering from:
– Cold
– Dry Cough
– Blocked Nose
2 days prior to presentation:
Miss B’s symptoms became worse Unable to book an appointment to see
her G.P. G.P. did see her 1 year old child who
had also been unwell with the same symptoms
Erythromycin was prescribed Child’s health has since improved
1 day prior to presentation:
Miss B developed temperature of 40 ºC Vomiting Non blanching rash under left breast Couldn’t get emergency G.P. to visit N.H.S. direct told Miss B she probably
had flu Advised to take paracetamol and
Ibuprofen
5/11/03 AM
Called emergency G.P. who attended home Miss B complained of Headache Rash noted by G.P. G.P. offered to review Miss X if symptoms became
worse
22:35 Parents took Miss B to St George’s A&E
complaining of photophobia and neck stiffness
SH
Studying biochemistry degree @ Kingston University
Lives with her partner and 1 year old child
Non smoker No alcohol Hasn’t travelled abroad recently Not working
On Examination
Eyes closed
GCS V=5 E=3 M=6 14/15
Neck Stiffness
Photophobia
Afibrile 36.0 ºC
Miss B had cold peripheries
BP = 80/40
HR =120
Was finding it hard to breath
15% oxygen given
Pectechial Rash
Several Spots on the dorsal area of each foot
Four spots on right arm
One large spot measuring approx 1.5cm x 1.0cm under left breast
? Menigiococal septicaemia
2º to meningitis
Investigations: 5/11/03
Full blood count
Urea and electrolytes
Chest X-Ray
Blood culture
Clotting screen
FBC:
Test Results Units Ref Range
WBC 25.8 10^9/L 4.0-11.0
Platelets 135 10^9/L 150-450
Neutrophil 23.8 10^9/L 1.8- 8.0
U&E:
Test Results Units Ref Range
Urea 11.6 mmol/L 2.5-8.0
Creatinine 187 μmol/L 60-110
Bilirubin 18 μmol/L 0-17
Sensitive 327.1 mg/L 0-8
CRP
Blood Clotting
Test Results Ref Range
INR 1.6 0.8 - 1.1
Blood Culture
Neisseria Meningitidis isolated in one bottle
Typed as Group B
Bacterial Meningitis
Inflammation of the meninges due to bacteria
Blood Brain Barrier normally keeps pathogens out of meninges
If pathogens penetrate through BBB and start growing in the CSF it is very hard for the body to fight them
Transmission of Bacteria
The bacteria that commonly cause Meningococcal Meningitis live in the nose and throat of 10-15% of the healthy population. This can rise to up to 25% in university students.
The bacteria travel up to the meninges via direct spread from the ears, nasopharynx or blood stream
Transmission Routes
The bacteria travel by the respiratory route
Close contact needed as bacteria does not “travel well”
Bacteria commonly spread by:– Sharing cutlery / drinking glasses– Sneezing / coughing– Kissing
Cytokines Cause swelling (especially histamine) Increase the body temperature (fever). This is make
the body too hot for bacteria to survive and multiply Release enzymes that are needed to destroy bacteria Damage surrounding healthy tissue, e.g. nerve cells.
This could lead to:– Facial paralysis– Loss of vision / hearing– Mental confusion– Drowsiness
Menigiococal septicaemia 1
Bacteria enter and infect the blood Bacteria normally invade the
bloodstream via the nasal mucosa This is more likely to happen following
an upper respiratory tract infection In menigiococal septicaemia the
bacterial endotoxins (Lipopolysaccharides) induce pro-inflammatory cytokines (TNF)
Menigiococal septicaemia 2
This leads to hyperactivation of the immune system, causing:– DIC (Disseminated intervascular
coagulation)– Hypotension– Activation of complement– Decreased platelets– Increased vascular permeability
This leads to:
•DEATH
•SEPTIC SHOCK
•ORGAN FAILURE
Symptoms
Meningitis
– Headache– Drowsiness– Neck stiffness– Delirium– Photophobia
Menigiococal septicaemia
– Muscle / joint pains– Diarrohoea
– Rash
– Cold Peripheries
– Rapid respiratory rate
– Gasping/Panting
– Loss of conscious
– Hypotension
Symptoms 2
Some signs and symptoms occur in both meningitis and menigiococal septicaemia together:– Fever– Vomiting / Nausea– Lack of energy
Types of Meningitis
Bacterial Meningitis Viral Meningitis Fungal Meningitis Syphilitic Meningitis Carcinomatous Meningitis Drug Induced Meningitis
Viral Meningitis
Acute onset Meningeal signs and symptoms CSF abnormalities typical of meningitis Absence of bacteria on smear/culture of
CSF Self limiting, benign course
Fungal Meningitis
Most common in the immunosupperssed due to:– AIDS– Organ transplantation– Immunosuppressive chemotherapy– Chronic corticosteroid therapy
Meningeal signs and symptoms may occur up to 3 – 6 months after initial infection
Clinical Features of Fungal Meningitis
Usually mild meningeal symptoms– Headache– Fever– Photophobia– Nausea / Vomiting– Skin lesions– Cranial nerve palsies
Syphilitic Meningitis
6 types of neurosyphilitic syndromes Acute syphilitic meningitis one of them
– Meningeal symptoms typically develop within 1 year
– Usual symptoms:• Headache• Nausea / Vomiting• Stiff neck• Papilloedema
Carcinomatous Meningitis
Dissemination of malignant cells throughout the leptomeninges
Adenocarcinoma and malignant melanoma are the most common solid tumours to metastasize to leptomeninges
Mechanism for how tumour cells reach the leptomeninges is unknown
Treatment of Bacterial Meningitis Immediate antibiotics upon clinical
diagnosis Mrs B given 2 antibiotics:
– Cefotaxime (2g qds)– Rifampicin (600mg bd)
Also given pain killers as required:– Paracetamol– Codeine Phosphate
Blood Investigations: 14/11/03
Test Results Units Ref Range
WBC 8.7 10^9/L 4.0-11.0
Platelets 622 10^9/L 150-450
Neutrophil 6.4 10^9/L 1.8- 8.0
U&E’s: 14/11/03
Test Results Units Ref Range
Urea 3.7 mmol/L 2.5-8.0
Creatinine 47 μmol/L 60-110
Bilirubin 14 μmol/L 0-17
Albumin 25 g/L 35-48
Sensitive 6.1 mg/L 0-8
CRP
Prophylaxis 1
For meningitis caused by N. meningitidis, prophylaxis recommended for close contacts:– Household contacts– Day care centre members– Anyone exposed to oral secretions
Also can be given to the index case Recommended agent is rifampicin Other agents used are ciprofloxacin and
ceftriaxone
Epidemiology of Meningitis 1
Since World War II, the largest epidemics of meningococcal disease affect mainly sub-Saharan countries within the so-called 'meningitis belt'.
Epidemic meningococcal disease is a worldwide problem and can affect any country regardless of different climate
Epidemiology of Meningitis 2
Epidemics of Meningococcal meningitis, 1971-1997
Meningitis Belt
Risk Factors
Immunodeficiency states, respiratory tract infections, malnutrition, anaemia, smoking
Male > Female Age distribution of meningitis varies from
area to area Dry season Low socio-economic status