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Meningitis and meningococcal septicaemia: an update

Nelly Ninis
Consultant Paediatrician
St Mary's Hospital, London

Nurses play a central role in the diagnosis of meningitis and are vital for disseminating accurate health information to patients, including advising on and administrating vaccines

Meningitis means an inflammation of the fine protective membranes that cover the brain and spinal cord. Meningococcal septicaemia (bacteria in the blood stream) causes a devastating illness with a purple rash on the body. This condition is often called 'meningitis' leading to confusion about diagnosis and treatment. It is important for nurses to know the differences between the symptoms of both meningitis and septicaemia.

What causes meningitis?
Meningitis can be caused by viruses, bacteria and fungi, although the latter is only really seen in patients with reduced immunity or special groups like premature babies.
Viruses. These are common causes of meningitis. Mumps used to be the leading cause but now other viruses such as entero-viruses are more common. Generally, viral meningitis is less serious than bacterial meningitis.
Bacteria. In adults and children over three months of age who have normal immunity, the three main pathogens are:

  • Streptococcus pneumonia (the pneumococcus). There are many serotypes of peumococcus circulating but only a few cause invasive disease.
  • Neisseria mengitidis (the meningococcocus). There are five different groups - A, B, C, Y and W135. In the UK, the majority of infection is caused by group B. Group C disease was a serious problem among teenagers until the introduction of the meningitis C vaccination in 1999. There is currently an increase in the number of cases caused by serogroup Y disease. Group A causes epidemics in Africa and Asia but not in the UK. Both pneumococci and meningococci live in the nose and throat of many people without causing disease.
  • Haemophilus influezae type B (HiB) and haemophilus type F (HiF).

Babies under three months of age
This group of children (neonates) is at risk of meningitis from a wider range of bacteria as well as those listed above. Group B streptococcus causes meningitis, septicaemia and bone infections up to three months of age. Listeria and E. coli also cause meningitis in newborn babies. Risk factors for neonatal infection include:

  •     Prematurity.
  •     Prolonged rupture of the membranes (>24 hours).
  •     Known maternal carriage with group B streptococcus.
  •     Fever in mother or baby around delivery.

Vaccination: the 'meningitis' vaccines
The routine UK vaccination schedule for children includes specific vaccinations against the organisms that cause meningitis or septicaemia. There are three vaccines designed to reduce cases of meningitis. Although effective they do not cover all the organisms that cause disease so cases will continue to occur. Neonates under three months of age remain very vulnerable as they will only have had their first set of vaccinations by three months and there is no vaccine for group B streptococcus and the other bacteria causing neonatal disease.

Prevenar 13
This contains 13 serotypes of pneumococcus and covers the most common types of pneumococcus that cause disease (74% of all cases in 2008/09 in children under five years).
The vaccine will give good protection against these forms of pneumococcal disease but not to any of the other pneumococcal serotypes and children remain vulnerable to developing pneumococcal meningitis.
A new group B vaccine has recently been developed for the UK. It will not cover all the serotypes of group B but will aim to cover the more common serotypes. Therefore, it will not eradicate meningococcal disease completely.

HiB
This vaccine has been given to children for 20 years and has had a dramatic impact on the number of cases of HiB meningitis. There are only a few cases every year.

Meningitis C
This vaccine gives protection against disease caused by group C meningococcus and has reduced the incidence by 95%. It offers no protection at all for the other types of meningococcal groups.  Those travelling to Africa, where group A causes massive epidemics in the 'meningitis belt' or on pilgrimage to the Hajj, where outbreaks of meningococcal disease have occurred, should be offered the ACWY travel vaccine.
Vital signs, Vital Issues: A Guide for Community Practitioners, endorsed by the Royal College of Nursing (RCN), is available from the Meningitis Research Foundation (see Resources).

DiagnosiS: is it meningitis?
Meningococcal disease (MD) presents as meningitis or septicaemia or a mixed picture with features of both. The septicaemic form of the disease without meningitis is the most dangerous form of meningococcal disease. After the patient starts to develop MD there is period where they are non-specifically unwell. Then they will either develop a true meningitic picture or a septicaemic picture. The symptoms and signs of these forms vary considerably.

Symptoms
Recent research into the symptoms of children with MD showed that they develop at different rates in children of different ages. Generally, the younger the child, the faster the symptoms emerge. All age groups became critically unwell in the 24 hours after the first symptom. For all patients the initial symptoms were vague and non-specific, including fever, vomiting and headache. At this stage the symptoms were similar to those of other more trivial illnesses. This initial period can last up to four hours in infants and eight hours in teenagers but it can also be much shorter. After this stage the symptoms become more specific.

Septicaemia
In septicaemia the bacteria are multiplying very rapidly in the blood, releasing toxins that cause the circulation to fail. Patients develop fevers with rigours (shaking), have muscle aches and become pale with mottled skin and cold extremities. They may develop severe limb pain with nothing to find on examination. Patients with pure septicaemia do not develop neck stiffness or photophobia and they remain alert and able to talk.

This often leads to nurses and doctors underestimating how unwell they are. As the illness progresses they stop passing urine and breath faster. The pulse rate will rise from early on, the capillary return is prolonged but blood pressure may remain normal until very late in the illness especially in children. Death from septicaemia is caused by cardio-vascular failure (shock).

The rash
The classic dark rash that does not go away is the hallmark of meningococcal septicaemia. It is caused by blood leaking outside vessels and does not fade when pressed. This is the basis of the tumbler test. However, the rash often starts as a non-specific pink rash that does blanch. Therefore, it is important parents are told to keep examining rashes in their children as they may change. The rash may be petechial (pin pricks) or purpuric (>2 mm across) and widespread. In meningitis, the rash may be very scanty. Parents may misunderstand the significance of the rash as it looks very different to usual childhood rashes.

Meningitis
The symptoms are very dependent on age. The younger the child the less likely it will be to have any specific symptoms. All babies under three months of age with a fever above 38 degrees have to be admitted to hospital for specialist investigation.

In young children (those under two) it is very unusual to see neck stiffness and photophobia. They will have irritability, vomiting, seizures and drowsiness. Parents are the best guide to their children's neurological functioning as they understand subtle deviations from normality in their behaviour. Severe headache with vomiting are also important signs. In older children, the specific signs of meningitis often do not develop till 12-15 hours after the start of the illness. Teenagers will often become combative and may be thought to be intoxicated.

All patients with meningitis must be carefully assessed for signs of raised intracranial pressure (fluctuating level of consciousness, coma, dilating pupils, bradycardia and hypertension). Death occurs from brain stem herniation through the base of the skull, 'coning'.

Pneumococcal meningitis presents in a very similar way to meningococcal meningitis but it may seem to emerge over the course of a few days. This is because pneumococcal meningitis may follow a viral illness. It is a devastating infection with often very poor outcome.

Resources
Early Recognition of Meningitis and Septicaemia: Vital Signs for
Frontline Nurses
www.meningitis.org/health-professionals/frontline-nurses

Meningitis research foundation website (also available as a card)
www.meningitis.org/health-professionals/immunisation-and-community
nurses

National Institute for Health and Clinical Excellence
Bacterial meningitis and meningococcal septicaemia in children
2010
www.nice.org.uk/nicemedia/live/13027/49339/49339.pdf

Management of fever in children under 5 years of age
www.nice.org.uk/nicemedia/live/13027/49339/49339.pdf