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Meningitis

Meningitis is an acute inflammation of the meninges. Meninges are the three membranes 
( dura mater , arachnoid mater and pia mater ) that line the vertebral canal and skull and enclose the brain and spinal cord

Meninogococcal disease ( MD ) – refers to meningococcal meningitis , meninogocccal septicaemia or a combination of both.

Causes

Bacterial –Neisseria meningitidis Steptococcus pneumoniae Haemophilus influenzae Streptococcus – GBS and GAS Listeria monocytogens E Coli Salmonella Tuberculosis – Rare but serious -can be fatal in few hrs Often with serious consequences Incidence reduced due to vaccination

Viral –Enteroviruses- this group includes 
enteroviruses
coxsackieviruses
echoviruses Measles Influenza Mumps Herpesvirus as
EBV
HSV
Varicella-zoster Arboviruses Lymphocytic Choriomeningitis Virus 
( rare ). Most common cause of aseptic meningitis Usually self limiting and with no serious consequences with the exception of viral encephalitis

Others- Fungal e.g Cryptococcus species Parasitic Amebic Non-infectious e.g
certain cancers
SLE
certain medicines
head injury
brain surgery

Pathogens- In the UK most common causes of bacterial meningitis in children under 3 or older and adults are

Neisseria meningitis ( meningococcal meningitis )
Streptococcus pneumoniae ( pneumococcal meningitis )
Haemophilus influenzae type b ( Hib-meningitis )

These organisms occur normally in the upper respiratory tract but if the organisms invade the bloodstream it can lead to MD 
 When the term ” meningococcal meningitis ” is used it implies Neisseria meningitidis as the cause and can involve features of “meningitis ” or
 ” septicaemia ” – in isolation or together

♦ Neisseria meningitidis is a gram negative diplococcus and member of the bacterial family Neisseriaceae – humans are sole natural host

♦ Several different groups of meningococcal bacteria can cause meningitis , the most common ones are A , B , C , W and Y. These are frequently mentioned as MenA , MenB , MenC , MenW and MenY

♦ Vaccination- Introduction of vaccine MenC in 1999 had a dramatic impact and cases of MenC meningococcal disease has dropped by more than 90 % 
 ( Hib-meningitis has also seen a decline since vaccination )

♦ Serogroup B meningococcal disease – was more common in children even before the MenC vaccine was introduced and currently no vaccine can protect against most group B serotypes and subserotypes


It is important to understand the difference in presentation , pathophysiology and outcome between 
Meningitis ( symptoms of raised ICP ) and Meningococcal septicaemia ( Sepsis ) with shock which is a medical emergency – see below how the two disease processes differ

Babies may present with – Poor feeding Irritability particularly when handled with a high pitched or moaning cry Abnormal tone , either increased or decreased or abnormal posturing Vacant staring , poorly responsive or lethargic Tense fontanelle Cyanosis

Sepsis – Limb / joint pain Cold hands and feet and prolonged CRT Pale / mottled /blue skin Tachycardia Tachypnoea , laboured breathing , hypoxia Rigors Oliguria / thirst Rash anywhere on the body ( may not be an early
 symptom ) Abdominal pain ( sometimes with diarrhoea ) Drowsiness / confusion/ impaired consciousness 
( late sign in children ) Hypotension ( very late , pre-terminal sign in children ) Rapid deterioration is typical.
Focus on the following – symptoms of sepsis
 Fever Rigors Aches Limb pain Gastro-intestinal symptoms Weakness Rash Decreased urine output Cold hands and feet , mottled skin

Meningitis-Severe headache Neck stiffness ( not always present in young children ) Photophobia ( not always present in young children ) Drowsiness / confusion / impaired consciousness Seizure ( late sign ) Focal neurological deficit including cranial nerve involvement and dilated / unequal / poorly reacting pupils ( late signs ) Severe headache Neck stiffness ( not always present in young children ) Photophobia ( not always present in young children ) Drowsiness / confusion / impaired consciousness Seizure ( late sign ) Focal neurological deficit including cranial nerve involvement and dilated / unequal / poorly reacting pupils ( late signs ).

Meningococcal disease can present as
♦ bacterial meningitis – 15 % cases
♦ septicaemia – 25 % of cases
♦ combination of the two syndromes – 60 % of cases
 Acute bacterial meningitis is the leading cause of death 
( one of top 10 ) caused by infections worldwide Diagnosis can be extremely challenging
♦ classical signs of meningitis are often absent in infants 
♦ children present as an acutely febrile child – may not have a rash at first
♦ symptoms can be subtle
♦ febrile disease of sudden onset –> classical picture of MD

Take a detailed history The disease can be extremely unpredictable Check vaccination status Ask and make sure you understand what is exactly worrying the parent and why they are seeking help at this point Close contact Speed of progression Travel for e.g sub-Saharan Africa or Hajj pilgrims Symptoms reported are very common to many self limiting viral illnesses. A MRF study has shown that upto 50 % of children presenting to GPs with meningococcal disease were sent home on their 1st visit and these children were more likely to die.

Any child with febrile illness –Fully undress the child and examine systemically-Look thoroughly for focus of infection – think about hidden sites as meninges , urinary tract and bloodstream sepsis-Rash found – check if its is blanching or not- Narrow window of opportunity about 1 in 10 children with MD die and most fatal cases die within 24 hrs of the onset of symptoms

Development of symptoms – First symptoms reported by parents of children with meningitis and sepsis were common to many self limiting illnesses. Prodromal phase lasts 4 hrs in young children to up to 8 hrs in adolescents- In all age-group signs of sepsis and circulatory shut-down develops next – 72 % of children had limb pain , cold hands and feet or pale or mottled skin at a median 8 hrs from onset of illness- Younger children also 
reported drowsiness , rapid or labored breathing & some time diarrhoea- thirst was 
reported
 in older children – First classic symptom – rash 8-9 hrs median time in babies and young children- later in older children Rash is not always present- most common classic feature of MD Meningitis symptoms- neck stiffness , photophobia , bulging fontanelle appear later 12-15 hrs from onset Late features as confusion / delirium / impaired consciousness eventually develop in nearly 1/2 the children while seizures amd coma were uncommon. They occur 15-24 hrs from disease onset

Safety netting –SAFETY NET
 If sending home – NICE fever in under 5s and SIGN guideline highlight the importance of safety net Provide information – how and when to seek help taking into account parents anxiety and capacity to manage the situation




ACUTE SYSTEMIC FEBRILE ILLNESS + ANY OF FOLLOWING – REFER IMMEDIATELY TO HOSPITAL see links for antibiotic dosage a haemorrhagic rash an impaired level of consciousness signs of meningococcal infection clinical features not normally expected in children with acute self limiting systemic febrile illnesses the patient is a close contact of someone who was recently diagnosed as having meningococcal disease even if the current patient received antibiotics

Please refer to the main page for full list of references , links and resources. A4Medicine is grateful to Meningitis Research Foundation who kindly granted permission to reproduce material here for educational use .


LINKS AND RESOURCES

PARENT INFORMATION

A wonderful website and project – has information for patients and health care, professionals which is well presented and up to date. Symptom checker https://www.meningitis.org/meningitis/check-symptoms

This is a poster which many practices display in their waiting area- you may print and fix this on the wall – Meningitis baby watch https://www.meningitis.org/getmedia/f14a583a-f137-48a5-8321-d007db5ffaf5/Babywatch-Poster-Dec-2017

Information leaflets from Meningitis Now – can be downloaded as PDF. An excellent resource https://www.meningitisnow.org/how-we-help/resources/view-download-order/information-leaflets/

CDC on meningitis https://www.cdc.gov/meningitis/index.html

Printable information from Public Health protection Unit http://library.nhsggc.org.uk/mediaAssets/Infection%20Control/Leaflet%20-%20public%20_FAQ%20meningitis_%20_2_.pdf

Brain and Spine Foundation on meningitis – with easy explainer diagrams https://www.brainandspine.org.uk/our-publications/our-fact-sheets/meningitis/

INFORMATION FOR HEALTHCARE PROFESSIONALS

This is the section resources for health professionals and their patients from Meningitis. Org. Every leaflet here is worth reading and looking back if in doubt about the nature of the rash/illness. This is excellent work from Meningitis Foundation for which we should be eternally grateful- it’s a complete resource on meningitis for GPs https://www.meningitis.org/healthcare-professionals/resources

This is an easy to read section from Comomeningitis. Org which is a confederation of Meningitis Organisations Facts about meningitis http://www.comomeningitis.org/facts-about-meningitis/

NICE guidance Meningitis ( bacterial ) and meningococcal septicaemia in under 16s : recognition and management CG 102 https://www.nice.org.uk/guidance/cg102/chapter/guidance#pre-hospital-management-of-suspected-bacterial-meningitis-and-meningococcal-septicaemia

Dose and antibiotic choice for prehospital management from CKS https://cks.nice.org.uk/meningitis-bacterial-meningitis-and-meningococcal-disease#!scenario

Safety netting from Healthier Together- printable consider giving to all patients https://what0-18.nhs.uk/professionals/pharmacists/safety-netting-documents-parents/fever-children-under-5-years

Management algorithm ( in -patient ) from Meningitis Org https://www.meningitis.org/getmedia/21891bb1-198a-451a-bc1f-768189e7ecf1/Management-of-Bacterial-Meningitis-in-Children-and-Young-People-September-2018?disposition=attachment

DoH Gov UK Meningococcal disease: clinical and public health management https://www.gov.uk/guidance/meningococcal-disease-clinical-and-public-health-management
Guidance on Public Health Management updated 2019 pdf https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/829326/PHE_meningo_disease_guideline.pdf

A quick read from BMJ ( free access ) ADC Education and Practice -How to use clinical signs of meningitis https://ep.bmj.com/content/105/1/46

Learn about vaccination from Vaccine Knowledge Project https://vk.ovg.ox.ac.uk/vk/meningococcal-disease

 

References

  1. Meningitis Research Foundation – resources for healthcare professionals https://www.meningitis.org/healthcare-professionals/resources
  2. CDC- Meningitis Resources for Healthcare Professionals https://www.cdc.gov/meningitis/index.html
  3. CKS – bacterial meningitis and meningococcal disease July 2019
  4. Meningococcal Meningitis and Sepsis Guidance Notes Diagnosis and Treatment in General Practice 2018 edition UK Meningitis.org
  5. BMJ Best Practice- Bacterial meningitis A primary care physicians approach to a child with meningitis

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