1. The document describes a case of meningococcal meningitis in a 14-year-old male student who presented with high fever, headache, nausea, vomiting, stiff neck and confusion. Examination found a positive Kernig's sign and white blood cell counts were elevated in both blood and cerebrospinal fluid. 2. The document then provides background information on meningococcal meningitis, including that it is caused by Neisseria meningitidis bacteria, signs and symptoms, routes of transmission, risk groups, treatment which includes antibiotics and supportive care, and prevention through vaccination and chemoprophylaxis of close contacts. 3. Differential diagnoses and diagnostic testing are also

1. Department of Infectious Diseases ( Shi Hong ) MENINGOCOCCAL MENINGITIS

2. Meningococcal meningitis Meningococcal meningitis Morbidity mortality rate Morbidity mortality ● early diagnosis ● modern therapy ● supportive measure HIGH low

3. A case Beijing Center for Disease Control and Prevention (CDC) January 11, 2007 ◆ The patient was a 14-year-old male student. ◆ The onset of this case started quickly with high fever(39°C) and headache. ◆ Other clinical symptoms included nausea, vomiting, stiff neck and confusion. ◆ There was little petechiate rash emerged on the patient’s four limbs. ◆ The Kernig’s sign was positive and Brudzinski’s sign was negative. ◆ The numbers of white cell in the blood and cerebrospinal fluid (CSF) were 3.6×10 10 /L and 1.7×10 9 /L, respectively. What was the most likely diagnosis

4. Definition Meningococcal meningitis : ★ Neisseria meningitides ★ Respiratory tract ★ Purulent meningitis (an acute inflammation of the membranes that cover the brain and spinal cord) Meningococcal meningitis

5. Etiology ◆ gram-negative coccus ◆ Neisseria species ◆ 13 serogroups ◆ groups A, B, C What causes Meningococcal meningitis

6. Epidemiology Sources of infection : carriers and patients Infectious period : between late incubation period and acute phase, no more than 10 days of onset Meningococcal meningitis

7. Epidemiology Routes of transmission ⑴ Respiratory tract: ⑵ Close contact: cough/sneeze bosoming/kiss/breast-feed Meningococcal meningitis

8. Epidemiology Susceptibility ☆ Everybody without specific immunity ★ 6 months to 2 years of age. Epidemical features ◇ the common season : in the winter and early spring (November to May in next year) The peak incidence is in March to April Who is at risk?

9. Pathogenesis Immunity ＞ bacterial quantity and virulence A . bacteria eliminated . B . benign nasopharyngeal carriage or upper respiratory tract infection ->-> cured C . temporal meningococemia ->-> cured Meningococcal meningitis

10. Pathogenesis Immunity < bacterial quantity and virulence A . meningococcal septicemia. B . meningococcal meningitis. C . meningococcal arthritis and pericarditis Meningococcal meningitis

11. Pathogenesis Immunity < bacterial quantity and virulence A. meningococcal septicemia Meningococcal meningitis endothelial cells endotoxin ▼ Petechia ▼ infectious shock ▼ acidosis, ▼ DIC ▼ multiorgans failure invade release

12. Pathogenesis Immunity ＜ bacterial quantity and virulence B. meningococcal meningitis Neisseria meningitides the mucosal barrier the bloodstream the central nervous system increased intracranial pressure convulsion, coma, herniation CSF turbid, sometimes circular obstacle of cerebrospinal fluid and hydrocephalus Meningococcal meningitis

13. Clinical manifestations What are the signs and symptoms petechia in the skin (Meningococcal meningitis)

14. Clinical manifestations Incubation period : generally 2 to 3 days (Range is 1 to 10 days) Four types: ⒈ Meningococcal meningitis ( Moderate type ) ⒉ Fulminate type （ shock type, Meningoencephalitic type ) 3. Mixed type （ Meningococcemia- meningitis ） 4 . Mild type ( Mild acute meningococcemia ) What are the signs and symptoms

15. Clinical manifestations Meningococcal meningitis Septic period ▲ an abrupt onset ▲ chills high fever ▲ Headache ▲ Petechias ▲ purpuras ▲ Splenomegaly Meningitic period ▲ intracranial pressure ▲ headache ▲ vomiting ▲ restlessness ▲ Stiff neck ▲ Kernig (+) ▲ brudziski (+) ▲ gradually disappears , ▲ recovers to normal . Prodromal period Septic period Meningitic period Convalescent period

16. Clinical manifestations Meningococcal meningitis

17. Clinical manifestations Meningococcal meningitis

18. Laboratory examination ⒈ Routine laboratory studies of blood: Meningococcal meningitis WBC>20×10 9 /L Polymorphonuclear leukocyte platelet count(DIC)

19. Laboratory examination Lumbar puncture: Meningococcal meningitis CSF

20. Laboratory examination ⒉ Cerebrospinal fluid examination (an important method to establish diagnosis) : ● pressure ● glucose ● WBC ● sodium ● protein chloride Meningococcal meningitis turbid >1000 ×10 6 /L

21. Laboratory examination ⒊ Bacteriological examination (an important method to definitive diagnosis) : Meningococcal meningitis Smear: skin lesions spun sediment of CSF Bacterial culture of blood and CSF

22. Laboratory examination Meningococcal meningitis Figure : Neisseria meningitidis Gram-stain of a pure culture

23. Diagnosis  ⒈ Epidemic season, age and epidemic situations.  ⒉ Clinical features. ⒊ Manifestations of severe form in sepsis and meningoencephalitis  ⒋ Increased leukocytes and polymorphonuclear leukocytes predominantly in peripheral blood. ⒌ Increased intracranial pressure and purulent changes in CSF.  ⒍ Positive results in bacteriological examination. Meningococcal meningitis

24. Differential diagnosis ⒈ Purulent meningitis caused by other purulent bacteria. ⑴ Streptococcus pneumonia meningitis, ⑵ Haemophilus influenzae meningitis, ⑶ Staphylococcus aureus meningitis. ＆ (no overt season,no petechae or purpura) ⒉ Meningeal tuberculosis . ＆ (the history, no petechae or purpura,Bacillus tuberculosis) ⒊ Sepsis (Shock type) ＆ (other causative bacteria in blood cultures) How to diagnose Meningococcal meningitis

25. A case Beijing Center for Disease Control and Prevention (CDC) January 11, 2007 ◆ The patient was a 14-year-old male student. ◆ The onset of this case started quickly with high fever(39°C) and headache. ◆ Other clinical symptoms included nausea, vomiting, stiff neck and confusion. ◆ There was little petechiate rash emerged on the patient’s four limbs. ◆ The Kernig’s sign was positive and Brudzinski’s sign was negative. ◆ The numbers of white cell in the blood and cerebrospinal fluid (CSF) were 3.6×10 10 /L and 1.7×10 9 /L, respectively. What was the most likely diagnosis

26. Problems To analyze the case what’s the most likely diagnosis? 1 what do we still do for definitive diagnosis? 2 How to treat this young patient? 3

27. Treatment 1 General treatment ① Isolation hospitalization: ② Careful monitor nursing. ③ Prevent complication. ④ Maintain the balances of fluid and electrolytes 2 Etiological treatment ① Antibacterial activity. ② Concentration in CSF. ③ Resistance to drugs Penicillin G （ 200~400u/kg/day ) B.Chloromycetin C.Cephalosporis 3 Other treatment ● High fever: anti-pyretic (physical chemical ) measures. ● Increased intracranial pressure: 20 % mannitol ( 0.5g/kg~2g/kg )

28. Treatment Meningococcal meningitis ⑴ Shock type ① Etiology treatment: . Penicillin G ② Shock should be corrected promptly: a. Volume expanded. b. Metabolic acidosis corrected. c. Vasoactive drugs. d. Adrenal corticosteroids. e. Important organs protected Fulminate type ⑵ Meningococcemia-meningitis type ① Effective antibacterial drugs. Penicillin G. ② Alleviate cerebral edema Mannitol and 50 per cent Glucose. ③ Adrenal corticosteroids: Dexamethasone ④ Treatment in respiratory failure: lobeline, coramine ⑤ High fever and seizure: Sedatives: wintermine phenergan

29. Prognosis Meningococcal meningitis Fulminate meningo-coccemia early diagnosed appropriately treated in the extremes of age Good poor poor

30. Prevention Meningococcal meningitis Protect Protection of the susceptible population Protect Protection of the susceptible population Administer meningococcal vaccines, Chemoprophylaxis isolate for 3 days after the symptoms disappeared, generally no less 7 days after the onset observe Close contacts: observed medically for 7 days . Disrupt To go to the crowd places should be avoided during the epidemic

31. Multiple choice  1. A diagnosis of meningococcal infection requires the following to be present: a) Headache b) Neck stiffness c) Photophobia d) vomiting e) Pyrexia Meningococcal meningitis

32. Multiple choice 2. Meningococci: ( which one is right?) a ) Are most often harmless commensals colonising the nasopharynx b ) Are carried by some adolescents who show no signs of disease c ) Are transmitted by aerosol d ) Are usually transmitted with minimal contact e ) Cause infection most frequently in teenagers Meningococcal meningitis

33. Summarization ⒈ Definition Meningococcal meningitis is an acute purulent meningitis caused by meningococci ⒉ Transmission route occurs through respiratory tract . ⒊ The incidence of meningococcal meningitis The incidence of meningococcal meningitis is the first in purulent meningitis among children. Meningococcal meningitis

34. Summarization ⒋ Clinical characteristics ⑴ high fever rapidly; ⑵ severe headache; ⑶ vomiting frequently; ⑷ petechiae and purpura in the skin; ⑸ meningeal irritations; ⑹ infectious shock and injuries in brain parenchyma occurred in severe cases and often result in death. Meningococcal meningitis

35. Summarization What is meningitis? What is encephalitis? What causes meningitis and encephalitis? Who is at risk for encephalitis and meningitis? How are these disorders transmitted? What are the signs and symptoms? How are meningitis and encephalitis diagnosed? How are these infections treated? Can meningitis and encephalitis be prevented? What is the prognosis for these infections ? . Meningococcal meningitis

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38. Features of meningococcal meningitis in infants ⒈ Causes of atypical symptoms are that the crania and fontanelle are not still closed and the central nervous system is not well developed. ⒉ The features of clinical manifestations ⑴ Respiratory symptoms always presents with cough. ⑵ Gastroenteric symptoms Refusal to take food, vomiting and diarrhea are common gastroenteric symptoms. ⑶ Increased intracranial pressure includes irritability, shrill, seizures and fullness of the fontanelle. ⑷ Meningeal irritation always is not overt Meningococcal meningitis

39. Features of menigococcal meningitis in the old ⒈ The causes of high incidence in fulminate type In the old the immunity is lower, properdin deficiency and sensitive to endotoxin. ⒉ Clinical manifestations ⑴ Symptoms of upper respiratory tract are commonly presented in the old. ⑵ Mental obtundation is overt. ⑶ Petechia and purpura are more common. ⒊ Complications and prognosis usually can be seen with high mortality. ⒋ Leukocytes Leukopenia is often seen due to lower human body’ reaction Meningococcal meningitis