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