Invasive meningococcal disease

Abstract

Invasive meningococcal disease (IMD) is a major public health issue due to its global distribution, potential of epidemic spread, predominant disease burden in children and adolescents, high case-fatality rates and substantial morbidity [1][2][3] . This disease presents a broad spectrum of manifestations and it is a neurological and clinical emergency that requires prompt recognition and initiation of therapy. In this article, we present a review on the epidemiology, pathophysiology, diagnosis, treatment and prevention of IMD, with focus on its neurological issues. MicrobiologyNeisseria meningitidis (N. meningitidis) is an exclusively human gram-negative diplococcus that has a great genetic variety 1 . Its genetic plasticity and phenotypic diversity are hallmarks of the meningococcus evolution, as this bacteria acquired various genes from other species of Neisseria and also from other bacterias, like Haemophilus spp. The microorganism is a frequent colonizer of the human nasopharynx and oropharynx, but can also be found in other places, like the oral mucosa, the rectum and the urogenital tract . Meningococcal virulence is related to the major outer membrane components: capsular polysaccharide, outer membrane proteins (pili, porins, Opa, Opc, meningococcal iron-acquiring proteins), and lipo-oligosaccharide (endotoxin) [4][5][6] . There are 13 serogroups of N. meningitidis based on different capsular polysaccharide structures, but only six serogroups (A, B, C, W-135, Y and more recently X) cause most life-threatening disease 2,6,7 .Instituto de Infectologia Emílio Ribas, São Paulo SP, Brazil.Correpondence: José Eduardo Vidal; Rua Capote Valente 688 / apto. 78; 05409-002 São Paulo SP, Brasil; E-mail: josevibe@gmail.com ABStrACt Invasive meningococcal disease (IMD) is a major public health and continues to cause substantial mortality and morbidity. Serotype C is the most frequent in Brazil. The clinical spectrum of IMD is broad (meningitis, meningococcemia or both) and the clinical evolution may be unpredictable. Main features associated with mortality are: age higher than 50 years old, seizures, shock, and meningococcemia without meningitis. Blood cultures should be obtained immediately. Lumbar puncture can be performed without previous computed tomography scan (CT) in most cases. Clinical features can be useful to predic patients where an abnormal CT scan is likely. Cerebrospinal fluid (CSF) culture and Gram stain should always be required. Latex agglutination sensitivity is highly variable. Polymerase chain reaction is specially useful when other methods are negative or delayed. Usually ceftriaxone should not be delayed while awaiting CSF study or CT. Dexamethasone can be used in meningococcal meningitis. Early suspicion of IMD and antibiotic in primary care before hospitalization, rapid transportation to a hospital, and stabilization in an intensive-care unit has substantially reduced the case-fatality rate. Vaccines against serotypes A, C, W-135, and Y are available while vaccines against serotype B are expecte...

Treatment of Meningococcal Disease

“…The initial onset of IMD follows the clinical course of a classic bacterial infection which may pose a challenge for the attending physician. Typically, a nonspecific febrile illness with chills, muscle aches, nausea, and vomiting may precede the development of more specific features of meningococcal infection, such as classic features of meningitis (e.g., headache, neck stiffness, photophobia, and altered mental state); however, less than a third of patients will present with this traditional "typical" diagnostic combination [5,7]. In approximately 40%e70% of patients with meningococcal disease, the nonspecific features will progress to sepsis due to meningococcal septicemia, with signs of circulatory insufficiency, shock, and the pathognomonic petechial/purpuric rash [8].…”

“…Post-infectious inflammatory syndrome occurs in approximately 6%e15% of individuals with IMD typically within 4e12 days of IMD onset [7]. Arthritis is the most common inflammatory pathology associated with this syndrome and results primarily from the accumulation of antigen-antibody complexes that contain bacterial polysaccharide [7]. Approximately 10% of IMD cases have some form of arthritic sequelae [33].…”

“…However, multiple joint involvement can occur. Other sequelae characteristics of post-infectious inflammatory syndrome include vasculitis, pleuritis, pericarditis, iritis, and episcleritis [7]. Usually, treatment of these post-infectious complications requires symptomatic treatment with antipyretics or nonsteroidal antiinflammatory agents.…”

Meningitis in adults: diagnosis and management

“…1 Despite ongoing advances in diagnostic methods and treatment strategies, mortality remains as high as 30% in pneumococcal meningitis and 5-10% in meningococcal meningitis. 2,3 However, outcomes are improved by prompt therapy. [4][5][6] It is critical that clinicians recognise the need to prioritise initial investigations while not delaying life-saving treatment with dexamethasone and antibiotics, which should be administered as soon as possible within the first hour following presumptive diagnosis.…”

The efficiency of sodC gene / N. meningitidis detection in comparison with the classical methods for the diagnosis of meningococcal infection / Evaluarea eficienţei Real Time PCR TaqMan utilizând gena sodC / N. meningitidis în comparaţie cu metodele clasice utilizate în diagnosticul infecţiei meningococice

“…Due to its worldwide distribution, epidemic potential, serious complications that can occur, and increased case fatality and morbidity rate, rapid and accurate diagnosis and early treatment are essential (1). For confirming the aetiology, cerebrospinal fluid (CSF) and/or blood culture was until recently the gold standard samples for the diagnosis of meningococcal infection.…”