Canterbury HealthLaboratoriesMeningococcal septicaemiaRachel C Hutton, PhDMedical Laboratory Scientist
Canterbury HealthLaboratoriesDiagnosis Meningococcus• Disease• Transmission• Symptoms• Diagnosis• Treatment• Prevention• C...
Canterbury HealthLaboratoriesMeningococcal Disease• Contagious bacterial disease• Neisseria meningitidis– Fastidious aerob...
Canterbury HealthLaboratoriesTransmission– Exchange of respiratory/throat secretions– Cough/sneeze– Close contact – househ...
Canterbury HealthLaboratoriesSymptoms• Meningitis– Nausea– Vomiting– Photophobia– Altered mental status• Meningococcemia– ...
Canterbury HealthLaboratoriesDisease• 5-10% of patients die within 24-48H• Meningitidis– Brain damage– Hearing loss– Learn...
Canterbury HealthLaboratoriesDiagnosis• Clinical Examination• Gram Stain• Culture• Agglutination• PCR• MALDI-TOF– Suscepti...
Canterbury HealthLaboratoriesTreatment & Prevention• Medical Emergency• Antibiotics immediately ( after LP/Blood)– Penicil...
Canterbury HealthLaboratoriesCASE STUDY:MENINGOCOCCALDISEASECase Study:Meningococcal disease
Canterbury HealthLaboratoriesCase Study:Meningococcal diseaseDay Event Tests/Results Treatment0 Presents to GP Diagnosed a...
Canterbury HealthLaboratoriesDay Event Tests/Results Treatment0 Presents to GP Diagnosed as EBVNo bloodsNone – sent home1 ...
Canterbury HealthLaboratoriesDay Event Tests/Results Treatment1 ED GCS 9/15CT head Scan = No pathologicalchangesIV Dexamet...
Canterbury HealthLaboratoriesDay Event Tests/Results Treatment1 ED GCS 9/15CT head Scan = No pathologicalchangesIV Dexamet...
Canterbury HealthLaboratoriesDay Event Tests/Results Treatment2 Extubated Continued improvementMild headache & photophobia...
Canterbury HealthLaboratoriesThis is not the end of the story…
Canterbury HealthLaboratoriesDiagnosis ArthritisDay Event Tests/Results Treatments9 Increasing unwellPainful knee + elbowL...
Canterbury HealthLaboratoriesBlood Tests: TrendsWBCNeutrophilsPlateletsINR Fibrinogen
Canterbury HealthLaboratoriesCRPpH Blood Base Excess
Canterbury HealthLaboratoriesEDTAN. meningitidis DNA detected
Canterbury HealthLaboratoriesSamples Sent to MicrobiologyDay Sample Results9 L Elbow Aspirate BC bottle NG9 L Elbow Aspira...
Canterbury HealthLaboratoriesThe Value of PCRDay Sample Results9 L Elbow Aspirate BC bottle NG9 L Elbow Aspirate PottleAnt...
Canterbury HealthLaboratoriesRequest Forms
Canterbury HealthLaboratories
Canterbury HealthLaboratoriesThe Value of PCRDay 12: Hip AspirateTest Add N. meningitidis PCRResult = Positive
Canterbury HealthLaboratoriesMeningococcal Burdon
Canterbury HealthLaboratoriesMeningococcal Burden• Meningococcal disease causes life-threatening meningitis and sepsiscond...
Canterbury HealthLaboratoriesThank you• Dr Sophie Wen• Jen Fahey• Elaine Keith• CHL
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Meningococcal septicaemia

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Rachel Hutton, Medical Laboratory Scientist at Canterbury Health Laboratories presented this case study on Meningococcal septicaemia at the NZIMLS South Island Seminar in Hokitika in April 2013

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  • Contagious bacterial diseaseCausative organisim = Meningitis – Infection of the meninges : SwellingSepticaemia – Blood stream Infection: Damages blood vessel walls causing bleeding into the skin & organs
  • Exposure to asymptomatic carriers
  • Meningitis develops3-7 post exposureEarly symptoms = generalLate symptoms = disease specific
  • MALDI-TOF Matrix assisted laser desorbtion ionisationTime of flight – mass spec = mass:charge ration measured (ions accelerated by electric field)Susceptibility = appropriate ABxImportant to ID serotypes = Epidemiology
  • Treat with ABXPrevent with vaccine3 types – cover epidemic strainsIf cant grow cant test susceptibility/ serogroup? ALL LISCENCED IN nz
  • 16yr old femaleRenalimpaiment
  • Table showingThe Day, Event, Test & resultsClassic presentation – early non-specific symptoms16yr old femaleRenal impairment
  • DIC = Diseminated Intravascular Co-agulation
  • INR =DIC =
  • Day 9 = re-admitted due to the onset of an oligoarthristis
  • Red = AbnormalBlood Count:WBC + Neutrophils High due to immune responsePlatelets (circulating) Low due to consumption the increase as a result of the inflammatory processCo-Aggulation Tests: DIC indicator: Low grade DIC is common with sepsisINRInternational Normalised rate = Clotting time, hi for a pt not on WarfarinNot really useful if the patient is NOT on WarfarinFibrinogen Low/falling indicates DIC High indicates sepsis/CALow fibrinogen lads to prolonged reaction times for other factorsIf fibrinogen Decreased  Prolongs others
  • CRP:marker for inflammation, part of complement systemnormal <4Remains high probably due to oligoarthritisCRP V ESR: CRP immediate (ESR much slower to increase and to drop again)Blood Gases: AcidosispH & Base Excess Acidosis due to metabolic disturbance (CO2 = respiratory disturbance)Physiological pH = 7.365
  • Primers = Target CTR A geneEnzyme = TM It is a rapid real time PCR test based on Taqmanchemisty and involves amplifying a section of the CTR A gene.This gene is exclusive to meningococcus and forms part of the capsual biosynthesis locus. The 3 prime end of the CTR A gene is highly conserves amoungstmeningococcus irrespective of serogroupThe PCR test is able to detect less than 1 organism/ml of sampleSample types that can be tested by PCR include EDTA whole blood, CSF, Tissue biopsy and lesion aspirations
  • Remember N.meningo PCR pos 12 days ago!
  • Remember N.meningo PCR pos 12 days ago!
  • No mention of prev meningococcal diseaseOnly 1 sample request N.meningo PCR
  • Finally on 12th December somebody thinks a PCR for n. meningitidis would be a good idea
  • This was a very good outcome, most cases are not detected &/or treated so earlyMeningococcus is a very serious disease Sepsis: body.bacterial toxins rupture blood vessels and can rapidly shut down vital organs.
  • Meningococcus is a very serious disease This was a very good outcome, most cases are not deteted/treated so earlySepsis: bacterial toxins rupture blood vessels and can rapidly shut down vital organs. Largest burdon in an area of sub-saharanafrica – the meningitidis beltAfrica 1996 largest outbreak in historyover 250,000 cases reported25,000 deaths registeredIn NZ – Epidemic began in mid 1991 Group B 96 cases in 2010 (2.4/100,000) Maori 43.8% European 36.5% Case-fatality rate 6.3%
  • Meningococcal septicaemia

    1. 1. Canterbury HealthLaboratoriesMeningococcal septicaemiaRachel C Hutton, PhDMedical Laboratory Scientist
    2. 2. Canterbury HealthLaboratoriesDiagnosis Meningococcus• Disease• Transmission• Symptoms• Diagnosis• Treatment• Prevention• Case Study
    3. 3. Canterbury HealthLaboratoriesMeningococcal 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
    4. 4. Canterbury HealthLaboratoriesTransmission– Exchange of respiratory/throat secretions– Cough/sneeze– Close contact – household members– 10% population are carriers (nose/throat)– Carriers are crucial to disease transmission
    5. 5. Canterbury HealthLaboratoriesSymptoms• 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
    6. 6. Canterbury HealthLaboratoriesDisease• 5-10% of patients die within 24-48H• Meningitidis– Brain damage– Hearing loss– Learning disability• Septicaemia– Haemorrhagic rash– Rapid circulatory collapse
    7. 7. Canterbury HealthLaboratoriesDiagnosis• Clinical Examination• Gram Stain• Culture• Agglutination• PCR• MALDI-TOF– Susceptibility testing– Serogroups
    8. 8. Canterbury HealthLaboratoriesTreatment & 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)
    9. 9. Canterbury HealthLaboratoriesCASE STUDY:MENINGOCOCCALDISEASECase Study:Meningococcal disease
    10. 10. Canterbury HealthLaboratoriesCase Study:Meningococcal diseaseDay Event Tests/Results Treatment0 Presents to GP Diagnosed as EBVNo bloodsNone – sent home
    11. 11. Canterbury HealthLaboratoriesDay Event Tests/Results Treatment0 Presents to GP Diagnosed as EBVNo bloodsNone – sent home1 Found by mother Unresponsive Ambulance calledAmbulance GCS 8/15 (E2V2M4)Skin cool & mottledRash (Non-blanching erythematousconfluent)HR 76BP not palpableAirway patient – sat not recorded (NR)IV ceftriaxone
    12. 12. Canterbury HealthLaboratoriesDay Event Tests/Results Treatment1 ED GCS 9/15CT head Scan = No pathologicalchangesIV DexamethasoneIV fluidsAdrenalinICU LP not performed due to coagulopathyLow BPBlood tests-INR 3.1-No evidence of DIC-Raised blood glucoseIV VancomycinIV Acyclovar2 u FFPNoradrenalinInsulin infusionSerology EBV IgG PositiveEBV IgM NegativeEBV EBNA PositiveEvidence of PASTinfection with EBVMicrobiology Blood Cultures = Negative-Blood, Arterial, CVCIV Acyclovar StoppedIV DexamethasoneStopped
    13. 13. Canterbury HealthLaboratoriesDay Event Tests/Results Treatment1 ED GCS 9/15CT head Scan = No pathologicalchangesIV DexamethasoneIV fluidsAdrenalinICU LP not performed due to coagulopathyLow BPBlood tests-INR 3.1-No evidence of DIC-Raised blood glucoseIV VancomycinIV Acyclovar2 u FFPNoradrenalinInsulin infusionSerology EBV IgG PositiveEBV IgM NegativeEBV EBNA PositiveEvidence of PASTinfection with EBVPrimary diagnosis=meningococcalmeningitisBlood Cultures = Negative-Blood, Arterial, CVCEDTA – N. meningitidis PCR = PositiveIV Acyclovar StoppedIV DexamethasoneStopped
    14. 14. Canterbury HealthLaboratoriesDay Event Tests/Results Treatment2 Extubated Continued improvementMild headache & photophobia3 Transferred to Ward Ceftriaxone 2g Q12HTEDS7 Discharged
    15. 15. Canterbury HealthLaboratoriesThis is not the end of the story…
    16. 16. Canterbury HealthLaboratoriesDiagnosis ArthritisDay Event Tests/Results Treatments9 Increasing unwellPainful knee + elbowLines present L hand + R groinAdmitted to orthopaedic wardCRP 102WCC elevatedPyreticR Knee = swollen, effusion,good ROMGroin = visible scab from line,no erythema, tender, able toweight bareWash out elbow + knee(under GA)IV ceftriaxoneIV flucloxacillin12 Washout L elbow CRP 32Full ROM Hip & KneeLimitation at extremes of leftelbow extensionR hip joint aspirated & washed out N. meningitidis DNA detected18 Discharged
    17. 17. Canterbury HealthLaboratoriesBlood Tests: TrendsWBCNeutrophilsPlateletsINR Fibrinogen
    18. 18. Canterbury HealthLaboratoriesCRPpH Blood Base Excess
    19. 19. Canterbury HealthLaboratoriesEDTAN. meningitidis DNA detected
    20. 20. Canterbury HealthLaboratoriesSamples Sent to MicrobiologyDay Sample Results9 L Elbow Aspirate BC bottle NG9 L Elbow Aspirate PottleAnti co-ag tubeNOSWBC 175600 x106/L– predom polynucleatedRBC 12700 x106No CrystalsNG9 R Knee Aspirate BC bottle GPCNG9 R Knee Aspirate PottleAnti co-ag tubeOccasional GPCWBC 5950 x106/L– predom polynucleatedRBC 1520 x106/LNo CrystalsNG16S rRNA PCR: Bacterial DNA not detected10 R Knee Aspirate Syringe NOSScanty leucocytesNG12 Hip Aspirate PottleAnti co-ag tubeNOSWBC 51650 x106/L– predom polynuecleatedRBC 2800 x106/LN. meningitidis PCR = Detected
    21. 21. Canterbury HealthLaboratoriesThe Value of PCRDay Sample Results9 L Elbow Aspirate BC bottle NG9 L Elbow Aspirate PottleAnti co-ag tubeNOSWBC 175600 x106/L– predom polynucleatedRBC 12700 x106No CrystalsNG9 R Knee Aspirate BC bottle GPCNG9 R Knee Aspirate PottleAnti co-ag tubeOccasional GPCWBC 5950 x106/L– predom polynucleatedRBC 1520 x106/LNo CrystalsNG16S rRNA PCR: Bacterial DNA not detected10 R Knee Aspirate Syringe NOSScanty leucocytesNG12 Hip Aspirate PottleAnti co-ag tubeNOSWBC 51650 x106/L– predom polynuecleatedRBC 2800 x106/LN. meningitidis PCR = Detected
    22. 22. Canterbury HealthLaboratoriesRequest Forms
    23. 23. Canterbury HealthLaboratories
    24. 24. Canterbury HealthLaboratoriesThe Value of PCRDay 12: Hip AspirateTest Add N. meningitidis PCRResult = Positive
    25. 25. Canterbury HealthLaboratoriesMeningococcal Burdon
    26. 26. Canterbury HealthLaboratoriesMeningococcal Burden• Meningococcal disease causes life-threatening meningitis and sepsisconditions• Patients health can change from good to mortally ill within hours• As the antibiotics kill the bacteria, they release more toxin. It can takeseveral 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 sufferpermanent brain damage
    27. 27. Canterbury HealthLaboratoriesThank you• Dr Sophie Wen• Jen Fahey• Elaine Keith• CHL

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