Download - Meningococcal septicaemia
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Canterbury Health Laboratories
Meningococcal septicaemia
Rachel C Hutton, PhDMedical Laboratory Scientist
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Canterbury Health Laboratories
Diagnosis Meningococcus
• Disease• Transmissio
n• Symptoms• Diagnosis• Treatment• Prevention
• Case Study
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Canterbury Health LaboratoriesMeningococcal Disease
• Contagious bacterial disease
• Neisseria meningitidis– Fastidious aerobe– Gram Negative Diplococci (GNDC)– 12 serogroups
• 6 can cause epidemic (A, B, C, W135, X, Y) (WHO)
• Humans only natural carriers
• Meningitis• Meningococcemia• Pneumonia• Arthritis• Urethritis
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Canterbury Health LaboratoriesTransmission
– Exchange of respiratory/throat secretions
– Cough/sneeze
– Close contact – household members
– 10% population are carriers (nose/throat)
– Carriers are crucial to disease transmission
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Canterbury Health LaboratoriesSymptoms
• Meningitis– Nausea– Vomiting– Photophobia– Altered mental status
• Meningococcemia– Fatigue– Vomiting– Cold hands and feet– Cold chills– Severe aches or pain– Rapid breathing– Diarrhoea– Petechial rash (dark purple)
Source: CDC online
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Canterbury Health LaboratoriesDisease
• 5-10% of patients die within 24-48H
• Meningitidis– Brain damage– Hearing loss– Learning disability
• Septicaemia– Haemorrhagic rash– Rapid circulatory collapse
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Canterbury Health LaboratoriesDiagnosis
• Clinical Examination
• Gram Stain
• Culture
• Agglutination
• PCR
• MALDI-TOF
– Susceptibility testing– Serogroups
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Canterbury Health LaboratoriesTreatment & Prevention
• Medical Emergency
• Antibiotics immediately ( after LP/Blood)– Penicillin– Ampicillin– Chloramphenicol– Ceftriaxone
• Vaccination– Polysaccharide
• Bivalent (A&C), Trivalent (A,C,W), Tetravalent (A,C,Y,W135)– Outer Membrane Protein (OML)
– Group B– Conjugate Vaccines
• Tetravalent (A,C,Y,W135)
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Canterbury Health Laboratories
CASE STUDY:MENINGOCOCCAL DISEASE
Case Study: Meningococcal disease
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Canterbury Health Laboratories
Case Study:Meningococcal disease
Day
Event Tests/Results Treatment
0 Presents to GP Diagnosed as EBVNo bloods
None – sent home
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Canterbury Health Laboratories
Day
Event Tests/Results Treatment
0 Presents to GP Diagnosed as EBVNo bloods
None – sent home
1 Found by mother
Unresponsive Ambulance called
Ambulance GCS 8/15 (E2V2M4)Skin cool & mottledRash (Non-blanching erythematous confluent)HR 76BP not palpableAirway patient – sat not recorded (NR)
IV ceftriaxone
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Canterbury Health Laboratories
Day Event Tests/Results Treatment
1 ED GCS 9/15CT head Scan = No pathological changes
IV DexamethasoneIV fluidsAdrenalin
ICU LP not performed due to coagulopathyLow BPBlood tests-INR 3.1-No evidence of DIC-Raised blood glucose
IV VancomycinIV Acyclovar2 u FFPNoradrenalin
Insulin infusion
Serology EBV IgG PositiveEBV IgM NegativeEBV EBNA Positive
Evidence of PAST infection with EBV
Microbiology Blood Cultures = Negative-Blood, Arterial, CVC
IV Acyclovar StoppedIV Dexamethasone Stopped
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Canterbury Health Laboratories
Day Event Tests/Results Treatment
1 ED GCS 9/15CT head Scan = No pathological changes
IV DexamethasoneIV fluidsAdrenalin
ICU LP not performed due to coagulopathyLow BPBlood tests-INR 3.1-No evidence of DIC-Raised blood glucose
IV VancomycinIV Acyclovar2 u FFPNoradrenalin
Insulin infusion
Serology EBV IgG PositiveEBV IgM NegativeEBV EBNA Positive
Evidence of PAST infection with EBV
Primary diagnosis = meningococcal meningitis
Blood Cultures = Negative-Blood, Arterial, CVCEDTA – N. meningitidis PCR = Positive
IV Acyclovar StoppedIV Dexamethasone Stopped
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Canterbury Health Laboratories
Day Event Tests/Results Treatment
2 Extubated Continued improvementMild headache & photophobia
3 Transferred to Ward
Ceftriaxone 2g Q12HTEDS
7 Discharged
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Canterbury Health Laboratories
This is not the end of the story…
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Canterbury Health LaboratoriesDiagnosis Arthritis
Day Event Tests/Results Treatments
9 Increasing unwellPainful knee + elbowLines present L hand + R groin
Admitted to orthopaedic ward
CRP 102WCC elevatedPyreticR Knee = swollen, effusion, good ROMGroin = visible scab from line, no erythema, tender, able to weight bare
Wash out elbow + knee (under GA)IV ceftriaxoneIV flucloxacillin
12 Washout L elbow CRP 32Full ROM Hip & KneeLimitation at extremes of left elbow extension
R hip joint aspirated & washed out
N. meningitidis DNA detected
18 Discharged
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Canterbury Health LaboratoriesBlood Tests: Trends
WBCNeutrophils
Platelets
INR Fibrinogen
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Canterbury Health Laboratories
CRP
pH Blood Base Excess
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Canterbury Health Laboratories
EDTA N. meningitidis DNA detected
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Canterbury Health Laboratories
Samples Sent to Microbiology
Day Sample Results
9 L Elbow Aspirate BC bottle NG
9 L Elbow Aspirate PottleAnti co-ag tube
NOSWBC 175600 x106/L– predom polynucleated
RBC 12700 x106
No CrystalsNG
9 R Knee Aspirate BC bottle GPCNG
9 R Knee Aspirate PottleAnti co-ag tube
Occasional GPCWBC 5950 x106/L– predom polynucleated
RBC 1520 x106/LNo CrystalsNG16S rRNA PCR: Bacterial DNA not detected
10 R Knee Aspirate Syringe NOSScanty leucocytesNG
12 Hip Aspirate PottleAnti co-ag tube
NOSWBC 51650 x106/L – predom polynuecleatedRBC 2800 x106/L
N. meningitidis PCR = Detected
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Canterbury Health LaboratoriesThe Value of PCR
Day Sample Results
9 L Elbow Aspirate BC bottle NG
9 L Elbow Aspirate PottleAnti co-ag tube
NOSWBC 175600 x106/L– predom polynucleated
RBC 12700 x106
No CrystalsNG
9 R Knee Aspirate BC bottle GPCNG
9 R Knee Aspirate PottleAnti co-ag tube
Occasional GPCWBC 5950 x106/L– predom polynucleated
RBC 1520 x106/LNo CrystalsNG16S rRNA PCR: Bacterial DNA not detected
10 R Knee Aspirate Syringe NOSScanty leucocytesNG
12 Hip Aspirate PottleAnti co-ag tube
NOSWBC 51650 x106/L – predom polynuecleatedRBC 2800 x106/L
N. meningitidis PCR = Detected
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Canterbury Health LaboratoriesRequest Forms
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Canterbury Health Laboratories
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Canterbury Health Laboratories
The Value of PCR
Day 12: Hip Aspirate
Test Add N. meningitidis PCR
Result = Positive
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Canterbury Health LaboratoriesMeningococcal Burdon
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Canterbury Health LaboratoriesMeningococcal Burden
• Meningococcal disease causes life-threatening meningitis and sepsis conditions
• Patient's health can change from good to mortally ill within hours
• As the antibiotics kill the bacteria, they release more toxin. It can take several days for the toxin to be neutralized from the body
• Despite antibiotic therapy ~ 1/10 will die
• ~ 1/10 survivors will lose a limb, loose their hearing or suffer permanent brain damage
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Canterbury Health LaboratoriesThank you
• Dr Sophie Wen• Jen Fahey• Elaine Keith• CHL