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Hot topics - meningitis

Dr Mona Kular gives the lowdown on a hot topic for the MRCGP exams

Dr Mona Kular gives the lowdown on a hot topic for the MRCGP exams

What is meningitis?

Meningitis is the term given to inflammation of the meninges and is separate from septicaemia where micro organisms invade the bloodstream. Causes may be bacterial, viral, fungal or parasitic, among others.

While all can cause serious illness, bacterial meningitis is by far the most dangerous. The most common pathogen is Neisseria meningitidis or meningococcus, with Streptococcus pneumoniae a close second. Other causative micro organisms include Escheri-chia coli and Listeria monocytogenes in the neonatal period, with Haemophilus influenzae implicated in infants and children. Here we look at meningococcal disease.

What is meningococcal disease?

Meningococcal disease is the term used to cover both meningitis and septicaemia caused by Neisseria meningitidis or meningococcus. This is exclusively a human pathogen and carried by approximately 50% of the population within the nasopharynx.

It is not completely clear what triggers the invasion of meningococcus from the naso-pharynx into the blood stream but it is thought to be affected by factors such as the strain¹s virulence, host status, genetic factors and environmental influences.

There are a minimum of 13 groups of meningococcus of which only group C currently has a vaccination available in the UK.

Epidemiology

Meningococcal disease is a notifiable disease and, according to the Health Protection Agency, half of the cases in the UK occur in children under four.

The incidence in the UK is about five per 100,000, with the introduction of the MenC vaccine in 1999 seeing a reduction in the number of cases notified.

Symptoms and signs

The classic presentation of meningococcal disease ¬ non blanching rash, signs of meningism and fever ¬ are actually late in the progression of the disease. Earlier signs, present at around eight hours into the disease, have been found to include leg pains, cold hands and feet and abnormal skin colour. Other early symptoms might include vomiting and diarrhoea.

These signs could, of course, be markers of serious illnesses other than meningococcal disease. Even given these early markers, recognising the disease can be extremely difficult and it is reasonable to review children over a period of hours if concerns exist. A non blanching, purpuric rash of >2mm in an unwell, pyrexial child is likely to be meningococcal disease, and we mustn¹t forget the disease can progress extremely fast and changes in clinical status occur quickly.

Management

If you suspect a child may have meningococcal disease, benzylpenicillin should be given within half an hour. The iv/im dose for children under a year is 300mg, and for those aged one to nine years it is 600mg. Ideally this would be intravenously, but intramuscular administration will suffice.

The child should be admitted to hospital as an emergency, where high-dose intravenous antibiotics will continue, along with investigations and resuscitation measures as necessary. Disease severity can be assessed using the Glasgow meningococcal septicaemia prognostic score.

Prognosis

Meningococcal disease is fatal for around 8% of children. Of the remainder, deafness and neurodevelopmental sequelae and abnormalities occur. However, due to earlier recognition and treatment, survival rates are increasing. NICE guidelines for meningococcal disease and meningitis in children and young people are currently under development and are due to be published in 2009.

Further reading

• Clinical review, Meningococcal disease and its management in children, C Anthony Hart. BMJ 2006;333:685-690

• Health Protection Agency, www.hpa.org.uk

• Clinical recognition of meningococcal disease in children and adolescents, The Lancet 2006; 367:397-403

Dr Mona Kular is a GP in Nottingham

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