‫‪Meningococcal meningitis‬‬

‫احلمى الشوكية النيسريية‬

‫‪Dr.Khaled D.Al-Harby‬‬
‫د‪ -‬خالد ضيف اهلل الغيداني‬
 Background

 ICD-9
- Vieusseux in Geneva 1805
 1st isolation of N. Meningitides 1887
 1st successful treatment 1944
9– ‫اٌزظُٕف اٌذوٌٍ ٌالِشاع‬ 
1805 ‫فبَىعُىط فٍ خُٕف‬ 
1887 ‫اٌؼضي االوي ٌٍدشثىِخ إٌُغُشَخ‬ 
1944 ‫اٌؼالج ثٕدبذ ثبٌّؼبداد‬ 
 Pathophysiology

 G-ve aerobic encapsulated diplococcus

 At lease 13 serogroups
(A,B,C,D,E,H,I,K,L,W135,X,Y,Z)
 99 % of cases are due to (A,B,C ,29E,
W135)
‫ ِغطبح ثىجغىٌخ‬, َ‫ عٍجُخ ششَسخ خشا‬
(A,B,C ‫ ٔىع ػًٍ االلً (أهّهب‬13 
Natural habitat is the mucosal surface of
human nasopharynx

 5-10 % of adults are asymptomatic

nasopharyngeal carriers ( increase to
60-80 % in closed populations )
‫ ِغزىؽٕخ ؽجُؼُخ فٍ االٔف واٌسٍك‬
ٓ‫ فٍ اٌضزبَ واالِبو‬% 80-60 : ٍُِٓ‫ زب‬% 10-5 
‫اٌّغٍمخ‬
 Modes of transmission:
direct contact, respiratory droplets

 I.P = C.P = 3-4 days (range 1-10 days )

 Bacteria can be found in the
nasopharynx up to 24 hours after the
start of antibiotics
ٍ‫ سرار رٕفغ‬, ‫ ِجبشش‬: ‫ ؽشق االٔزمبي‬
َ‫ ِذح اٌسؼبٔخ = ِذح اٌؼذوي ورظً اًٌ ػششح اَب‬
‫ عبػخ‬24 ‫ َّىٓ ػضي اٌدشثىِخ ِٓ فُ اٌّظبة اًٌ ِذح‬
‫ثؼذ ثذء اٌذواء‬
In most cases : -
sub clinical or mild infection
in 10 –20 % of cases : enters the blood stream
 Either killed or give rise to a disease
 Systemic disease precedes meningitis
by 24 –48 hours
‫ اػشاع ثغُطخ فمؾ‬: ‫ اغٍت اٌسبالد‬
ُ‫ اٌدشثىِخ رذخً اٌذَ ثُ لذ َغزطُغ اٌدغ‬: % 20– 10 
‫لزٍهب او رزغٍت ػًٍ إٌّبػخ فزغجت اٌّشع‬
Infants are protected in the 1st 6 months by
transferred maternal antibodies

 Susceptibility peaks at 6-12 months of age

and decreases again after colonization of
closely related nonpathogenic bacteria such
as N.Lactamica (similar surface antigen)
‫ األؽفبي دوْ عٓ اٌغزخ اشهش ٌذَهُ زّبَخ ؽجُؼُخ ٔزُدخ وخىد‬
ُ‫اخغبَ ِؼبدح ارزهُ ِٓ اِهبره‬
ٍ‫ ثُ رجذأ ف‬, ‫ رضداد اٌؼشػخ ٌٍخطش ثؼذ رٌه ززً ػّش عٕخ‬
‫االٔخفبع ثغجت أىشبف اٌشفشح اٌخبسخُخ‬
Smoking and concurrent viral infections of
URTIs decrease the integrity of the respiratory
mucosa and the likelihood of invasive disease
 Crowding living conditions also facilitate
disease spread, since individuals from
different areas have different strains of
meningococci
‫ اٌزذخُٓ واالٌزهبثبد اٌزٕفغُخ اٌفُشوعُخ رؼؼف رّبعه عطر‬
‫اٌدهبص اٌزٕفغٍ ِّب َضَذ فشطخ االطبثخ ثبٌّشع ثشذح‬
ِٓ ‫ اٌضزبَ اَؼب َضَذ ِٓ رٍه اٌفشص ( وً َسًّ شىال ِخزٍفب‬
) ‫اٌدشثىِخ‬
In the (( African meningitis belt )),it frequently
occurs in epidemics during the hot and dry
weather (December - March )

‫ فٍ زضاَ اٌسًّ اٌشىوُخ االفشَمٍ رىثش اوثئخ اٌشىوُخ‬

ً‫خظىطب فٍ االشهش اٌسبسح اٌدبفخ ِٓ دَغّجش زز‬
‫ِبسط‬
 PROGNOSIS:

fair unless the patient has: focal

neurological deficits, stupor or coma,
thrombocytopenia, lower coagulation
index
Moderate anemia, altered mental state,
convulsions.
‫هٕبن ثؼغ اٌؼالِبد اٌزٍ رٕزس ثبٌخطىسح ارا طبزجذ زبٌخ‬
‫اٌسًّ اٌشىوُخ ِثً االُُّٔب‬
 Even if the disease is diagnosed early and
adequately treated, the case-fatality rate ranges
from 5-10 %

 It may exceeds 40 % in patients with

Meningococcal sepsis
 10-20 % of survivals experience
neurological complications
‫ ززً ِغ اٌزشخُض اٌّجىش واٌؼالج اٌغٍُُ لذ رظً ٔغجخ‬
‫ ٌىً زبٌخ‬% 40 ًٌ‫اٌىفبح ا‬
ُٓ‫ ِٓ إٌبخ‬% 20– 10 ٍ‫ اٌّؼبػفبد اٌؼظجُخ رمغ ف‬
It most commonly affects children & adolescents

 It rarely occurs in those older than 50

years
‫ اغٍت اٌسبالد رمغ ثُٓ عٓ اٌثالس عٕىاد وعٓ اٌّشاهمخ‬
‫ ٔبدسا ِب َظبة اٌزَٓ ردبوصد اػّبسهُ اٌخّغُٓ ػبِب‬
 HISTORY:

 intense headache, fever, nausea, vomiting,

photophobia, lethargy, irritability and stiff
neck
 In young children: sub acute infection that
progress over several days
 Seizures occur in 40 % of children
, ‫ رهُح‬, ْ‫ غثُب‬, ‫ اعزفشاؽ‬, ًّ‫ ز‬, ‫ طذاع شذَذ‬: ٍ‫ اٌزبسَخ اٌّشػ‬
) ‫طشع ( خظىطب ٌذي االؽفبي‬
‫ لذ رىىْ ِدشد اػشاع ػبِخ وثغُطخ رضَذ‬: ‫ ثبٌٕغجخ ٌٍظغبس‬
َ‫رذسَدُب ػًٍ ِذي اَب‬
 Physical examination:

 fever, altered mental state, meningism.

 Multi-organ failure (the Waterhouse-
Friderichsen syndrome ) may develop in
10-20 % of affected children
 Rash (petichial or purpuric )
, ‫ رغُش اٌسبٌخ اٌزهُٕخ‬, ‫ اسرفبع دسخخ اٌسشاسح‬: ‫ اٌؼالِبد اٌغشَشَخ‬
‫رُجظ اٌشلجخ‬
ٍ‫ ِٓ األؽفبي اٌّظبثُٓ َسذس فشً خّبػ‬% 20– 10 ٍ‫ ف‬
‫الػؼبء اٌدغُ اٌهبِخ‬
 Lab studies:

 * CSF: increased opening pressure ( > 180

mmH2O)
, increased WBC between 10 – 10,000 cells
/ mm3
 Increased protein concentration (> 45
mg/dl), and decreased glucose
concentration (< 45 mg/dl)
‫ عبئً إٌخبع اٌشىوٍ ػٓ ؽشَك خضػخ‬: ‫ اٌفسىطبد اٌّخجشَخ‬
, ‫ وشَبد اٌذَ اٌجُؼبء‬, ‫ اٌجش ورُٕبد‬, ‫ اسرفبع اٌؼغؾ‬:‫اٌظهش‬
‫وأخفبع ٔغجخ اٌغىش‬
Gram stain of CSF: -
+ve in 70-90 % o untreated cases

CSF culture: +ve in 80 % of cases -

IS-1106 PCR: rapid, sensitive (not -
affected by prior antibiotic therapy)
confirmatory test
‫ اَدبثُخ‬: ‫طجغخ خشاَ ٌٍغبئً اٌشىوٍ ووزٌه اٌّضسػخ‬ -
‫فٍ اغٍت اٌسبالد‬
‫هٕبن فسض رأوُذٌ عشَغ ودلُك وال َزأثش ثأعجمُخ اٌؼالج‬ -
ٌ‫ثبٌّؼبد اٌسُى‬
 MRI with contrast is preferred to CT scan
because MRI better demonstrates meningeal
lesions, cerebral oedema, and ischemia

Indications for performing imaging

studies before the lumbar puncture:
altered mental state, papilledema, focal
neurological deficits, seizures.
‫ َفؼً اٌفسض ثبٌشُٔٓ اٌّغٕبؽُغٍ ػًٍ اٌفسض ثبالشؼخ‬
‫اٌّمطؼُخ‬
‫ هٕبن زبالد ِؼُٕخ رؤخً فُهب خضػخ اٌظهش اًٌ ِب ثؼذ‬
‫االشؼخ اٌذِبغُخ‬
It is a medical emergency
obtain CSF promptly and institute antibiotics as
soon as possible after L.P

 Empirical treatment: infants <4wks of age

(ampicillin + cefotaxime ) , 4-12 wks
(ampicillin + 3rd gen. Cephalosporine ), 12
wks- 18 y (ampicillin or 3rd gen.ceph. +
chloramphenicol ), 18y- 50 y (3rd gen.cep.)
 > 50 y ( ampicillin + 3rd gen. ceph.)
‫ رؼزجش زبٌخ دخىي ػبخٍخ وَجذأ اٌؼالج ثبٌّؼبد اٌسُىٌ إٌّبعت‬
‫ ثؼذ خضػخ اٌظهش ِجبششح‬, ‫زغت اٌؼّش‬
 The use of dexamethasone in the management of
bacterial meningitis in adults remains
controversial.

 It may be used in children, especially in

those with meningitis caused by
haemophilus influenzae.
 Person –to – person transmission can be
interrupted by chemo prophylaxis which
eradicates the asymptomatic
nasopharyngeal carrier state
‫ سثّب َىىْ هٕبن اعبط ػٍٍّ العزخذاَ اٌذَىغبُِثبعىْ فٍ زبالد‬
ٓ‫ وٌى‬, ‫اٌسًّ اٌشىوُخ إٌبخّخ ِٓ اٌّغزذُِخ إٌضٌُخ ٌذي االؽفبي‬
‫ٌُظ هٕبن اعبط ِّبثً ٌذي اٌىجبس خظىطب فٍ اٌسًّ إٌُغُشَخ‬
‫ اٌؼالج اٌىلبئٍ َّٕغ اٌؼذوي ِٓ االشخبص اٌسبٍُِٓ ٌٍُّىشوة‬
 Chemo prophylaxis :

 in general, not recommended during

epidemics (multiple sources, prolonged
risk of exposure, as well as high cost.
 It can be considered for people in close
contact with patients in the endemic
situations
 {it is not an effective mean of interrupting
transmission during an epidemic }
‫ ال َؼزجش اٌؼالج اٌىلبئٍ االخزُبس االِثً خالي فزشح اٌىثبء ٌزؼذد‬
ّٓ‫ِظبدس اٌؼذوي وغالء اٌث‬
‫ َّىٓ اعزخذاِه ٌٍّخبٌطُٓ فمؾ‬
• Rifampicin:

 adult dose: 600 mg p.o for 2 days

 Pediatric dose:
< 1 month: 5mg/kg p.o q 12 h. for 2 days
- > 1 month : 10 mg/ kg
p.o q 12h. For 2 days
 Pregnancy: C-class
 Caution: hepatic disease
ً‫ َغزخذَ ػالج اٌشَفبِجُغُٓ وؼالج ولبئٍ وخظىطب ٌالؽفبي ال‬
‫ عٕخ ِٓ اٌؼّش‬18 ِٓ
‫ ال َٕظر ثبعزخذاِه ارا وبْ اٌسًّ ِسزّال‬
 Ciprofloxacin : •

 adult dose: 500 mg p.o single dose

 Pediatric: not recommended for those <
18 y. of age (cartilage damage)
 Pregnancy: C-class
 Caution: nill for single dose
ٍ‫ ٍِدُ ِشح وازذح َؼزجش اٌؼالج اٌىلبئ‬500 ٌ‫ اٌغُجشوثب‬
‫ عٕخ ِٓ اٌؼّش‬18 ِٓ ً‫االفؼً ػذا ٌٍسىاًِ واالؽفبي ال‬
 ‫• ‪Ceftriaxone:‬‬

‫‪adult dose: 250 mg I.M stat‬‬

‫‪Pediatric: < 15 y.: 125 mg I.M‬‬
‫‪> 15y : 250 mg I.M‬‬
‫‪Pregnancy : the drug of choice‬‬
‫زمٕخ اٌغفزشاَىغىْ ِشح وازذح فٍ اٌؼؼً رؼزجش اٌخُبس‬
‫االِثً ٌٍسىاًِ وَّىٓ اعزخذاِهب ٌالؽفبي ِغ رخفُفهب اًٌ‬
‫إٌظف ٌّٓ هُ الً ِٓ ‪ 15‬عٕخ ِٓ اٌؼّش‬
 Vaccination

 ACYW135 ( no vaccine for B)

 Epidemics usually spread rapidly to a
peak within weeks but may last for several
months in the absence of vaccinations
 Mass vaccination: AC
B ‫ َغطٍ اٌشثبػٍ اسثؼخ أىاع ٌُظ ِٓ ػّٕهب‬
ٍ‫ ارا ظهش اٌىثبء وٌُ َغزخذَ اٌزطؼُُ فمذ َجمً اشهش فٍ إٌّطمخ اٌز‬
‫ظهش فُهب‬
ٍ‫ َّىٓ اعزخذاَ اٌثٕبئٍ فٍ اٌزطؼُُ اٌدّبػ‬