Meningococcal Disease (Neisseria meningitidis Infection)

What is Meningococcal Disease (Neisseria meningitidis Infection) ?

Neisseria meningitidis, a type of bacteria, was first identified in 1887 by Anton Weichselbaum while studying a patient suffering from meningitis, a brain inflammation disease. This bacteria is known for causing a range of illnesses, known as meningococcal disease. Interestingly, up to 10% of people carry this bacteria in their mouth and nose without developing any illness. Certain factors can increase the chance of carrying these bacteria, such as being a teenager or a young adult, being male, living in shared accommodations, exposure to cigarette smoke, and frequently visiting bars and parties.

Neisseria meningitidis is known to cause many infections. It’s particularly linked to dangerous conditions like meningococcal meningitis (a severe form of brain inflammation) and fulminant meningococcemia (an overwhelming infection in the bloodstream). Despite recent vaccination efforts to reduce the complications of meningococcal disease, it continues to pose a significant risk for certain vulnerable groups.

What Causes Meningococcal Disease (Neisseria meningitidis Infection) ?

N meningitidis is a type of bacteria that only affects humans and can survive with or without oxygen. It comes in various forms called serotypes, identified by unique traits of the bacteria’s outer coating. At least 12 different serotypes of N meningitidis exist. Serotypes A, B, C, W, X, and Y are behind most infections caused by this bacteria.

In Africa, serotypes A and C cause most of the disease. In Europe, the United States, and Canada, serotypes B, C, and Y are the primary culprits. Serotype W is known to cause outbreaks globally and is typically associated with people who have made religious pilgrimages to Saudi Arabia.

In the United States, N meningitidis is a frequent cause of bacterial meningitis, a severe infection of the membranes covering the brain and spinal cord, that affects both children and adults. It is a potentially deadly infection with a high death rate. It is the second most common cause of this type of meningitis, after Streptococcus pneumoniae.

Besides meningitis, N meningitidis can cause a variety of other infections. These include meningococcemia, an infection of the bloodstream; pneumonia, an infection of the lungs; septic arthritis, an infection of the joints; pericarditis, an infection of the membrane around the heart; and urethritis, an infection of the urethra. It can also cause both local and widespread infection outbreaks, affecting normally healthy adults.

Risk Factors and Frequency for Meningococcal Disease (Neisseria meningitidis Infection)

The number of people getting meningococcal disease has gone down thanks to the use of routine vaccinations. In the United States, the rate of this disease dropped from 1.2 cases per 100,000 people in 1996, down to 0.1 cases per 100,000 people in 2018. Infants under 1 year old are the most at risk, with 2.45 cases per 100,000 individuals. The bacteria that causes this disease, N meningitidis, can cause widespread outbreaks.

• It is a major cause of bacterial meningitis in sub-Saharan Africa, leading to the area being known as the ‘meningitis belt’.
• The death rate for this disease can range from around 10% to 14% for those who get treatment.
• Without treatment, the death rate can go up to 50%.

Signs and Symptoms of Meningococcal Disease (Neisseria meningitidis Infection)

N. meningitidis, also known as meningococcal disease, can be challenging to diagnose because its early symptoms are common to many other illnesses. These include sudden fever, headache, nausea, vomiting, severe muscle aches, a nonspecific rash, sore throat, and other respiratory symptoms. Because it can rapidly progress and can even lead to death within hours, identifying the disease can be difficult. In its later stages, this illness may cause further symptoms such as neck stiffness, sensitivity to light, a bleeding rash, mental disorientation, shock, abnormal skin color, or even a severe blood clotting disorder.

Vital signs like low blood pressure and an increased heart rate can hint at early stages of sepsis. A full physical examination, particularly checking for rashes, is recommended. The rash can evolve from small spots that can be urticarial, macular, or papular, into different forms of bruising and bleeding skin lesions. However, some traditional symptoms of meningitis, like specific responses to neck movements, can be unreliable. It is worth noting that seeing fever, mental disorientation, and stiff neck together is quite rare, occurring in about 44% of cases.

One serious complication of this disease is purpura fulminans, which leads to blood clotting, skin hemorrhage, and possibly skin death. This situation may develop to a point where painful areas of necrosis form, along with blisters and sores, and may result in gangrenous necrosis that necessitates limb amputation. Unusual skin color, cold hands and feet, and painful legs may be signs of vascular compromise.

While rarely, N. meningitidis can also cause pneumonia, septic arthritis (an infection in a joint), urethritis (urinary tract inflammation), and pericarditis (inflammation of the sac surrounding the heart).

Testing for Meningococcal Disease (Neisseria meningitidis Infection)

A lumbar puncture, also known as a spinal tap, is the preferred method to diagnose meningitis. This procedure is essential for quick evaluation and diagnosis. However, it may not be suitable for everyone. Conditions that might make a lumbar puncture unsafe include high pressure in the brain, recent onset of seizures, swollen optic disc (papilledema), a compromised immune system, specific neurological deficits, clotting abnormalities, and severe heart or lung disease.

If the doctor strongly suspects meningitis, they might start antibiotic treatment promptly, even before the lumbar puncture is done. Performing laboratory tests on blood samples and cerebrospinal fluid (CSF, the fluid surrounding the brain and spinal cord) can still provide valuable information, even if antibiotics have been started. These tests might include gram staining and culture for microbes, and measuring levels of glucose (sugar), cell count, and protein in the CSF.

In bacterial meningitis (one type of meningitis), the glucose levels in the CSF are often decreased, the protein levels are increased, and there’s a higher number of a specific type of white blood cell (polymorphonuclear leukocytes). The culture of CSF is the best way to diagnosis bacterial meningitis.

However, other types of tests can be helpful in confirming the diagnosis or in patients who have begun antibiotic treatment and have negative CSF cultures. These tests include PCR (polymerase chain reaction, a kind of DNA test), and latex agglutination (a test that detects bacterial proteins).

Computed tomography (CT scan), a type of detailed X-ray, can be useful in patients with altered mental status, mainly to exclude other possible conditions. However, if a CT scan is necessary, it’s important to coordinate with the nursing and radiology teams to ensure that treatment with antibiotics doesn’t get delayed.

Treatment Options for Meningococcal Disease (Neisseria meningitidis Infection)

Identifying and treating meningococcal infections as soon as possible is essential to improve the patient’s outcome. The main focus of meningococcal infection treatment includes giving antibiotics, ensuring isolation and precautions to prevent spread, consulting with infection specialists, monitoring in the intensive care unit, managing blood clotting disorders (coagulopathies), and identifying people at risk who may have been exposed to the bacteria causing meningococcal infections (Neisseria meningitidis).

Since meningococcal meningitis can look like other bacterial infections of the meningitis group, a treatment approach that assumes bacteria are present (empiric treatment) is often started while waiting for lab results. This preemptive treatment includes a class of antibiotics known as third-generation cephalosporins such as ceftriaxone or cefotaxime. If lab tests indicate that penicillin can kill the bacteria (penicillin-susceptible), the treatment can be switched to penicillin G. Nevertheless, continuing the third-generation cephalosporin treatment is also an option. For patients who have severe allergies to penicillin and other similar drugs, an antibiotic named chloramphenicol may be an alternative. The antibiotic treatment is usually given for 5 to 6 days.

Dexamethasone, a high-dose steroid medication, should be given as soon as bacterial meningitis is suspected because it can help protect the brain in some types of meningitis. It should be given intravenously up to 4 hours before or no more than 12 hours after the first dose of intravenous antibiotics. However, if meningococcal meningitis is confirmed, dexamethasone doesn’t typically help and should be stopped.

Patients with meningococcal infections should also receive intensive support, especially if they have sepsis or septic shock, life-threatening conditions caused by the body’s response to an infection. This can include intravenous fluids and the use of medications to increase blood pressure, like norepinephrine. If the infection leads to problems with blood clotting (disseminated intravascular coagulation), the patient may need aggressive hydration, blood transfusions, platelet replacement, and possibly the addition of clotting factors. Although there’s been some discussion about using protein C as an additional treatment, it’s use is still debated and not commonly used at this moment.

What else can Meningococcal Disease (Neisseria meningitidis Infection) be?

Streptococcus Pneumoniae, commonly known as S. pneumoniae, is the biggest cause of bacterial meningitis in America. It’s important to consider this when diagnosing someone who might have a type of meningitis caused by meningococcal bacteria. Other, less common bacteria can also cause meningitis, such as Haemophilus influenzae, group B Streptococcus, and Listeria monocytogenes. But it’s not always bacteria responsible for meningitis – viruses, tuberculosis, other types of infection, and even malignant (cancerous) conditions can cause it.

When confronted with a patient who has a combination of a fever and maculopapular rash (a rash made up of both raised bumps and flat patches), doctors shouldn’t jump to conclusions. They need to think about all possibilities, which could include many different diseases and conditions:

• infections like mononucleosis, West Nile virus, Zika virus, HIV, Ebola virus
• conditions caused by bacteria or other microorganisms, like Rocky Mountain spotted fever and ehrlichiosis
• reactions to medication

Children displaying the same symptoms might suffer from a different range of diseases such as:

• Kawasaki disease
• common childhood illnesses like measles, scarlet fever, rubella, and parvovirus B19
• lesser-known conditions like roseola
• infections caused by certain viruses, such as the Epstein-Barr virus – the cause of mononucleosis or “mono”
• hand, foot, and mouth disease

What to expect with Meningococcal Disease (Neisseria meningitidis Infection)

Meningococcal infection, if left untreated, can have a high mortality rate of about 50%. However, with early and intensive treatment, this rate can be brought down to around 10% to 14%. It is crucial to start antibiotics as soon as possible to improve the chances of a good recovery. Still, despite treatment, a percentage of survivors, between 11% to 19%, may face long-term complications.

Like other bacterial meningitis cases, individuals who survive meningococcal infections need to have regular medical check-ups. A hearing check is advised within four weeks of leaving the hospital. Those who have had amputations due to the infection will need routine orthopedic visits and prosthetic fittings. The infection can also potentially cause psychological issues, including Post-Traumatic Stress Disorder (PTSD), depression, and behavioral abnormalities. Therefore, patients may need to see psychologists and psychiatrists regularly post-recovery.

Possible Complications When Diagnosed with Meningococcal Disease (Neisseria meningitidis Infection)

Meningococcal disease can have many long-term effects. These can include ongoing pain, scars on the skin, the need to cut off a limb, and problems with the brain and nerves. This could be anything from having trouble hearing or seeing to having difficulty moving. About 3% of people with this disease will have problems with hearing or need a limb amputated. Around 10% of people will develop arthritis, and between 6% and 15% of people will develop an inflammatory syndrome after the infection.

Sadly, up to one in three survivors of meningococcal disease will have mental health problems. This can include post-traumatic stress disorder, anxiety, and depression.

There are also immediate, serious complications that can happen with meningococcal disease. These can include a severe, life-threatening infection in the blood (septic shock), a rash of purple spots (purpura fulminans), fits (seizures), and buildup of fluid in the brain (hydrocephalus). Other risks include blood clotting in the brain (cerebral venous sinus thrombosis) and an infection in the space between the brain and skull (subdural empyema).

Common Complications:

• Chronic pain
• Skin scarring
• Limb amputation
• Neurological impairments, such as hearing or visual problems
• Arthritis (10% of cases)
• Postinfection inflammatory syndrome (6%-15% of cases)
• Mental health problems, such as post-traumatic stress disorder, anxiety, and depression
• Septic shock
• Purple spots rash (purpura fulminans)
• Seizures
• Fluid buildup in the brain (hydrocephalus)
• Blood clotting in the brain (cerebral venous sinus thrombosis)
• Infection in the space between the brain and skull (subdural empyema)

Preventing Meningococcal Disease (Neisseria meningitidis Infection)

Identifying and treating meningococcal infection early is critical, as this powerful disease has caused severe outbreaks in the past and has the potential to do so again. Meningococcal infection must be reported to local health departments to help control its spread.

The best approach to prevent the disease is vaccination, especially for people at a higher risk. A specialty nurse who handles infectious diseases should talk to patients about the importance of getting vaccinated. In the United States, vaccines for various types of meningococcus bacteria (N meningitidis serogroups A, C, W, Y, and B) are encouraged for teenagers, young adults, and others at heightened risk of getting meningococcal disease. This vaccination program has played a key role in reducing infections globally.

Individuals who are more likely to catch the disease—such as college students, military recruits, and immunocompromised patients (those with weakened immune systems) like people living with HIV/AIDS, those with complement deficiency (a rare immune disorder), and those without a spleen—should consider getting the vaccine. Similarly, those who work with N meningitidis in labs, those traveling to areas where the disease is common (like the “meningitis belt”), and those who have been exposed to outbreaks of meningococcal disease, should also get vaccinated based on the prevalence of the disease in their local area.

In the United States, the recommended routine meningococcal vaccinations for healthy adolescents and young adults aged 11 to 23 include:

1. MenACWY vaccination, recommended for ages 11-21:
– The first dose is given around ages 11 or 12.
– For those who didn’t receive the vaccine at this age, a catch-up vaccination can be given between the ages of 13 and 18.
– Another dose is given at age 16 or later, but there should be at least an 8-week gap between doses.
– Despite the recommendation to give this vaccine to individuals aged 11 through 18, it may also be given to individuals aged 19 through 21 if they haven’t been vaccinated before.

2. MenB vaccination, recommended for ages 16-23:
– These doses are typically given between ages 16 and 18.
– There are two types of vaccines – MenB-4C and MenB-FHbp. For MenB-4C, two doses are given at least one month apart. For MenB-FHbp, two doses are given at least six months apart.
– Boosters (extra doses) for this vaccine are not usually recommended unless the patient becomes at risk.

Moreover, the MenACWY vaccine is also compulsory for all individuals visiting Mecca for Hajj/Umrah.