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16.04.2020 Feature Article

CerebroSpinal Meningitis,-Update

The seasonal Meningitis
CerebroSpinal Meningitis,-Update
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CEREBROSPINAL (MENINGOCOCCAL) MENINGITIS.
Neisseria meningitidis, are bacteria that live harmlessly in the noses and throat of about 15% of the general population. The carriage rate is even, much higher in adolescents and during epidemics.

WHY IS CEREBROSPINAL MENINGITIS DANGEROUS?
Meningococcal meningitis is associated with high fatality (up to 50% if untreated) and severe brain damage awaits 10% of those who survive the disease.

Even when the disease is diagnosed and treated early, 1 out of 8 patients die, often within the first 2 days

Early antibiotic treatment improves survival and reduce complications.

Humans are their only natural hosts.
In overcrowded environments, like boarding houses, and during cold dry weather conditions, the bacteria spread very fast, and as they do so, some of the bacteria can transform into disease causing types.

Other risk factors associated with disease causing bacteria in adolescents, include:

Male gender
Symptoms of upper respiratory tract infection
Marijuana use and smoking
Close gatherings, including attendance at night clubs, jamborees.

Disease causing bacteria invade the blood stream and multiply rapidly and release their toxins.

In the cranial circulation, they cause meningitis by affecting the brain and the thin brain coverings.

In the small blood vessels, they release toxins that leads to bleeding into the skin. This can lead to extensive destruction of the skin and the surrounding tissues.

SPREAD
N meningitidis is found only in the nose and throats of humans and is spread via respiratory droplets or contact with secretions.

During the harmattan period, dust winds, cold nights, and having a common cold combine to damage the nasopharyngeal mucosa, allowing the bacteria to enter the blood stream to cause the disease.

The bacteria spread to other persons, via respiratory droplets from colonized individuals, therefore, close contact is required.

There is increased risk, if there was close contact for at least 4 hours during the 7 days before illness onset.

Intimate kissing is a risk factor for meningococcal meningitis in adolescents

Incubation period: Average is 4 days, but ranges from 2-10 days and symptoms, normally, start to show within 4 days

High Risk factors for acquiring meningitis:
1.) Adolescent age group
2.) Living in a group situation (college dormitories, military recruits)

3.) People with impaired immunity
SEROGROUPS:
There are more than 13 serogroups of Neisseria meningitidis, based on the type of polysaccharides in their cell walls.

5 primary types: A, B, C, Y and W-135 account for 90% of all human infections.

Type B cause sporadic disease in children under 4 years of age.

Outbreak of epidemic diseases are due, mainly to group A and C

In the African meningitis belt, which runs from Senegal to Ethiopia, serogroup A is the usual culprit. During the harmattan season, about 30,000 cases are reported each year.

CLINICAL FEATURES
The disease can affect anyone however, it commonly affects babies, preschool children and adolescents.

The disease is marked by very rapid deterioration in health status, from being well to very sick within hours.

The person may complain of:
Sudden onset of headache
Fever
Nausea and vomiting
Early non-specific signs of meningitis include:
Leg pain, (appears at about 7 hours)
Thirst (at about 8 hours)
Diarrhea (at about 9 hours)
Abnormal skin color (at 10 hours)
Breathing difficulty (at 11 hours)
Cold hands and feet (at 12 hours)
Classic Symptoms:
Purpuric rash, from bleeding into the skin (at 13 hours)

Neck pain or stiffness (at 13 hours)
Photophobia (at 15 hours)
Confusion or Delirium (16 hours)
Seizure (17 hours)
Unconsciousness (at 22 hours)
Management
Early recognition of the above signs and symptoms of meningococcemia is an important determinant of survival.

Most children with invasive meningococcal disease have an illness with symptoms and signs lasting only a few hours to a day.

Many patients are initially thought to have a viral infection. Doctors must beware of the adolescent with fever malaise and purple skin rash

The initial diagnosis can be made by clinical examination and spinal tap that shows purulent spinal fluid.

TREATMENT:
The disease is a medical emergency due to the high fatality rate.

High-dose intravenous penicillin G for 5-7 days is the preferred treatment for infection due to N meningitidis. Ceftriaxone is the alternative.

Prompt treatment of shock with intravenous fluids, heart medications or ventilatory support when needed, may be critical in improving survival.

PREVENTION AND DISEASE CONTROL
Chemoprophylaxis:
Preventive antibiotic medication is given to:
All household contacts
Child care
School contacts or
Anyone exposed to a patient's secretions.
The medications should be given within 24 hours of recognizing the primary case,

Rifampicin, given twice daily for 2 days)
Azithromycin (single dose) Ciprofloxacin, (single dose) Ceftriaxone (single dose intramuscularly).

VACCINATION
Meningococcal conjugate vaccines (MEN ACW-Y) confer a protection of more than 5 years, Booster doses are given at 5-yearly intervals.

Meningococcal Group B vaccine (MEN B) is available as MENB-4C (Bexsero) and MENB-FHbp (Trumenba). MEN B Vaccines need booster-doses every 2-3 years

The Polysaccharide vaccines, that are used during outbreaks, offer a 3-year protection for vaccinated individuals.

Who Needs Vaccination
All 11-12year old, should be vaccinated with meningococcal conjugate vaccine, with booster dose given at age 16 years old.

All teens may be vaccinated with serogroup B, preferably, at 16 through 18year old.

Adults and younger children with impaired immunity, including sickle cell disease, HIV, spleen problems, may be vaccinated

Due to waning immunogenicity, all college freshmen up to age 21 years should be revaccinated if they received the vaccine before they were 16 years old.

Alex Sarkodie MD.

Alex Sarkodie MD
Alex Sarkodie MD, © 2020

Alex Sarkodie,MBChB has over 30 years experience in the field of MedicineColumn: AlexSarkodie

Disclaimer: "The views/contents expressed in this article are the sole responsibility of the author(s) and do not neccessarily reflect those of Modern Ghana. Modern Ghana will not be responsible or liable for any inaccurate or incorrect statements contained in this article."

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