Pediatric infection

*Meningococcal infection* *Lec 4*

Causative agent
It is Weichselbauns meningococcus (Nisseria meningitis). Gram negative, diplococcus, grows in moist environment in temperature of 37 c0. It is localized inside the neutrophilis.

Pathogenic factors:
1. Capsular polysaccharide: It is protect bacteria against phagocytosis. 13 serotypes A, B, C, W, and Y. A serotype appears only in epidemic. 2. Lipoligosaccharide: Endotoxin appears in the blood due to decompression of microbes. This endotoxin leads to DIC (the main cause of rash). 3. Pilli: It is responsible for adherence. 4. IgA protease: Damage of secretary IgA.

Epidemiology:
Sources of infection: 1. Sick person (catarrhal phenomena is present). 2. Carriers (asymptomatic [catarrhal phenomena is absent]). Ways of transmission: - Aerial droplet (distance 0.5-1 meter). Season: - More common in winter and early spring. The disease is more typical for children who are younger than 10 years.

Pathogenesis:
The bacteria colonize in the mucus membrane of naso-pharynx (95% leads to carrier stage). Bacteria enters non-ciliated epithelial cells by a parasitic direct endocytic process. Bacteremia (0,5-1%). Phagocytosis is incomplete and naso-pharynx mucus get through hemolytic encephalitic barrier and lead to development of meningitis (because neutrophilis cant produce myloperoxidase). Activation of fibrinolytic system which increase the chance of development of DIC, multiple organs failure (due to appearance of endotoxin) and septic shock. 1

Pediatric infection When concentration of toxin is 800micrograms or more it leads to lethal outcome. Coetaneous hemorrhage ranging from petechia to purpura (due to acute vasculitis with fibrin deposition in arterioles and capillaries). Thrombus contains bacteria so we can take swab from the rash for laboratory investigations.

Clinical classification by Pokrusky:

I. Local forms: 1) Naso-pharyngitis. 2) Healthy carrier. Generalized forms: 1) Meningitis. 2) Meningococcemia. 3) Meningoencephalitis. 4) Mix meningitis meningococcemia. Rare forms: 1) Arthritis. 2) Iridocyditis. 3) Chorioditis. 4) Pneumonia.

II.

III.

Incubation period:
3-10 days

Healthy carriers:
It is difficult to diagnose. We should take a bacterial swab from nasopharynx for all people in contact.

Nasopharyngitis:
Symptoms: 1. Fever. 2. Headache. 3. Nausea. 4. Vomiting. 5. Respiratory nasopharyngitis. 6. Meningohypoplasia of lymphoid tissues. 7. Scanty discharge from the nose. Changes in blood: 1. Leucocytosis. 2. Shift to left. 3. Increase of ESR. 4. Aneisonophilia. 2

Pediatric infection

Meningitis:
Symptoms: 1. Very severe headache. 2. Repeated vomiting and dont bring relief to patient. 3. High fever. - All symptoms appears at once the patients general condition is very severe. - Vomiting is no related to food intake and no nausea before it. - Headache occurs due to increase of intracranial pressure and accompanied by dizziness, hyperesthesia and hyperalgia. Meningeal sings: 1. Neck rigidity. 2. Brusinski sign (upper, middle, and lower). 3. Kerning sign. These signs are always positive in child under 1 year (normal physiology). Patients position: - Lying on the side, legs are flexed, and head is towered downward. The pressure in the spinal cord is increased. Meningococcal infection can lead to activation of all viral infections especially herpes simplex mainly after 2-3 days. In adults (constipation and flat abdomen), in children (diarrhea and tensmus).

Peculiarities for children: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. The child refuse to suck. Persistent vomiting with high fever. Marked hyperesthesia. Loss of weight. Loud screaming. Dyspeptic syndrome. Meningeal signs. Fontanel are protruded and tensed. Red demographism. Convulsions, tremors, and hypertonia. Hypertension. Irritability and drowsiness. Lesarge symptom: rise the patient and the child will move , in meningitis the child will flex his legs and hands.

Meningococcal encephalitis:
Symptoms: 3

Pediatric infection 1. Hallucinations. 2. Mental disorders. 3. Loss of consciousness. Laboratory investigations: 1. Lumbar puncture: - Increase of pressure 300-500. - Turbid and purulent. - Pliocytosis. - Increase neutrophils. - Increase proteins. - Decrease glucose. - Cells proteins dissociation increase (cells are more than proteins). 2. Bacteriological test: - Nasopharynx swabs. - Blood culture. - CSF. - Rash. 3. CBC. 4. Serology: - PCR. - Agglutination test. - PRHA.

Meningococcemia:
Acute onset of the disease. Toxicity. High fever. Hemorrhagic rash. o From the lower extremities, buttocks. o In severe cases the rash are large with central necrosis, very hard n palpation and never disappear when we press it. o Rash can be present on trunk, upper extremities and face. Vomiting. Myalgia. Arthralgia.

Prognostic factors: 1. 2. 3. 4. 5. If petechia appears in 2-20 hrs. Quick spreading of the rash. Seizures and signs of shock. Hypothermia (<36o)or hyperthermia (>41o). Hypotension SBP <50 mmHg. 4

Pediatric infection 6. Leucopenia < 4.109/l. 7. Thrombocytopenia < 100.109 [prothrombin index < 40%; high level of endotoxin > 8000 micrograms and increase of tumor necrosis factor (TNF)]. 8. Absences of meningitis. 9. Frederickson water-house syndrome (hemorrhage in adrenals): 1) Hyper-pyrexia. 2) Myalgia. 3) Arthralgia. 4) Vomiting (with blood). 5) Bloody diarrhea. 6) DIC. 7) Loss of consciousness. 8) Decrease of BP. 9) Appearance of rash. 10) Hypoxemia. 11) Multiple organs failure that lead to shock and death (usually patient dies within 24 hrs).

Chronic form of meningococcemia:

Last for 2-3 years. Increase of temperature (but not as much as acute form). Rash like meals. Irritability. Self limited disorder. Bacterioscopy is positive after 11-12 hrs.

Meningo-encephalitis:
Cortical disorders.

Arthritis:
Edema, disturbances of functions of joint (usually small one).

Iridocyditis:
Changes in the color of the eye (dust color).

Differential diagnosis:
1. Meningism is any other diseases: - Signs (very severe headache, vomiting, fever). - If we control the toxemia the temperature and signs of meningism will disappear. - Dissociation of meningeal signs (e.g only neck rigidity, or only lower brusinski). 5

Pediatric infection - No changes in CSF. Serous meningitis (viral infections, mumps): Toxemia is not so pronounced. - Signs of meningitis are no so pronounced. - CSF: o Transparent. o Lymphocytosis. o Poliocytosis. o Normal glucose. o No cellular protein dissociation. TB meningitis: - The disease start gradually. - Moderate pyrexia. - Paraesthesia on the 10th -12th day of the disease. - Tuberculin test is positive. - X-ray of lungs shows milliary TB. - CSF: o Web like pedicles of fibrin on the surface. o MBT. o Lymphocytes. Meningeal form of poliomyelitis: - CSF: o Transparent. o Cellular proteins dissociation on the 10th day. - Disappearance of tendon reflex. - Paralysis. Hemophilic influenzal meningitis: - Common in age of 3 months to 1 year. - Convulsions. - Subdural effusion. - Auditory defect. Subarachnoid hemorrhage: - Sudden headache. - Fever. - Meningeal irritation are marked. - Changes in CT and MRI. Thrombocytic purpura: - The disease begin with no fever, but with petechia of the skin. - Nasal, intestinal bleeding, abdominal pain. - The general condition is not so disturbed. - CBC: thrombocytopenia. Hemorrhagic vasculitis: - Affects joints. - Abdominal pain, fever is absent. 6

2.

3.

4.

5.

6.

7.

8.

Pediatric infection General condition is not so disturbed.

Treatment:
Local form: - Isolation. - Rifampicin 10-20mg/kg for 5-10days. - Antiseptic sol (nasal and gaggling in throat). - Perform laboratory investigations again to find if the patient is a carrier. Germanized meningitis: - Hospitalization. - IV infusion 50-100 ml/kg/day (to prevent edema of the brain give colloids and salts, in severe cases albumin and rheopolyglucins). - Ceftriaxone 100mg/24 hrs. - Cefaxime 200mg/24hrs. - Hormones therapy 2-3mg/day. - Diuretics (manitol): 20% - 0.5g/kg + potassium. - Seduxen to control convulsions. - 4% of sodium bicarbonate in case of acidosis. - Dopamine 1-7microg/kg/min in BP is decreased. - Vitamin B complex. - Nortropic drugs. All drugs should be given IV or IM. If the patient is allergic to penicillin we give cephalosporins. When to stop antibiotics treatment: 1. No fever for 5 days. 2. CSF proteins and sugar are normal. 3. CSF cellular count is less than 70/mm3, and 70% of all cells are lymphocytes. Meningococcemia: - IV infusion to control shock. - Chloromphenicol 50-100 mg X4/day. - Ceftriaxone 100mg/kg/day. - Hormone therapy 2-3mg/kg: o Shock stage 1: 5mg/kg. o Shock stage 2: 5-10mg/kg. o Shock stage 3: 15-20mg/kg. - Inotropic drugs dopamine 17 micrograms/kg/min Supportive therapy: Nasopharynx swab. 7

Pediatric infection Vitamin B complex. Noortropic drugs.

Prophylaxis:
1. 2. 3. 4. Isolation and treatment of patients. 2 days after the antibiotics course repeat bacteriological test. Repeat bacteriological test after 7 days of isolation of patient and he can go to school. Vaccination (capsular polysaccharide of meningococcal group A, C, Y W135), it is not used for children under 2 years.