Because of its unpredictability and rapid course, meningococcal disease is dangerous. Every tenth patient with this disease dies. Early diagnosis, timely treatment can prevent the development of complications: epilepsy, hydrocephalus, deafness and dementia in an adult or a child.
What is meningococcal infection
Many are interested in what meningococcal infection is and who is more susceptible to this disease. Anthroponotic (peculiar to humans only) disease, which combines a whole group of infectious diseases with different clinical manifestations (nasopharyngitis, meningococcal sepsis), is called meningococcal. A rapid spread path is characteristic, leading to purulent leptomeningitis and septicemia. The cause of the disease is considered to be a bacterium - Neisseria meningitide.
The causative agent of meningococcal infection
Often the carrier of the infection is absolutely healthy man, while the disease is asymptomatic, even there is no characteristic rash. Such a carriage of meningococcus provides the owner with the formation of immunity to a pathogenic strain. At the same time, the causative agent of meningococcal infection is not able to provoke the occurrence of pathology in the carrier, but for the rest it poses a great threat.
The transmission of meningococci is carried out by aspiration. Spread by sneezing, talking, coughing. Infection is facilitated by close long-term contact between people indoors. The number of cases increases during the cold, damp season, reaching its peak in March. The disease can affect people of any age, but children often suffer from this disease. Often, transmission occurs during long-term contact with the source of infection.
Incubation period
According to the severity of the lesion and the form of the disease, the incubation period of meningococcal infection varies, and usually ranges from 1 day to a week (rarely 10 days). The main clinical forms are meningoencephalitis (purulent meningitis), acute meningococcal nasopharyngitis. Nuances:
- fever able to hold up to 3 days;
- changes in the mucous membrane - a week;
- follicular hyperplasia - 2 weeks.
Begins purulent stage disease suddenly, with chills. The temperature can reach up to 39-40 C, vomiting, headache, dizziness appear. In young children, a coma, convulsions join, a fontanel triad occurs. Meningococcal nasopharyngitis can be subclinical, that is, passing without symptoms. Often, the hypertoxic form precedes the development of the generalized stage of the disease.
Epidemiology
In many countries, people are susceptible to meningococcal disease, but the highest prevalence is in Africa. As a rule, the medical history is recorded in the form of epidemics and local outbreaks. The disease spreads faster where there is a large crowd of people, for example, in kindergartens, hostels. Contributes to the development of infection poor living conditions, population migration. Adolescents and young children are more affected.
The mechanism of transmission of meningococcal infection is aerosol (airborne). The source can be healthy and sick carriers - up to 20% of the total population. Among the sick in the inter-epidemic period, small children predominate. During an epidemic, older people are more susceptible to the disease. age group. The disease occurs in mild, severe and moderate forms.
The pathogenesis of meningococcal infection
The inflammatory process occurs in the mucous membrane of the pharynx. Only in some patients, meningococci overcome the barrier of the lymphoid ring and enter the bloodstream, while spreading throughout the body, causing bacteremia. In the pathogenesis of meningococcal infection, the main role is played by lipopolysaccharide of the outer membrane (endotoxin), which enters the bloodstream due to autolysis and reproduction of meningococci. The severity of the infection is proportional to the plasma endotoxin content.
Symptoms
The manifestations of such a disease are deceptive. It is often difficult for a specialist to make a correct diagnosis at the first signs of an illness. When a detailed picture of the patient appears, it is no longer possible to save. At the initial stage, as the pathology develops, the following symptoms can be observed:
- headache;
- jumps in body temperature;
- weakness;
- loss of consciousness;
- the pulse is quickened;
- drowsiness;
- rash with meningococcemia;
- chills, fever;
- pale skin;
- high blood pressure;
- muscle pain;
- sudden mood swings.
In children
Recognizing the signs of the onset of the disease in a child is very difficult. It is important not to confuse them with the harbingers of influenza and acute respiratory infections. The first symptoms of meningococcal infection in children:
- temperature increase;
- heart sounds are muffled;
- increased intracranial pressure;
- strong pain in the joints;
- pulse thready;
- lack of appetite;
- hemorrhagic rash on the body;
- brain cry (shrill);
- thirst;
- trembling of the limbs;
- repeated vomiting that is not associated with taking medication or food;
- the baby may have swelling of the crown.
Meningeal symptoms can develop at lightning speed, so you need to urgently call an ambulance. After the diagnosis, the doctor will be able to determine the stage of the disease. Allocate generalized (meningitis, meningococcemia, meningococcemia) and rare forms (endocarditis, pneumonia, iridocyclitis). There are mixed variants (meningococcemia). Frequent localized forms (acute nasopharyngitis). The manifestation of the disease depends on how much the child's immune system is weakened.
In adults
Often the symptoms of meningococcal pneumonia, nasopharyngitis, meningitis proceed in the same way as rhinitis or any other disease of a similar etiology. A specific meningococcal rash accompanies only sepsis or a severe form of meningococcemia. The spots do not have clear contours. Gradually, their bright color will disappear, necrosis is formed in the center. Symptoms in adults:
- the appearance of vascular purpura;
- headache;
- fever;
- severe hyperesthesia;
- vomit;
- neck stiffness;
- rashes (hemorrhages can be all over the body);
- characteristic posture;
- symptoms of Kernig, Lessage and Brudzinsky (middle, upper, lower).
Diagnosis of meningococcal infection
Due to the non-specific nature of the symptoms, the diagnosis of meningococcal infection is somewhat difficult. Even if the doctor could not determine the presence of the disease, it is recommended to additionally check the patient. Recognition of the disease means:
- determination of a bacterial pathogen from the cerebrospinal fluid, joint fluid and from the blood;
- sowing mucus from the nasopharynx (a swab is taken with a sterile swab);
- carrying out PCR analysis of liquor and blood;
- serological studies RNGA and WIEF;
- performing a lumbar puncture.
Analysis
Many patients are often interested in the question of which tests for meningococcal infection will help to accurately determine the presence of the disease. Options:
- One of the main research methods is bacteriological, and the material is nasopharyngeal mucus, blood, cerebrospinal fluid.
- With bacteriocarrier, the discharge is indicative respiratory tract.
- Serologically valuable diagnostic methods are ELISA, RNGA.
- A general analysis carries little information, although a high content of ESR and an increase in the number of new cells may be noted in the blood.
Treatment
Inpatient and outpatient treatment of meningococcal infection involves the use of antibiotics. In any clinic of a generalized and moderate form of the disease, antibacterial drugs are used. Only in the treatment of a mild form of nasopharyngeal infection should such drugs not be used. The cure here is simple: you need to gargle with an antiseptic, use plenty of warm drink and immuno-strengthening drugs that will remove the symptoms of intoxication. In the nose with nasopharyngitis drip special preparations from a runny nose.
The remaining severe and generalized forms are treated under the supervision of doctors in a hospital. Treatment of meningococcemia consists in the appointment of drugs that alleviate the patient's condition: diuretics, hormones. Emergency first aid involves the introduction of intravenous special solutions, antibiotics, plasma. Physiotherapeutic methods are also used: ultraviolet irradiation and oxygen therapy. With renal acute insufficiency using hemodialysis.
Complications
Often, the combined form of the disease - meningococcemia in children - causes a number of irreversible consequences, such as:
- DIC;
- cerebral edema;
- infectious-toxic shock;
- kidney failure;
- pulmonary edema;
- syndrome of cerebral hypotension;
- myocardial infarction;
In an adult, complications of meningococcal infection may include the following:
- arthritis;
- dyspnea;
- deafness;
- epilepsy;
- tachycardia;
- leukocytosis;
- osteomyelitis;
- fulminant liver failure;
- myocarditis;
- decline intellectual abilities;
- purulent meningoencephalitis;
- development of gangrene;
- cerebral hypotension;
- hormonal dysfunction.
Prevention
As a rule, the prevention of meningococcal infection consists in observing personal hygiene rules that prohibit the use of someone else's toothbrush, lipstick, smoking one cigarette (the main transmission occurs through them). Preventive options:
- There is a drug-specific prophylaxis, which involves vaccination with bacterial particles (it is carried out once, after which immunity is maintained for 5 years). Vaccinations are given for the first time to children older than a year, then revaccination can be carried out no earlier than after 3 years.
- Since the infection can be transmitted through the air, it is often necessary to carry out airing, washing the room, and routine cleaning with detergents.
- If there is special equipment, then it is possible to disinfect the room where the patient was constantly (working room, apartment).
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Epidemiology
The source of infection is patients (especially at the beginning of the disease) and bacteria carriers. Way of transmission of infection: airborne. The contagiousness index is low. The incidence is 5-5.5 per 100 thousand of the population. Children are predominantly affected early age.
Etiology and pathogenesis
Meningococcus (Neisseria meningitidis), gram-negative diplococcus: unstable, quickly dies in the external environment.
In the pathogenesis of the development of hemorrhagic rash, disturbances in the processes of hemostasis are important, which lead to the development of DIC. Meningococci can cross the blood-brain barrier through the hematogenous route and enter the meninges, causing inflammation.
Principles of classification
In form: localized - nasopharyngitis, generalized - meningitis, meningoencephalitis, meningococcemia. By severity: mild, moderate and severe.
Clinic
The incubation period is from 1 to 7 days. The duration of periods of peak, reverse development, convalescence depends on the severity and clinical form of the disease. Meningococcal nasopharyngitis is rarely diagnosed, if positive result inoculation of meningococcus from the mucosa of the nasopharynx in contacts. Meningococcemia or meningococcal sepsis is a life-threatening form of the disease for a child. The average incidence is 1 per 1000 children infected with meningococcus. The main symptoms of this form are rapidly increasing severe intoxication and a characteristic urticarial, maculopapular hemorrhagic stellate rash. In the first hours of the disease, elements of the rash appear on the skin of the feet, legs, buttocks, then spread to the limbs, face and trunk. The rash is purple, cyanotic, round or star-shaped, the elements may merge. Extensive hemorrhages, at the site of which necrosis occurs, followed by their rejection and the formation of defects and scars that remain long time. With meningococcemia, joints (polyatritis), eyes (uveitis, iridocycline, panophthalmitis), heart (endo, myo-, pericarditis), liver (hepatolienal syndrome), kidneys (pyelitis, glomerulonephritis), adrenal glands (acute adrenal insufficiency) can be affected.
Meningococcal meningitis (meningoencephalitis) is characterized by an acute onset, a pronounced syndrome of general intoxication, headaches, repeated vomiting, meningeal symptoms - neck stiffness, Kernig's symptom, Lesage's, Brudzinsky's symptoms, pulsation and bulging of the large fontanel. Focal symptoms indicate the development of encephalitis, cerebral edema. In the general clinical analysis of blood: leukocytosis, neutrophilia with a shift to the left, aneosinophilia, increased ESR.
Diagnostics
Consultation of infectious disease specialist, neurologist. Sowing from the nasopharynx for meningococcus. Bacterioscopy of blood and cerebrospinal fluid for meningococcus. Mucus, blood and cerebrospinal fluid cultures for meningococcus. Serological diagnostics - RPGA, VIEF in dynamics.
Differential Diagnosis
It is carried out with angina, acute pharyngitis, peritonsillar abscess, pseudotuberculosis, scarlet fever, tuberculous meningitis, adrenal insufficiency, etc.
Treatment and prevention
All patients with suspected meningococcal infection are subject to hospitalization in an infectious diseases hospital. Etiotropic therapy. Penicillin every 4-6 hours intravenously in high doses or erythromycin, with meningitis "ceftriaxone (rocefin) or cefotaxime, chloramphenicol intravenously for 1 week. Children of the 1st year of life with meningitis are given a short course of dexazone: 0.6 mg per day (for 4 injections) for 2 days against the background of antibiotic therapy. Emergency care for acute adrenal insufficiency: intravenous injection of a 10% glucose solution, hydrocortisone 20-50 mg. After the appearance of a pulse, they switch to a drip of liquid (the daily dose of prednisolone is adjusted to 2.5-7 mg / kg, hydrocortisone to 10-15 mg / kg). The total duration of steroid therapy is 3-5 days.
Recovery Criteria: complete disappearance clinical symptoms. Conducting a full course of antibiotic therapy. Double negative cultures from the mucous membrane of the nasopharynx for meningococcus. Follow-up after recovery by a pediatrician and a neuropathologist clinical indications at least 1 year. Anti-epidemic measures: isolation of the patient until complete clinical and bacteriological recovery. Quarantine on contacts is imposed for 10 days from the moment of separation from the patient. Contacts are monitored clinically with daily thermometry. All contacts with invasive forms of meninococcal infection (meningitis, meningococcemia) are prescribed chemoprophylaxis: 2 days of rifampicin or a single dose of ceftriaxone, ciprofloxacin. Sowing from the nasopharynx in contacts for meningococcus at least 2 times at intervals of 3-7 days, daily wet cleaning and ventilation of the premises.
Vaccination: meningococcal A, C, Y vaccines are administered to children at risk (asplenia, children under 2 years of age, primary immunodeficiency), during outbreaks of the disease.
RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols MH RK - 2014
Infectious diseases in children, Pediatrics
general information
Short description
RSE on REM "Republican Center for Health Development"
Ministry of Health and social development Republic of Kazakhstan
Meningococcal infection- acute infection human, caused by meningococcus and characterized by a variety of clinical manifestations: from nasopharyngitis and healthy carriage to generalized forms in the form of purulent meningitis, meningoencephalitis and meningococcemia with lesions various bodies and systems.
I. INTRODUCTION
Protocol name: Meningococcal infection in children
Protocol code:
Code (codes) according to ICD-10:
A39 - Meningococcal infection
A39.0 Meningococcal meningitis
A39.1 - Waterhouse-Friderichsen syndrome (meningococcal adrenal syndrome)
A39.2 - Acute meningococcemia
A39.3 Chronic meningococcemia
A39.4 Meningococcemia, unspecified
A39.5 - Meningococcal heart disease
A39.8 - Other meningococcal infections
A39.9 Meningococcal infection, unspecified
Abbreviations used in the protocol:
In / in - intravenously
V / m - intramuscularly
GP - general practitioner
VR - recalcification time
GHB - gamma-hydroxybutyric acid
DIC - disseminated intravascular coagulation
DDU - preschool institution
IMCI - integrated disease management childhood
ITSH - infectious-toxic shock
ELISA - enzyme immunoassay
CDC - consultative and diagnostic center
KOS - acid-base state
CT - computed tomography
KShchR - acid-base balance
INR - international normalized ratio
MRI - magnetic resonance imaging
ENT - laryngo-otoringologist
OPO - common signs danger
PT - prothrombin time
PHC - primary health care
PCR polymerase chain reaction
RNGA - reaction indirect hemagglutination
RPGA - reaction passive hemagglutination
FFP - fresh frozen plasma
ESR - erythrocyte sedimentation rate
FAP - feldsher-obstetric station
CSF - cerebrospinal fluid
cranial nerves
TBI - traumatic brain injury
N. meningitidis
Protocol development date: 2014.
Protocol Users: pediatric infectious disease doctor, general practitioner, pediatrician, emergency doctor medical care, anesthesiologist-resuscitator, paramedic.
Classification
Clinical classification of meningococcal infection
According to clinical forms:
1. Typical:
A) localized forms: carriage; nasopharyngitis;
b) generalized forms: meningococcemia, meningitis, meningoencephalitis; mixed form (meningitis + meningococcemia);
c) rare forms: endocarditis, arthritis, pneumonia, iridocyclitis.
2. Atypical:
A) subclinical form;
b) abortive form.
According to the severity of the process:
1. light;
2. moderate;
3. heavy.
According to the course of the disease:
1. acute;
2. lightning fast;
3. protracted;
4. chronic.
Classification of complications:
By the time of development of complications:
I. Early:
Infectious-toxic shock I, II, III degree;
swelling of the brain;
DIC;
Acute renal failure;
Cerebral hypotension;
subdural effusion;
Ependymatitis.
II. Later:
Impairment of the intellect;
Hypertension syndrome;
Hydrocephalus;
epileptic syndrome;
Paralysis and paresis;
Necrosis of the skin and subcutaneous tissue;
Endocrine disorders (diabetes insipidus, diencephalic obesity, hair loss, etc.);
Arthritis;
Hearing impairment.
Diagnostics
ΙΙ. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT
List of basic and additional diagnostic measures
Basic (mandatory) diagnostic examinations performed at the outpatient level in patients with meningococcal nasopharyngitis, meningococcal carriage and contact persons:
General blood analysis;
Additional diagnostic examinations performed at the outpatient level: not performed.
The minimum list of examinations that must be carried out when referring to planned hospitalization: (only for planned hospitalization with nasopharyngitis and meningococcal disease):
General blood analysis;
Bacteriological examination of a swab from the nasopharynx for N. meningitidis.
The main (mandatory) diagnostic examinations carried out on stationary level
(in case of emergency hospitalization):
General blood analysis;
General urine analysis;
Biochemical blood test (creatinine, urea, glucose, total protein and protein fractions, electrolytes: potassium, sodium, calcium, chlorine, ALT, AST, bilirubin);
Coagulogram (PV-PTI-INR, PV, APTT, RFMK, fibrinogen, TV, clotting time, bleeding time);
Spinal puncture: examination of cerebrospinal fluid for cytosis, determination of sugar, chlorides, protein;
Bacteriological examination of a swab from the nasopharynx for N. meningitidis
Bacteriological examination of cerebrospinal fluid;
Bacteriological examination of blood;
Blood on a "thick drop" for bacterioscopy;
Bacterioscopy of cerebrospinal fluid.
Additional diagnostic examinations carried out at the hospital level(in case of emergency hospitalization):
Determination of blood gases;
Bacteriological examination of exudate from petechiae;
X-ray of organs chest;
MRI of the brain (in the absence of positive dynamics during treatment);
CT scan of the brain (in the absence of positive dynamics during treatment);
Diagnostic measures carried out at the stage of emergency emergency care:
Collection of complaints and anamnesis of the disease (including epidemiological anamnesis);
Physical examination.
Diagnostic criteria
Complaints and anamnesis:
Complaints:
Temperature increase;
headache, anxiety; painful shrill cry in infants;
Repeated vomiting that does not bring relief;
Rash on the body
convulsions;
Photophobia;
Nasal congestion;
Sore throat;
Anamnesis:
Acute onset of the disease;
Epidemiological history: contact with a patient with fever, rash and catarrhal phenomena, contact with a carrier of N. meningitidis.
Physical examination:
Pallor skin;
Rash with predominant localization on the buttocks, thighs, legs, hemorrhagic "star" with necrosis in the center at the onset of the disease; the presence of a hemorrhagic rash on the face indicates the severity of the disease and is an unfavorable prognostic sign;
In children under one year old - tension and bulging of a large fontanelle, a positive symptom of Lessage or "suspension";
Excitation, followed by lethargy;
Hyperesthesia, "brain scream";
Throwing back the head, the pose of the "pointing dog";
Neck stiffness;
Positive symptoms of Brudzinsky, Kernig;
Decreased abdominal reflexes;
Tachycardia, deafness of heart sounds, systolic murmur, decrease in blood pressure;
With the development of cerebral edema: a rapidly passing lesion of craniocerebral insufficiency - usually III, VI, VII and VIII pairs; positive symptom of Babinski (normally occurs in children under 1 month of age);
Hyperemia, edema and hyperplasia of the lymphoid follicles of the posterior pharyngeal wall, swelling of the lateral ridges, a small amount of mucus.
Laboratory research:
General blood analysis: neutrophilic leukocytosis with a stab shift to the left, increased ESR; possible anemia, thrombocytopenia.
General urine analysis: albuminuria, cylindruria, microhematuria (in severe generalized forms as a result of toxic damage to the kidneys).
CSF study:
Color - on the first day of illness, the cerebrospinal fluid may still be transparent or slightly opalescent, but by the end of the day it becomes cloudy, milky white or yellowish green (the norm is transparent);
Pressure - flows out in a jet or frequent drops, the pressure reaches 300-500 mm of water. Art. (norm - 100-150 mm water column);
Neutrophilic cytosis up to several thousand in 1 µl or more;
Increase in protein up to 1-4.5 g/l;
Decreased sugar;
Decrease in chlorides;
With the development of meningoencephalitis - high protein content.
X-ray of the respiratory organs: signs of pneumonia, pulmonary edema (with the development of nonspecific complications);
CT / MRI of the brain: cerebral edema, the presence of brain abscesses and volumetric process.
Indications for consultation of narrow specialists:
Consultation of a neurologist (for meningitis and meningoencephalitis);
Consultation of an ophthalmologist (for meningitis and meningoencephalitis);
Consultation of a surgeon (with meningococcemia - in case of development of necrosis);
Consultation of a neurosurgeon - if pathological changes are detected on CT / MRI of the brain;
Consultation of an otolaryngologist - with nasopharyngitis, differential diagnosis of meningitis.
Differential Diagnosis
Differential Diagnosis
Table 1)***Differential diagnosis of bacterial meningitis by etiology
|
Symptoms |
meningococcal meningitis | Pneumococcal meningitis | Hib meningitis |
| Age | any, most often children under 2 years of age | any | 1-15 years old |
| Epidemiological history | from the center or without features | without features | |
| Premorbid background | nasopharyngitis or no features | pneumonia | pneumonia, ENT pathology, TBI |
| The onset of the disease | sharp, stormy | acute | acute or gradual |
| Complaints | severe headache, repeated vomiting, fever up to 39-400C, chills | headache, repeated vomiting, fever up to 39-400C, chills | headache, fever, chills |
| Presence of exanthema | in combination with meningococcemia - hemorrhagic rash | with septicemia, a hemorrhagic rash (petechiae) is possible | not typical |
| meningeal symptoms | pronounced with an increase in the first hours of the disease | become pronounced from 2-3 days | become pronounced from 2-4 days |
| Damage to lymphoid tissue | - | - | - |
| Organ lesions | pneumonia, endocarditis, arthritis, iridocyclitis. With complications - hemorrhage and necrosis of the adrenal glands, cerebral edema, etc. | pneumonia, endocarditis | pneumonia, otitis, sinusitis, arthritis, conjunctivitis, epiglotitis |
| General blood analysis | hyperleukocytosis, shift of the formula to the left, increased ESR | severe leukocytosis with a shift to the left, increased ESR | |
| Color, transparency of liquor | milky white, cloudy | green-gray, cloudy | white with a greenish tinge, cloudy |
| Pleocytosis (cell/µl) | incalculable, neutrophilic (up to 1000-15000) | neutrophilic up to 1000-2000 | |
| 0,66-16,0 | 3,0-16,0 | 1,0-16,0 | |
| Dissociation in CSF | mostly cellular protein | more often proteinaceous | not typical |
| Glucose content in cerebrospinal fluid | reduced moderately | ||
| reduced moderately | |||
Table 2)***Differential diagnosis of viral meningitis by etiology
|
Symptoms |
Enteroviral meningitis | Mumps meningitis | tuberculous |
| Age | preschool and school age | any | |
| Epidemiological background | summer autumn | winter spring | social factors or contact with a patient, history of pulmonary or extrapulmonary tuberculosis, HIV infection |
| The onset of the disease | acute | gradual, progressive | |
| Clinic | headache, sharp, short, repeated vomiting, fever up to 38.5-390C, two-wave fever with intervals between waves of 1-5 days | in the midst of illness, after inflammation salivary glands, but sometimes severe headache, vomiting, hyperthermia appear before the development of parotitis | moderate headache, fever up to 37-39C |
| Organ manifestations of the disease | enteritis, exanthema, herpangina, myalgia, hepatolienal syndrome | damage to the salivary glands (mumps, submaxilitis, sublinguitis), orchitis, pancreatitis | specific damage to various organs, tuberculosis of the lymph nodes with hematogenous dissemination |
| meningeal syndrome | from the 1st-2nd day of illness, mild, short-term, absent in 20% of cases | positive meningeal symptoms | moderately pronounced, in dynamics with an increase |
| General blood analysis | normal, sometimes slight leukocytosis or leukopenia, neutrophilia, moderate increase in ESR | slight changes in leukogram parameters, moderate increase in ESR | |
| Color, transparency of CSF | colorless, transparent | transparent, when standing for 72 hours, a delicate film of fibrin falls out | |
| Pleocytosis (cell/µl) | initially mixed, then lymphocytic up to 400-800 | lymphocytic up to 500 | mixed up to 50-500 |
| Protein content in liquor (g/l) | normal or reduced | normal or elevated to 1.0 | 1,0-10,0 |
| Glucose content in cerebrospinal fluid | moderately elevated | normal or moderately elevated | significantly reduced |
| Chloride content (mmol/l) | moderately elevated | moderately elevated | significantly reduced |
Table (3)***Differential diagnosis of meningococcemia
|
Symptoms |
Meningococcal infection, meningococcemia | Measles | Scarlet fever | Pseudotuberculosis | allergic rash |
| 1 | 2 | 3 | 4 | 5 | 6 |
| The onset of the disease | acute, often violent, with an increase in body temperature, a violation of the general condition | catarrhal phenomena and intoxication, aggravated within 2-4 days | acute, fever, sore throat, vomiting | acute, with a gradual increase in symptoms, fever, abdominal pain | acute, rash and pruritus |
| Temperature response | rapid rise to high numbers in the first hours of the disease | up to 38-390С, two-wave (during the catarrhal period and during the period of rashes) | high up to 38-39С0 within 2-3 days | high, prolonged fever, may be undulating | - |
| Intoxication | pronounced | expressed within 5-7 days | pronounced | pronounced, prolonged | not typical |
| upper respiratory catarrh | pronounced: barking cough, rhinitis, conjunctivitis | is absent | is absent | is absent | |
| Time of rash onset | 1st day of illness, first hours of illness | On the 3rd-4th day of illness | 1st-2nd day of illness | 3-8th day of illness | 1st day of illness |
| The order of the rashes | simultaneously | staging of rashes, starting from the face, within 3 days | simultaneously | simultaneously | simultaneously |
| Rash morphology | hemorrhagic, stellate irregular shape, necrosis in the center, single elements are possible | maculopapular, irregularly shaped, prone to fusion against an unchanged skin background | punctate, abundant on a hyperemic background of the skin | polymorphic (small-spotted, small-spotted) on an unchanged background of the skin | maculopapular, erythematous, urticarial |
| Rash size | from petechiae to extensive hemorrhages | medium size and large | shallow | shallow | large and medium size |
| Localization of the rash | buttocks, lower limbs, face, arms, torso | depending on the day of the rash (1st day - on the face, 2nd day - on the face and trunk, 3rd day - on the face, trunk and limbs) | throughout the body (except for the nasolabial triangle), mainly on the flexion surfaces, symmetrical thickening in natural folds | on the flexion surfaces of the extremities, around the joints, like "socks", "gloves", "hood" | all over the body |
| Regression of the rash | necrosis and scars in the place of extensive hemorrhages | passes into pigmentation in the same order in which it appeared | disappears without a trace after 3-5 days | disappears without a trace | disappears after a few hours or days, sometimes with pigmentation |
| Peeling | is absent | small bran-like | large-lamellar, at 2-3 weeks of illness | small pityriasis on the body and large-lamellar on the palms, feet on the 5th-6th day | is absent |
| Changes in the oropharynx | hyperemia, hyperplasia of the lymphoid follicles of the posterior pharyngeal wall | diffuse hyperemia of the mucosa, Belsky-Filatov-Koplik spots, enanthema on the soft palate | limited hyperemia of the pharynx, a phenomenon purulent tonsillitis, crimson tongue | crimson tongue | is absent |
| Changes in other organs and systems | may be associated with meningitis | conjunctivitis, laryngitis, pneumonia | missing | damage to the intestines, liver, spleen, joints | angioedema |
| General blood analysis | hyperleukocytosis, neutrophilia, increased ESR | leukopenia, neutropenia, with complications - increased ESR | leukocytosis, neutrophilia, accelerated ESR | high leukocytosis and neutrophilia, a significant increase in ESR | eosinophilia |
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Treatment
Treatment goals:
Relief of intoxication;
Relief of meningeal syndrome and sanitation of cerebrospinal fluid;
Eradication (elimination) of the pathogen.
Treatment tactics
Non-drug treatment:
Bed rest (generalized forms).
The diet is a complete, easily digestible food.
Chloramphenicol - 40 mg / kg per day (tablets of 0.25 and 0.5 g);
Erythromycin - from 20 to 50 mg / kg per day (tablets of 0.1 and 0.25 gr.);
Amoxicillin - 45 mg / kg per day (tablets of 0.25 g, syrup of 5.0-125 mg).
Treatment of meningococcal meningitis
Antibacterial therapy(treatment course 7-10 days):
Options for antibiotic therapy regimens
Scheme 1: benzylpenicillin sodium salt - 300-500 thousand units / kg per day, administered every 3 or 4 hours, intramuscularly, intravenously;
Scheme 2: benzylpenicillin sodium salt - 300-500 thousand units / kg per day, administered every 3 or 4 hours, intramuscularly, intravenously; and / or ceftriaxone - 100 mg / kg per day (1-2 times a day) / m or / in,
Scheme 3: benzylpenicillin sodium salt - 300-500 thousand units / kg per day, (administered every 3 or 4 hours, intramuscularly, intravenously) in combination with cefotaxime - up to 200 mg / kg per day every 6 hours .
When indicating severe allergic reactions to cephalosporins and penicillins, prescribe chloramphenicol 100 mg/kg per day (iv).
Treatment of meningitis in combination with meningococcemia(without ITSH)
Antibacterial therapy(treatment course 7-10 days):
Chloramphenicol - 100 mg / kg per day IV for 1-2 days, followed by the appointment of benzylpenicillin sodium salt - 300-500 thousand U / kg per day, administered every 3 or 4 hours, intramuscularly, intravenously; (in the absence of the development of TSS) or according to the above schemes.
Criteria for antibiotic withdrawal:
clinical recovery;
Normalization of the parameters of the general blood test and sanitation of the cerebrospinal fluid (lymphocytic cytosis in 1 μl of less than 100 cells or total cytosis of less than 40 cells).
Detoxification therapy in dehydration mode
Infusion in / in is carried out in a volume of 30-40 ml / kg per day.
For this purpose, mannitol (15% solution) with furosemide, crystalloids (physiological saline, 10% dextrose solution) and colloids (dextran, hydroxyethyl starch solutions, gelafusin, meglumine sodium succinate) are used.
Pathogenetic therapy for the relief of intracranial hypertension:
Magnesium sulfate - 0.1-0.2 ml / kg of 20% solution in / m;
Acetazolamide - 10-15 mg / kg per day in combination with potassium and magnesium aspartate (according to the scheme).
Anticonvulsant therapy:
Phenobarbital at the rate of 1-3 mg / kg per day;
Diazepam - 5 mg / ml, solution - 0.1 ml / kg or 0.1 mg / kg / day.
Sodium oxybate - 20% solution - 50-150 mg / kg (single dose),
In the absence of effect - sodium thiopental - 5-10 mg / kg every 3 hours, daily dose up to 80 mg / kg;
Treatment of meningococcemia(without ITSH):
Criteria for antibiotic withdrawal:
clinical recovery;
Normalization of indicators of the general analysis of blood.
TSS treatment
For the treatment of patients with TSS in a hospital, it is necessary:
Continuous oxygenation by supplying humidified oxygen through a mask or nasal catheter;
The introduction of a catheter into the bladder for a period until the patient is taken out of shock to determine the hourly diuresis in order to correct the ongoing therapy.
Sequence of administration of drugs for TSS
Assess the patient's condition - hemodynamics (signs of shock in children under 5 years of age according to IMCI), respiration, level of consciousness, nature and growth of the rash.
Restore airway patency, give oxygen, if necessary - tracheal intubation and transfer to mechanical ventilation;
venous access. Start with central/peripheral venous catheterization.
Intensive infusion therapy successively 3 jet injections of 20 ml / kg (ratio of crystalloids and colloids 1: 1), if necessary, then more, based on the hemodynamic response to the infusion. If the child is severely malnourished, the amount of fluids and rate of infusion should be different, so check to see if the child is severely malnourished.
Administer prednisolone at a dose of:
With TSS 1 degree - prednisolone 2-5 mg / kg / day, dexamethasone - 0.2-0.3 mg / kg / day, hydrocortisone - 12.5 mg / kg per day;
With TSS 2 degrees - prednisolone 10-15 mg / kg / day, dexamethasone - 0.5-1.0 mg / kg / day, hydrocortisone - 25 mg / kg per day;
With grade 3 TSS - prednisolone 20 mg / kg / day, dexamethasone - 1.0 mg / kg / day, hydrocortisone - 25-50 mg / kg per day;
Introduce an antibiotic - chloramphenicol at a dose of 25 mg / kg IV (single dose), per day - 100 mg / kg, every 6 hours;
Heparin therapy (every 6 hours):
ITSH 1 degree - 50-100 units / kg,
ITSH 2nd degree - 25-50 units / kg,
ITSH 3 degrees -10-15 units / kg
In the absence of the effect of hormonal therapy, start the introduction of first-order catecholamine - Dopamine with 5-10 mcg / kg / min under the control of blood pressure;
Correction metabolic acidosis: transfer to a ventilator;
In the absence of a hemodynamic response to dopamine (at a dose of 20 mcg / kg / min), start the introduction of Epinephrine / norepinephrine at a dose of 0.05-2 mcg / kg / min;
Re-introduction of hormones at the same dose - after 30 minutes with compensated THS, after 10 minutes with decompensated THS;
Protease inhibitors - aprotonin - from 500-1000 ATU / kg (single dose).
With stabilization of blood pressure - furosemide 1% - 1-3 mg / kg / day;
In the presence of concomitant cerebral edema - mannitol 15% - 1-1.5 g / kg;
Transfusion of FFP, erythrocyte mass.
Transfusion of FFP 10-20 ml / kg, erythrocyte mass, if indicated, in accordance with the order of the Minister of Health of the Republic of Kazakhstan dated 06.11.2009 No. 666.
Treatment of cerebral edema
Treatment of cerebral edema is reduced to the elimination of cerebral hypoxia, normalization of the metabolism of brain tissue and osmoregulatory systems of the brain.
General medical measures with cerebral edema:
1. Ensure adequate lung ventilation and gas exchange. This is achieved either by various methods of oxygen therapy, or by transferring the patient to mechanical ventilation with the addition of non-toxic oxygen concentrations (30-40%) to the respiratory mixture. It is advisable to maintain PaO2 at the level of 100-120 mm Hg. with moderate hypocapnia (PaCO2 - 25-30 mm Hg), i.e. carry out IVL in the mode of moderate hyperventilation.
2. Ensuring vascular access
3. Dehydration therapy:
10% sodium chloride solution - 10 ml/kg for 1 hour
25% magnesium sulfate solution - 0.2-0.8 ml / kg
Osmodiuretics - daily dose of mannitol solution (10, 15 and 20%):
For infants - 5-15 g
younger age- 15-30 g
Older age - 30-75 g.
The diuretic effect is very well expressed, but depends on the rate of infusion, so the estimated dose of the drug should be administered 10-20 minutes before. The daily dose (0.5-1.5 g dry matter/kg) should be divided into 2-3 injections.
You should pay attention!
Contraindications to the appointment of mannitol are:
Acute tubular necrosis
BCC deficit
Severe cardiac decompensation.
Saluretics - furosemide at doses of 1-3 (in severe cases up to 10) mg / kg several times a day to supplement the effect of mannitol (introduced 30-40 minutes after the end of the mannitol infusion)
Corticosteroids - dexamethasone is prescribed according to the following scheme: an initial dose of 2 mg / kg, after 2 hours -1 mg / kg, then every 6 hours during the day - 2 mg / kg; then 1 mg/kg/day for a week.
4. Barbiturates. 10% sodium thiopental solution intramuscularly at 10 mg/kg every 3 hours. Daily dose up to 80 mg/kg. You should pay attention! You can not use barbiturates with arterial hypotension and not replenished BCC.
5. Antihypoxants- sodium oxybate 20% solution at a dose of 50-70 mg/kg (single dose).
6. With severe peripheral vasoconstriction- dopamine at a dose of 5-10 mcg / kg / min
7. Infusion therapy It is aimed at normalizing indicators of central and peripheral hemodynamics, correcting indicators of water and electrolyte balance, acid-base status, prevention and relief of DIC.
8. Limiting water load up to 2/3 of the daily requirement
Table Physiological needs for fluids depending on the age of the child
|
Age |
Water requirement, ml/kg/day |
| 1 day | 60-80 |
| 2 days | 80-100 |
| 3 days | 100-120 |
| 4-7 days | 120-150 |
| 2-4 weeks | 130-160 |
| 3 months | 140-160 |
| 6 months | 130-155 |
| 9 months | 125-145 |
| 1 year | 120-135 |
| 2 years | 115-125 |
| 4 years | 100-110 |
| 6 years | 90-100 |
| 10 years | 70-85 |
| 14 years old | 50-60 |
| 18 years | 40-60 |
9. Calculation of the child's daily fluid requirement: physiological need + fluid deficiency + pathological fluid loss
10. Calculation of fluid deficit:
dehydration 1 tbsp.:
up to 1 year - 5% of body weight (50 ml / kg / day)
> 1 year - 3% of body weight (40 ml/kg/mut)
Dehydration stage 2:
up to 1 year - 10% of body weight (75 ml / kg / day)
>1 year - 6% of body weight (60 ml/kg/day)
Dehydration 3 tbsp.:
up to 1 year - 15% of body weight (100 ml / kg / day)
>1 year - 10% of body weight (80 ml/kg/day)
11. Calculation of fluid pathological losses:
Losses to fever - 10 ml / kg / day for every degree Celsius over 37;
Losses due to tachypnea - 10 ml / kg / day for every 10 respiratory movements over the age norm;
Losses with vomiting - 10 ml/kg/day;
Losses with diarrhea - 20-30 ml / kg / day.
Medical treatment provided on an outpatient basis
List of essential medicines:
chloramphenicol tab 250 mg, 500 mg
erythromycin enteric coated tablets 250mg
amoxicillin tablets tablets 250 mg
Ibuprofen - oral suspension in vials 100mg/5ml 100g
List of additional medicines:
Medical treatment provided at the inpatient level
List of main medicines:
chloramphenicol - tablets 250 mg, 500 mg;
erythromycin - enteric-coated tablets 250 mg;
amoxicillin - tablets 250 mg;
benzylpenicillin sodium salt - powder for solution for intravenous and intramuscular administration in a vial 1000000 units;
ceftriaxone - powder for solution for injection for intramuscular and intravenous administration in a 1g vial
cefotaxime - powder for solution for injection for intramuscular and intravenous administration in a 1g vial
Chloramphenicol Powder for solution for intravenous and intramuscular administration, in the form of chloramphenicol sodium succinate - 0.5 g, 1.0 g.
Prednisolone solution for injections in ampoules 30mg/ml 1ml
Dexamethasone solution for injections in ampoules 4mg/ml 1ml
Hydrocortisone-hydrocortisone microcrystalline suspension for injection in 5 ml vials
Ringer - solution for infusions 200 ml, 400 ppm
Reopoliglyukin - solution for infusions 200 ml
Gelofusin fat emulsion
Sterofundin fat emulsion
Meglumine sodium succinate solution for infusion 1.5% in bottles of 100, 200 and 400 ml or in polymer containers of 250 and 500 ml
Albumin - solution for infusions 20% 100 ml
Fresh frozen plasma for infusions
Erythrocyte mass - solution for intravenous administration
Sodium chloride solution for infusion in vials 0.9% 200ml
Glucose solution for infusion in vials 5%,10% 200ml
Calcium gluconate solution for injection in ampoules 10% 5ml, tablets 0.5g
Heparin solution for injections in vials 5000IU/ml 5ml
Adrenaline solution for injections in ampoules 0.18% 1 ml
Norepinephrine - solution for intravenous administration
Aprotinin - powder for solution for injection in vials 100000 AtrE
Mannitol solution for injections 15% 200ml
Acetaminophen capsules, effervescent powder for oral solution [for children], solution for infusion, oral solution [for children], syrup, rectal suppositories, rectal suppositories [for children], oral suspension, suspension
Ibuprofen oral suspension in vials 100mg/5ml 100g
Benzodiazepine powder for solution for intravenous and intramuscular administration in a vial 1000000 units
Phenobarbital-: 100 mg tablets.
Diazepam - solution for injections in ampoules 10mg/2ml 2ml
Magnesium sulfate - solution for injection in ampoules 25% 5ml
Furosemide - solution for injection in ampoules 1% 2ml
Dopamine solution for injection in ampoules 4% 5ml
Diacarb tablets 250mg
Asparkam tablets 250mg
Diazepam - solution for intravenous and intramuscular administration, solution for injection
Sodium oxybate injection in ampoules 20% 5ml
List of additional medicines:
Metamizole sodium solution for injection in ampoules 50% 2ml
Drotoverin - solution for injections in ampoules 40mg/2ml 2ml
Diphenhydromine - solution for injections in ampoules 1% 1ml
Papaverine hydrochloride - solution for injection in ampoules 2% 2ml
Dibazol - ampoule of 1, 2 and 5 ml of 0.5 or 1% solution
Droperidol injection 0.25%
Sodium thiopental - powder for solution for intravenous administration in vials 1g
Other types of treatment: not carried out.
Surgical intervention
The presence of deep necrosis in meningococcemia: necrectomy.
The presence of abscesses and empyema of the brain: craniotomy to remove the abscess
Preventive actions:
Isolation of patients;
Frequent ventilation of the room where the patient is located;
Wet cleaning indoors;
In kindergarten, incl. in orphanages, orphanages, schools, boarding schools where a case of meningococcal infection is registered, quarantine is established for 10 days from the moment of isolation of the last patient. During this period, the admission of new and temporarily absent children, as well as the transfer of children and staff from one group to another, is prohibited;
All persons who communicated with the patient should be subject to medical supervision with daily clinical examination and thermometry, a single bacteriological examination;
Bacteriological examinations of contacts in kindergartens, incl. closed type are carried out at least 2 times with an interval of 3-7 days;
Persons who have communicated with patients and have catarrhal phenomena in the nasopharynx are given prophylactic treatment with erythromycin at age-specific dosages for 5 days without isolation from the team.
Further management:
to schools, preschool institutions, sanatoriums, educational institutions, persons who have had a meningococcal infection are allowed after a single negative bacteriological examination conducted 5 days after discharge from the hospital or recovery of a patient with nasopharyngitis at home;
Clinical examination of patients who have had a generalized form of meningococcal infection (meningitis, meningoencephalitis) is carried out for 2 years: examination by a neurologist during the first year of observation 1 time per quarter, then 1 time in 6 months.
Drugs ( active substances) used in the treatment
| Human albumin (Albumin human) |
| Amoxicillin (Amoxicillin) |
| Aprotinin (Aprotinin) |
| Acetazolamide (Acetazolamide) |
| Acetazolamide (Acetazolamide) |
| Bendazol (Bendazol) |
| Benzylpenicillin (Benzylpenicillin) |
| Heparin sodium (Heparin sodium) |
| Hydrocortisone (Hydrocortisone) |
| Hydroxyethyl starch (Hydroxyethyl starch) |
| Dexamethasone (Dexamethasone) |
| Dextran (Dextran) |
| Dextrose (Dextrose) |
| Diazepam (Diazepam) |
| Diphenhydramine (Diphenhydramine) |
| Dopamine (Dopamine) |
| Droperidol (Droperidol) |
| Drotaverine (Drotaverinum) |
| Ibuprofen (Ibuprofen) |
| Potassium chloride (Potassium chloride) |
| Potassium, magnesium aspartate (Potassium, magnesium aspartate) |
| Calcium gluconate (Calcium gluconate) |
| Calcium chloride (Calcium chloride) |
| Magnesium sulfate (Magnesium sulfate) |
| Mannitol (Mannitol) |
| Meglumine (Meglumine) |
| Metamizole sodium (Metamizole) |
| Sodium hydroxybutyrate (Sodium hydroxybutyrate) |
| Sodium chloride (Sodium chloride) |
| Norepinephrine (Norepinephrine) |
| Papaverine (Papaverine) |
| Paracetamol (Paracetamol) |
| Plasma, fresh frozen |
| Prednisolone (Prednisolone) |
| Sterofundin isotonic (Sterofundin Isotonic) |
| Succinylated gelatin (Succinylated gelatin) |
| Thiopental-sodium (Thiopental sodium) |
| Phenobarbital (Phenobarbital) |
| Furosemide (Furosemide) |
| Chloramphenicol (Chloramphenicol) |
| Cefotaxime (Cefotaxime) |
| Ceftriaxone (Ceftriaxone) |
| Epinephrine (Epinephrine) |
| Erythromycin (Erythromycin) |
| erythrocyte mass |
Hospitalization
Indications for hospitalization
Indications for emergency hospitalization:
Presence of HPF (for children under 5 years of age according to IMCI);
Generalized forms of meningococcal infection.
Patients with nasopharyngitis with severe symptoms of intoxication;
Indications for planned hospitalization:
Carriers of N. meningitidis according to epidemiological indications (children from boarding schools, orphanages, orphanages and families with unfavorable social and living conditions).
Information
Sources and literature
- Minutes of the meetings of the Expert Council of the RCHD MHSD RK, 2014
- 1) "Bacterial meningitis and meningococcal septicemia: Management of bacterial meningitis and meningococcal septicemia in children and youth under 16 years of age in primary and secondary care". KR 2010 2) Provision of inpatient care for children. WHO guidelines for the management of the most common diseases in primary hospitals adapted to the conditions of the Republic of Kazakhstan. pp. 1-36, 133-170 3) Zinchenko A.P. Acute neuroinfections in children. Guide for doctors. - L: "Medicine", 1986. 320s. 4) Uchaikin V.F. "Guidelines for infectious diseases in children" - M: GEOTAR-MED, 2002 509–527 p. 5) Order of the First Deputy Chairman of the Agency of the Republic of Kazakhstan for Health Affairs dated 12.06.2001 No. No. 566 “On measures to improve epidemiological surveillance, prevention and diagnosis of meningococcal infection 6) Izvekova, I. Ya. Meningococcal infection: a textbook / I. Ya. Izvekova, V. P. Arbekova. - Novosibirsk: Sibmedizdat NGMA, 2005. - 168 p.: ill. (Code 616.831.9-002 I-33) 7) Meningococcal infection in children / N. V. Skripchenko [et al.] // Epidemiology and infectious diseases. - 2005. - N 5. - C. 20-27. 8) Pediatric anesthesiology and resuscitation. Mikhelson V.A., Grebennikov V.A. 480 pages. Year of publication: 2001. 9) National Collaborating Center for Women's and Children's Health. Bacterial meningitis and meningococcal septicaemia. Management of bacterial meningitis and meningococcal septicaemia in children and young people younger than 16 years in primary and secondary care. London (UK): National Institute for Health and Clinical Excellence (NICE); Jun. 2010 10) Chaudhuri A, Martinez-Martin P, Kennedy PG, Andrew Seaton R, Portegies P, Bojar M, Steiner I, EFNS Task Force. EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. Eur J Neurol. 2008 Jul.
Information
III. ORGANIZATIONAL ASPECTS OF PROTOCOL IMPLEMENTATION
List of protocol developers with qualification data:
1) Kuttykozhanova G.G. - Doctor of Medical Sciences, Professor, Head of the Department of Children's Infectious Diseases of KAZ NMU named after S.D. Asfendiyarov.
2) Efendiev I.M. ogly - Candidate of Medical Sciences, Associate Professor, Head of the Department of Children's Infectious Diseases and Phthisiology, Semey State Medical University.
3) Baesheva D. A. - Doctor of Medical Sciences, Head of the Department of Children's Infectious Diseases of JSC "Astana Medical University".
4) Bakybaev D.E. - doctor - clinical pharmacologist of JSC "National Center for Neurosurgery".
Indication of no conflict of interest: none.
Reviewer:
Kosherova Bakhyt Nurgalievna - doctor medical sciences, Professor of RSE on REM "Karaganda State Medical University" Vice-Rector for Clinical Work and Continuous Professional Development, Professor of the Department of Infectious Diseases, Chief Freelance Infectionist of the Ministry of Health and Social Development of the Republic of Kazakhstan
Acceptance of proposals(with completed justification form) goes until March 29, 2019: [email protected] , [email protected] , [email protected]
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Meningococcal infection is a contagious disease that is transmitted by airborne droplets, affects the central nervous system, joints, heart muscle and often causes toxic shock. The causative agent of the disease, Neisseria meningitides, is a close relative of the gonococcus, but unlike it, it uses the epithelium of the upper respiratory tract as an entrance gate. Infectiousness in meningococcus is low, so outbreaks of the disease occur in conditions of crowding and close contact: in kindergartens, schools, barracks, boarding schools.
The incidence of meningococcal infection is undulating. The indicator periodically creeps up for several years, after which a steady decline is observed for 8-10 years. In the Russian Federation, the incidence on average remains at the level of 5 cases per 100 thousand of the population, in European countries - up to 3 per 100 thousand, in the countries of Central Africa - 20-25, reaching in unfavorable years up to 800 cases per 100 thousand of the population. African countries form the "meningitis belt" of the planet due to the high prevalence of the disease.
Children and young people under 30 suffer from meningococcal infection, but the disease is most severe in infants under one year old and in people over 60 years old. Sometimes events develop so quickly that a lightning-fast form of the disease is isolated separately. The consequences of meningococcal infection depend on the severity of its course and the prevalence of the pathogen, it can lead to severe disability and death.
Pathogen
Meningococcus is a round, gram-negative bacterium, immobile, does not form spores. In human cells, it is located in pairs, forming structures similar in appearance to coffee beans. This organization of bacteria is called a diplococcus. Young meningococci have thin and delicate filaments on the surface of the cell wall, with which they attach to epithelial cells.
Bacteria secrete a large amount of aggressive substances that contribute to their penetration into the blood and various tissues of the body. For example, hyaluronidase breaks down the main component of connective tissue - hyaluronic acid, due to which collagen bundles are loosened and a passage for meningococcus is formed. The bacterial cell wall is the strongest toxin for the human body. It negatively affects the central nervous system, kidneys, heart muscle and causes a powerful activation of the immune system.
The causative agent is unstable in the external environment. It quickly dies when heated, under the influence of ultraviolet radiation, when treated with disinfectants. The most favorable conditions for its life are high humidity (70-80%) and air temperature in the range of 5-15 degrees C, in which it retains its activity for up to 5 days. For this reason, the incidence increases significantly in the cool season - from February to April, subject to warm and snowy winters.
The source of infection is a sick person or a carrier. The carriage of meningococcus does not manifest itself subjectively, so the person does not know that he is dangerous to others. The causative agent is localized in the nasopharynx, is released outward with droplets of saliva when talking, coughing, sneezing. It has been noted that with the accumulation of carriers of about 20% in the population, mass outbreaks of meningococcal infection occur. Patients with meningitis or a common form of the infection are more contagious, but they tend to be isolated from society and pose a danger only to their caregivers.
The mechanism of the development of the disease
Meningococcus enters the mucous membrane of the nasopharynx of a susceptible person and is firmly fixed on it. Further interaction between the macroorganism and the microorganism depends on the activity of the immune system and the aggressiveness of the toxins of the pathogen. If local immunity is well expressed, then the carriage of meningococcal infection develops: bacteria multiply moderately in the nasopharynx and are excreted in small quantities into external environment. After some time, they leave the body.
If the virulence of meningococcus is sufficient to penetrate deep into the mucous membrane, meningococcal develops. Bacteria destroy the cells of the body, release aggressive substances into the tissues, which entails a reaction of the vessels and the immune system. The blood rushes intensely to the site of inflammation, its liquid part goes into the mucous membrane - hyperemia and edema are formed. They are designed to limit the pathological focus and prevent further spread of the pathogen.
Sensitive nerve endings in the area of inflammation react to biologically active substances that secrete destroyed cells and send a pain impulse to the brain, like a distress signal. It is further enhanced by bacterial toxins and the pressure of edematous tissues on the receptor. As a result, a person feels pain and sore throat.
If the inflammatory reaction has not stopped meningococcus in the nasopharynx, it penetrates into the blood and lymphatic vessels. In the blood of the pathogen, immune cells and protective proteins are attacked, which is why most of the microorganisms die with the release of a dangerous toxin. In situations where the forces are approximately equal, the disease ends at this stage, manifesting itself with a rash and intoxication.
diseases caused by meningococcus
If the immune cells waste their potential before they destroy all the bacteria, then incomplete phagocytosis occurs. The leukocyte captures meningococcus, but cannot digest it, so the pathogen remains viable and travels through the body in this form. Further development of events depends on where the bacteria penetrate. Penetrating through the meninges, they cause purulent arthritis through the joint capsule, and iridocyclitis into the iris of the eyeball.
Meningococci settle in the peripheral blood vessels and damage their vascular wall, which causes blood to rush into the tissues. So, a hemorrhagic rash is formed on the skin, which is a local hemorrhage.
A large amount of meningococcal toxin in the blood leads to paralytic vasodilation in the periphery and a sharp drop blood pressure. There is a redistribution of blood flow: blood is deposited in small vessels and does not flow in sufficient quantities to vital organs - the brain, heart, liver. Infectious-toxic shock develops - a deadly condition.
Disease classification
The interaction of meningococcus with the human body proceeds according to various scenarios, each of which requires special approach and treatment. In this regard, in 1976, Academician Pokrovsky developed a classification of meningococcal infection, which doctors use to this day. According to her, they distinguish:
Localized forms:
- The carriage of meningococcus is asymptomatic;
- Acute nasopharyngitis - manifested by symptoms of acute respiratory infections;
- Pneumonia - the clinic does not differ from other bacterial ones.
Generalized forms:
Clinical manifestations
From the moment of infection to the onset of symptoms of meningococcal infection, it takes from 1 to 10 days, on average, the incubation period lasts 2-4 days.
Nasopharyngitis
The disease begins acutely with scanty mucous secretions,. The temperature rises only in half of the patients, does not exceed 38.5 degrees C. It is accompanied by signs of intoxication: aching muscles and joints, headache, lack of appetite, lethargy. The fever lasts no more than 4 days, after which the patient quickly recovers.
When examining the pharynx, hyperemia of the posterior pharyngeal wall is visible, from 2-3 days of illness it becomes granular due to the reaction of small lymphoid follicles. The tonsils, their arches, and the uvula remain unchanged, although in children under 3 years of age, inflammation also extends to them.
Meningococcemia
The presence of meningococcus in the blood causes a rapid and powerful immune response, which immediately affects the patient's condition. The disease begins acutely with a sharp rise in temperature to 39 degrees C and above. There are signs of severe intoxication: chills, pain in the lower back, muscles, joints, headache, severe weakness. The patient may vomit without abdominal pain, and there is no appetite.
hemorrhagic rash with meningococcemia
6-24 hours after the temperature rise, the most feature meningococcemia - hemorrhagic rash. Initially, it may look like pink spots, pinpoint hemorrhages, which quickly transform into large, irregularly shaped bruises. The elements of the rash have a different shape and size, bulge somewhat above the surface of the skin, and are sensitive when touched. Most often they are located on the thighs, buttocks, shins and feet and have a star-shaped outline.
The rash falls asleep for 1-2 days, after which the reverse development of its elements begins. Small ones are pigmented and completely disappear after a while, large ones can leave behind retracted scars. The early appearance of a rash (up to 6 hours after a rise in temperature) and the location of its elements on the face, upper half of the body are signs of an extremely severe course of meningococcemia. Sometimes it ends with necrosis of the tip of the nose, fingers and toes.
The presence of meningococcus in the blood is fraught with the development of a formidable complication - infectious-toxic shock.. It usually begins in the first hours from the onset of the disease and, without emergency assistance, inevitably leads to the death of the patient. The first signs of an incipient shock are a marbled pallor of the skin, a drop in body temperature and blood pressure.. The patient gradually loses consciousness and plunges into a coma, death occurs from insufficient blood supply to the brain, heart and liver.
Another dangerous complication of meningococcemia is Friederichsen-Waterhouse syndrome. It develops when the adrenal cortex dies under the influence of a massive hemorrhage into it. The patient stops producing adrenal hormones, which are responsible for water-salt exchange and maintaining blood pressure. As a result, he dies from dehydration or heart failure.
Meningitis
Meningococcal meningitis begins with a rise in temperature to 38.5-39.5 degrees C and headache, which increases significantly by the end of the first day of illness.
meningitis symptoms
The pain in the head is bursting in nature, most often localized in the fronto-temporal or occipital regions, but can cover the entire skull as a whole. Pain is aggravated by bright light, loud sounds, when changing the position of the body. Often it is accompanied by vomiting with a fountain, which does not bring relief and occurs without previous nausea.
first sign of meningitis in a baby
By the end of the first day, symptoms of irritation of the meningeal membrane (meningeal signs) appear. These include soreness of the posterior neck muscles, the inability to fully straighten the leg in knee joint with flexed hip. In infants, the first signs of meningitis are considered to be a complete refusal to eat, a constant monotonous cry, and a bulging fontanel on the head. If you take a sick baby by the armpits, he bends his legs to the body - this is a symptom of suspension.
On the 3rd-4th day of the disease, in the absence of antibacterial treatment, the patient takes the characteristic position of the "pointing dog". He lies on his side, bending his legs and throwing his head back, while his back is strongly arched and tense. In children, this posture is more common and more pronounced than in adults. By the same time, consciousness becomes cloudy, the patient is inhibited, does not respond to questions or answers in monosyllables. In some cases, hearing is turned off, paralysis develops eyeballs, limbs, swallowing muscles. Often, meningococcal meningitis is combined with meningococcemia, which is manifested by a hemorrhagic rash on the skin.
Video: meningococcal meningitis
Diagnostics
Diagnosis of meningococcal infection is carried out by doctors of various specialties, which depends on the form of the disease and its manifestation. With acute nasopharyngitis, patients usually turn to a local therapist, an ENT doctor, with a rash - to an infectious disease specialist, a dermatovenereologist, with headaches, paralysis - to a neurologist. Cases of severe meningococcal disease are diagnosed in emergency departments. However, like any infectious disease, it belongs primarily to the competence of the infectious disease specialist.
The doctor examines the patient, collects an anamnesis, studies complaints. Epidemiological data play an important role: if over the past 10 days a patient has had prolonged contact with a person with nasopharyngitis or a case of meningococcal infection has been detected in his team, then meningococcal infection has occurred with a high degree of probability. An acute onset of the disease, a rise in temperature, the presence of a hemorrhagic rash on the skin, meningeal signs, and impaired consciousness also speak in favor of the diagnosis.
All patients with signs of meningitis undergo a lumbar puncture. to get cerebrospinal fluid (CSF) for analysis. With meningococcal infection, cerebrospinal fluid flows out under pressure that is higher than normal, has a yellow or yellow-green color. It is cloudy due to the high content of protein and cellular elements.
The following methods are used to confirm the diagnosis:
If necessary, instrumental methods of research are connected. An ECG is performed if there is a suspicion of toxic damage to the heart, CT or MRI of the brain if there are signs of focal damage to the central nervous system (paralysis, hearing loss).
Treatment
Patients with meningococcal infection are hospitalized in an infectious diseases hospital or in intensive care (with infectious-toxic shock). The term of hospitalization is up to 30 days in case of a severe form of the disease. At the time of treatment, the patient is shown a diet with a predominance of easily digestible protein, some restriction of fluid and sodium chloride. Elements skin rash treated with local antiseptics - fucorcin, brilliant green, potassium permanganate solution.
Medical treatment includes:
Recovery criteria include:
- Normal body temperature for more than 5 days;
- Absence of inflammatory changes in the nasopharynx;
- The disappearance of the rash;
- Absence of headache and meningeal signs;
- Normalization of blood counts;
- Negative bakposev and PCR-study of cerebrospinal fluid.
Follow-up after recovery
After discharge from the hospital, the patient must be observed by a local general practitioner for a year. During this period, a sick person needs to take a general blood test 4 times (1 time in 3 months), if necessary, he is shown an ECG, CT and MRI of the brain. Repeat 5 days after discharge bacteriological examination for which a swab is taken from the nasopharynx. With a negative result, a person is allowed to join the team and work.
Any vaccines are contraindicated for an ill person within 3 months after recovery. For one year, he should not sunbathe in the sun, change the climate zone drastically, overheat in a bath or sauna.
Prevention of meningococcal infection
If a patient with meningococcal infection is detected in the team, quarantine is imposed for 10 days, during which all its participants are examined for the carriage of meningococcus, thermometry and throat examination are performed daily. Besides, All contacts should be given prophylactic antibiotics: rifampicin 600 mg 2 times a day for 2 days, ciprofloxacin 500 mg intramuscularly once.
Specific prophylaxis is the introduction of a special anti-meningococcal vaccine. Since 2013, it has been included in the national vaccination calendar of the Russian Federation. It is administered intramuscularly to healthy children older than 2 months twice with an interval of 2 months. Emergency vaccination is carried out in the first 5 days after contact with a patient with meningococcal infection. The planned introduction is shown to first-year students living in a hostel, conscript soldiers.
Vaccination against meningococcal infection is carried out by vaccines:
- Dry vaccine meningococcal polysaccharide A ("Menugate");
- Vaccine meningococcal polysaccharide A + C;
- Tetravalent meningococcal vaccine (against serotypes A, C, Y, W-135) - "Mentsevax".
In addition, a combined intramuscular vaccine against Hemococcus and Pneumococcus is produced. Persistent immunity is formed during the 1st month after vaccination.
Meningococcal disease is an acute infectious disease caused by meningococcus (Neisseria meningitidis). It is transmitted by airborne droplets and is characterized by the presence of several clinical forms: meningococcal nasopharyngitis, carriage, meningitis and a generalized form with severe, often fatal changes in the human body.
Etiology
The causative agent of the disease, as mentioned above, is Neisseria meningitides, which appears to be a Gram-negative diplococcus. There are 13 serotypes of meningococci in nature. The disease is caused mainly by representatives of serotypes B and C.
Epidemiology
Meningococcus is extremely unstable in the environment. It grows at a temperature of 37C, and already at 35C it cannot reproduce and dies. At the same time, it can be alive in the mucus from the nasopharynx for up to 2 hours. The microbe dies within 5 minutes at an ambient temperature of +50C. With negative temperatures, his death occurs after 2 hours.
The source of infection are bacteria carriers and people sick with this infection. Immunity after illness remains strictly type-specific.
Pathogenesis
When meningococcus enters the mucous membrane of the respiratory tract, an inflammatory process develops, which usually occurs as a result of a reduced activity of local immune defense factors. This is how meningococcal nasopharyngitis occurs.
After damage to the mucous membrane, the bacterium enters the blood, in connection with which the manifestation of a generalized form of infection begins - bacteremia. Purulent meningitis and meningoencephalitis appear when an infectious agent breaks through the blood-brain barrier (BBB). In other organs, meningococcus penetrates less frequently.
Classification of meningococcal infection
There are localized forms:
- Carriage of meningococcus;
- Meningococcal nasopharyngitis.
In addition to localized forms, there are also generalized manifestations of infection in the form of:
- meningococcemia;
- meningitis;
- meningoencephalitis.
There are also rare forms:
- arthritis;
- endocarditis;
- iridocyclitis.
Symptoms of a meningococcal infection
The period of latent manifestations usually lasts from 1-2 days to 10 days. Most often this period lasts 3-5 days.
Clinic of localized forms: meningococcal nasopharyngitis
At the onset of the disease, body temperature rises sharply to febrile values. There is difficulty in breathing through the nose, there is practically no discharge from the nose. The pharynx is hyperemic and granular, the arches are edematous and injected. The patient feels a sore throat due to dryness.
Symptoms of intoxication are rapidly growing, manifested by headache, loss of appetite, lethargy, and malaise. Improvement occurs after 3-4 days, but 2-3 weeks the child feels weakness and drowsiness. In the general analysis of blood with localized forms, a shift of the leukocyte formula to the left is observed, ESR is accelerated.
Clinic of generalized forms: meningococcemia
Any generalized form of a disease such as can begin with a localized form, that is, nasopharyngitis. With the generalization of the process, intoxication increases, fever increases, and a hemorrhagic rash appears.
Body temperature at the beginning of the disease rises sharply and suddenly. Parents can name the exact time of the onset of the disease in the child. This pathological process is characterized by symptoms of intoxication: headache, nausea, vomiting, which does not bring relief. With meningococcemia, a rash appears.
At first, the rash has a roseolous character, then its elements change and hemorrhagic rashes appear. These elements are dense, do not disappear when pressed, their diameter is different. Spots of hemorrhages tend to merge and form huge areas of purple-bluish foci. Most often, the rash first appears on the legs, buttocks.
After stopping the process, roseolous elements disappear without a trace, and hemorrhagic ones go through the stage of pigmentation. If the rashes are large in area, necrosis is formed in their central part, trophic ulcers and subsequently cicatricial changes in the skin. If the case is severe, there is a risk of developing dry gangrene. When a rash appears on the face and eyelids on early stages the prognosis of the disease is unfavorable.
The severity of the infection
According to the severity of the course, meningococcemia is divided into;
Clinic of generalized forms: meningococcal meningitis
The onset of the disease is acute with fever and unbearable headache. The child is restless. In the presence of sound stimuli, when the head is turned, amplification occurs given symptom. In this regard, vomiting develops, which can be repeated several times. During the examination of the patient, sharply positive meningeal symptoms of Kernig, Brudzinsky, Lesage, bulging of a large fontanel are determined, if it is a child under one year old. The baby's skin becomes pale.
This condition confirms the presence of meningeal syndrome, the appearance of focal symptoms in the form of nystagmus, the presence of cerebral symptoms.
In the cerebrospinal fluid, changes typical of meningitis are found: the fluid is cloudy, neutrophilic pleocytosis, increased protein content, fluid flows out of the needle under pressure.
Clinic of generalized forms: meningococcal meningoencephalitis
Most often, young children are sick. The onset of this form of the disease is acute and rapid. As with other forms of meningococcal infection, the temperature rises to febrile values (38.5-40C). With meningoencephalitis, convulsions, motor excitation may appear. Patients lose consciousness, hemiparesis occurs, lesions of the cranial nerves. Meningeal syndromes are mild. This form has a high mortality rate.
Clinic of generalized forms: combined form
With this form, the body temperature rises, chills, nausea and vomiting appear.
Develops meningeal syndrome and clinic of meningococcemia.
Meningococcal infection in children first year of life
In such babies, the infection most often develops in the form of meningococcemia. As well as combined forms. With meningitis, the syndrome of intoxication is pronounced. There may also be a semblance of a meningeal syndrome in the form of manifestations of anxiety, a monotonous cry (the so-called brain cry), bulging and pulsation of the large fontanel, a positive symptom of Lesage.
Meningeal syndrome in full form appears with a delay of 1-2 days. In infants, the ependyma of the ventricles of the brain, the actual substance of the brain, is often affected, hydrocephalus develops.
Complications of meningococcal infection
The most common complication is cerebral edema. At the same time, the child's consciousness is disturbed, convulsions occur and focal symptoms develop, which are unstable, that is, they can disappear and reappear.
Edema contributes to squeezing the brain stem, which leads to coma and increased seizures.
Diagnostics
To detect infection, the main materials for research are nasopharyngeal mucus, cerebrospinal fluid and blood.
Bacterioscopic examination revealed gram-negative diplococci. However, they are visible to the eye only in half of the cases, so the culture method is widely used.
Meningococcal infection in children and her treatment
Generalized forms of the disease and persons with suspected meningococcal infection should be treated only in an infectious diseases hospital.
Help at the prehospital stage
There are clear algorithms for providing first aid to patients with suspected infection and with its obvious presence:
- The introduction of chloramphenicol succinate 25-30 mg/kg intramuscularly;
- Prednisolone 2-3 mg/kg intramuscularly. If an infectious-toxic shock has developed, it will not be superfluous to introduce the entire supply of hormones that is in the medical bag (10-30 mg / kg);
- Infusion therapy to maintain circulating blood volume (CBV);
- Lytic mixture for suspected meningitis;
- Diuretics - furosemide 1-2 mg/kg;
- Anticonvulsants (diazepam, Relium).
Etiotropic treatment
Meningococcus is still very sensitive to penicillin antibiotics, chloramphenicol, cephalosporins. When these drugs are ineffective, a reserve group of antimicrobials led by meropenem is used. Antibiotic therapy lasts from 7 to 10 days.
In parallel with etiotropic treatment, pathogenetic treatment is also used: dehydration, infusion therapy, anticonvulsant, inotropic, plasmapheresis, hemosorption.
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