Prognostic Factors in meningococcal disease

Antimicrobial therapy and case fatality in meningococcal disease

The effect of different initial antimicrobial treatments on the case fatality rate (CFR) was evaluated in 112 consecutive patients with meningococcal disease. The overall CFR was 9.8%. 85 patients received initial therapy with chloramphenicol in addition to benzylpenicillin or other antimicrobials, and 27 patients benzylpenicillin or other antimicrobials without chloramphenicol. Patients treated with chloramphenicol had a lower CFR than those not given chloramphenicol (5% vs. 26%; p = 0.004). However, severely ill patients were treated more often with penicillins, and adjustment for the severity of disease on admission to hospital demonstrated that this difference in favour of chloramphenicol was slight and nonsignificant (p = 0.58). High doses of benzylpenicillin and no chloramphenicol were also associated with a higher CFR than low doses. However, the difference was not significant (p = 0.22). More extensive studies should be carried out to evaluate the effect of benzylpenicillin doses and chloramphenicol on the outcome of meningococcal disease.

Multivariate prognostication in bacterial meningitis of childhood

A multivariate method for prognosticating the outcome of bacterial meningitis was computerized on the basis of initial clinical and laboratory data in 123 patients. The model, based on likelihood ratios, is simple and rapid. At the time of diagnosis, it predicted the outcome correctly in 104/123 cases (85%) in the basic group and in 67/98 independent controls (68%). The sensitivity of the method in predicting death or mild to severe neurological sequelae was 83% in both groups. The predictive value of a calculated good prognosis was 94% in the basic group and 97% in the control group, and that of a calculated poor prognosis was 63% and 26%, respectively. The predictive system can be used for rapid assessment of prognosis in individual patients and for comparisons between groups.

Endotoxin release from invasive meningococci related to sulfonamide resistance, serogroup and serotype

The relationship between endotoxin liberation, sulfonamide resistance, serogroups and serotypes was studied in 28 Neisseria meningitidis strains isolated from patients with meningococcal disease. Sulfonamide resistance was present in 15/28 strains. 22 strains belonged to serogroup B, and 5 to group C; 1 strain was non-groupable. Free endotoxin activity in growing cultures of meningococci with endotoxin titre of greater than or equal to 10(2) was found in 27/28 strains. A high endotoxin activity was present in both sulfonamide-sensitive and -resistant invasive meningococci. A high endotoxin release with titre greater than or equal to 10(3) seemed to be more associated with serogroup C than B, and more to the serotypes 2 and 15/16 than to the non-typable strains.

Benign meningococcemia with IgG and IgM antimeningococcal antibodies measured by ELISA

Six patients with benign meningococcemia are presented. The clinical picture was typically intermittent fever with chills, skin eruptions, maculopapules (often hemorrhagic) and arthritis/arthralgia in a person in good general condition. Meningococci of serogroup B were isolated from the blood of 3 patients, from the cerebrospinal fluid of 1 patient and from the nasopharynx of the remaining 2 patients. In 4 patients we assayed the levels of IgG and IgM antibodies against meningococcus serogroup B in an enzyme-linked immunosorbent test (ELISA), using whole bacteria as the antigen. All of them had higher antibody levels than the geometric means for healthy controls of both IgG and IgM, except for 1 patient who did not develop IgG antibodies.

Case fatality of meningococcal disease in western Norway

In the period 1976-84, 211 patients hospitalized with meningococcal disease were examined for possible relation between various epidemiological parameters and fatality. The peak incidences were in the age groups 0-4 and 13-18 years, with teenage girls peaking 2 years ahead of the boys. The overall case fatality rate was 8.5%. In septicemic patients (without meningitis) hypotension and/or ecchymoses on admission correlated strongly with a poor prognosis. Most deaths occurred during the months of March and November, and none during the summer months. There was a significant clustering of deaths among patients admitted during the morning hours, probably due to delayed diagnosis and treatment during the night. Since almost all patients who died had skin bleedings on admission, frequent examination of the skin in cases with acute unexplained fever might have saved lives.

Prognostic evaluation in meningococcal disease. A retrospective study of 115 cases

A retrospective study of the medical records of 115 consecutive cases of meningococcal disease with 11 fatalities was carried out in order to evaluate the power of 15 clinical and laboratory variables available on admission in predicting a fatal outcome. On linear discriminant analysis, six variables showed a significant discriminating power in predicting death: low systolic blood pressure, low platelet count, extensive petechiae, high body temperature, low CSF polynuclear cell count and absence of meningism. From a stepwise linear discriminant analysis, two alternative procedures for prognostic evaluation were derived. If a large high risk group is accepted which will include practically all patients at risk of death, a prognostic evaluation based only on systolic blood pressure on admission is sufficient. Alternatively, if unconventional, potentially hazardous therapy is considered for high risk patients, a small high risk group may be defined. Patients with systolic blood pressure less than 100 mm Hg, platelet count less than or equal to 125 X 10(9)/l and body temperature greater than 39 degrees on admission constitute a small group with a very high mortality. A similar risk group was defined if platelet count less than or equal to 125 X 10(9)/l was substituted for extensive petechiae. The advantage of the latter procedure is that only a simple bedside examination is required for the prognostic evaluation.

Surgical management of life-threatening and disfiguring sequelae of fulminant meningococcemia

In recent years, because of prompt diagnosis and effective, aggressive resuscitation, the majority of infants and children with fulminant meningococcemia are surviving. From 1974 through 1984, 135 patients with this diagnosis were treated, and 126 of them survived. Although a purpuric skin rash developed in almost all of these patients initially, in eight of them it progressed to multiple confluent areas of cutaneous gangrene, usually associated with extensive necrosis of underlying subcutaneous fat, fascia, skeletal muscle, and even bone. Tissue necrosis seemed to be most extensive in regions of reduced blood flow, such as the extremities, but it almost never followed a pattern of anatomic vascular distribution. A most significant microscopic finding was the presence of multiple fibrin thrombi in vessels, often in close proximity with the foci of tissue necrosis. Five children who ranged in age from 6 months to 12 years required operation. Initially, all surface wounds were treated like full-thickness burns with silver sulfadiazene (Silvadene) dressings. Once the patient's condition had stabilized and the extent of tissue necrosis was apparent, all necrotic tissue was excised and the resulting wounds were temporarily covered with biologic dressings to assure a clean, viable base for skin grafting. Because the resulting quality of life postoperatively in all five surviving patients has been satisfactory, we recommend an aggressive surgical approach in patients with fulminating meningococcemia, despite what may initially appear to be devastating and even lethal complications of this disease.

Unfavourable prognostic factors in Staphylococcus aureus septicemia and endocarditis

Factors predictive of a fatal outcome were retrospectively studied in 248 patients admitted with Staphylococcus aureus septicemia during 1965-1982, 78 of whom had endocarditis. 77 patients were intravenous drug addicts and 47 of them had endocarditis. 48 patients (19.4%) died. The fatality rate in addicts and non-addicts from septicemia was 0% and 17.9% and from endocarditis 8.5% and 61.3%, respectively. After analyzing clinical and laboratory data available early in the course of the disease 4 risk factors were found both in septicemia and endocarditis: age greater than or equal to 60 yr, pre-existing cardiovascular disease, prior hospitalization within 30 days of onset of illness, and neurological symptoms and/or signs. In addition, in endocarditis a platelet count before therapy less than 100 X 10(9)/l and left-sided involvement were unfavourable prognostic factors.

Mortality in meningococcal disease in Belgium

A survey of children admitted with meningococcal disease to 53 paediatric units in Belgium between 1975 and 1979 was made in order to assess the case mortality rate (CMR) and to identify risk factors associated with death. A total of 309 cases (226 bacteriologically confirmed and 83 unconfirmed) was recorded. The overall CMR was 6.1 per cent. It was 4.4 for bacteriologically confirmed cases and 10.8 for unconfirmed cases. The CMR was higher for septicaemia without meningitis (22.2 per cent) than for meningitis with or without signs of septicaemia (3.4 per cent). The risk of death was not related to the sex or nationality of the patients. Age was a major determinant of the CMR, independently of the clinical picture. The highest risk of death was in children under one year of age. Poor socio-economic conditions were a significant risk factor. Failure to recognise the severity of the disease by some poorly educated mothers, and the admission of the patient to a hospital lacking adequate facilities for managing severely affected children, were the two significant causes of delay of adequate treatment.

Endotoxin liberation and invasivity of Neisseria meningitidis

The relationship between endotoxin liberation and invasiveness was studied in 50 strains of Neisseria meningitidis isolated from blood or cerebrospinal fluid (CSF) of 16 patients with invasive disease, from nasopharynx of 9 patients with upper respiratory tract symptoms, and from nasopharynx and rectum (1, serogroup W-135) in 25 persons examined for venereal disease. Meningococci varied in their ability to liberate endotoxin. Free endotoxin was partly a function of growth and seemed to be associated with certain properties of the individual strain. Strains isolated for patients with invasive disease liberated significantly more endotoxin than strains isolated from the venereal group (p less than 0.002). All 16 invasive strains were sulfonamide resistant, against 5/9 strains from patients with upper respiratory disease symptoms and only 4/25 strains from the venereal group. The difference between the invasive group and the venereal group was significant (p less than 0.002). Serogroup A, B, C meningococci liberated significantly more endotoxin than non-A, B, C strains (p = 0.01, and serogroup A, B, C strains isolated from nasopharynx tended to have a higher endotoxin release than non-A, B, C strains isolated from the same place (not significant). Serogroup B meningococci were most frequently isolated both from patients with invasive disease and from the nasopharynx of the persons examined for venereal disease. Serogroup B meningococci had significantly more free endotoxin when isolated from blood or CSF than when isolated from nasopharynx of presumably healthy persons (p = 0.002).

Shift in the age-distribution of meningococcal disease as predictor of an epidemic?

Demographic data for several years before, during, and after an epidemic of meningococcal meningitis show that the age-distribution of the disease shifts considerably during an epidemic--although the highest incidence of meningococcal infections was still that among children under 5 years old, the proportion of patients aged greater than 4 years increased significantly. The ratio of the number of cases aged over 4 years to that aged up to 4 years was 0.833 and 0.775 in two non-epidemic periods, but 2.95 and 2.29 in two epidemic years. Careful demographic surveillance may reveal the approach of a meningococcal epidemic sooner than do the present surveillance methods.

Loss of sulfonamide resistance in Neisseria meningitidis

Four strains of Neisseria meningitidis were studied during serial passage. From two strains which originally were sulfonamide resistant, variants developed that had altered susceptibility to sulfonamides. One of the variants became relatively highly sulfonamide-sensitive, the other exhibited merely reduced sulfonamide resistance. There was a difference in the resistance pattern for two sulfonamides (sulfaisodimidine and sulfamethoxazole), and the effect of inoculum size and growth conditions in three different media could be demonstrated. Although the patterns of susceptibility to other antibacterial agents were different for the strains studied, no further susceptibility alterations occurred in parallel to the sulfonamide sensitivity changes. The variants also lost their ability to liberate free endotoxin.

[Prognostic factors in meningococcal disease: study related to 254 cases]

Analisa-se, em relação a 254 casos de doença meningocócica, a variação da letalidade sob a influência dos seguintes fatores que, segundo a literatura, agravam-lhe o prognóstico: grupos de idade extrema, tempo curto de história antes da admissão, presença de púrpuras e/ou petéquias na admissão, ocorrência de choque ou de coma, número de leucócitos normal ou diminuído no sangue periférico na admissão, líquido cefalorraquidiano normal na admissão, número de leucócitos normal ou diminuído no sangue periférico na admissão, número de leucócitos menor que 100/mm³, proteinorraquia maior que 300 mg/dl, ou glicorraquia menor que 10 mg/dl, no líquido cefalorraquidiano colhido na admissão. Dentre esses fatores, aqueles para os quais se demonstrou influência estatisticamente significativa sobre a letalidade foram: 1) idades extremas: maior letalidade em crianças com menos de um ano de idade e em adultos com mais de 40 anos; 2) tempo de história, antes da admissão hospitalar, menor que 48 horas; 3) presença de coma ou 4) choque na admissão; 5) número de leucócitos, no sangue periférico colhido na admissão, igual ou menor que 10.000/mm³. A combinação desses fatores evidenciou que, quanto maior o número deles associados, mais alto o índice de letalidade.

Meningitis and bacteremia due to Neisseria meningitidis: clinical and laboratory findings in 69 cases from Orebro county, 1965 to 1977

The records for 69 patients with meningococcal disease during 13 years in Orebro County were reviewed. The mean incidence during this period was 2.0/100 000 persons/year. The age group less than 1 year had the highest incidence, 15/100 000 infants/year. The mortality was 7.2% and sequelae were found in 13% of the patients. Four factors were significantly more frequent in the 7 patients with psycho-neurological sequelae: (1) Age greater than 40 years; (2) A condition prior to meningococcal disease that might have been associated with a lowered resistance; (3) Muscular hypertonia and/or marked irritability on admission; (4) Fever greater than 8 days after initiation of adequate treatment. Prodromal symptoms from the upper respiratory tract were noted in 50% of the cases. Signs and symptoms before and on admission, laboratory data and complicating events were analysed for each of 4 groups: meningitis without meningococcemia (12 patients); meningitis with meningococcemia (46): fulminant meningococcemia without meningitis (6); and benign meningococcemia (5).

Prognostic factors in acute meningococcaemia

During a meningococcal (group A) epidemic, 47 Nigerian children with acute meningococcaemia without meningitis were studied. Their mortality rate was 43% compared with 8% during the whole epidemic. Those presenting with coma and shock had a mortality of 93%, but without shock or coma mortality was only 6%. Coma or shock occurring alone carried an intermediate prognosis. The outcome correlated with initial serum antigen titre, but not with the serum levels of endotoxin, cortisol, or fibrin degradation products. Chloramphenicol was as effective as penicillin. A predictor of expected mortality, based on serum antigen titre and the presence of coma or shock, may allow new forms of treatment to be assessed.

Mortality in meningococcal infections

Among 124 patients with meningococcal infections between 1966-1976, 108 had meningitis with a fatality rate of 7.4%, and 16 septicaemia with 18.8% fatality. High risk patients (more than 3 prognostically unfavourable characteristics) increased from 3.5% 1966-1970 to 15.6% 1971-1976, and the total mortality from 3.6 to 10.4%. The most unfavourable prognostic factor was low blood pressure at admission. High risk patients were more common among those who had meningococci with complete or partial sulfonamide resistance (25.7%) than among those having sensitive meningococci (11.9%). When the meningococci were at least partially sulfonamide-resistant, initial therapy with the combination of benzylpenicillin, sulfaisodimidine and chloramphenicol seemed to be more successful than benzylpenicillin alone in patients above 10 years. Ampicillin was used only in children, and these all survived.

Disseminated intravascular coagulation in patients with meningococcal infection: laboratory diagnosis and prognostic factors

In 36 patients with meningococcal infection a close association between the laboratory evidence of disseminated intravascular coagulation (DIC) and unfavourable prognostic factors was established. Patients with platelet count lessthan 100000/microliter, Normotest lessthan 50% and plasma fibrinogen concentration less than 100 mg/dl had a serious prognosis. No significant differences could be extablished between patients with infection from serogroup A and B meningococci for either laboratory evidence of DIC or prognostic factors.

Prognostic value of blood platelet counts, coagulation factors and serum fibrin/fibrinogen degradation products (FDP) in acute infections

Platelet counts, P&P, factor V and fibrin/fibrinogen degradation products (FDP) in serum were determined in 96 patients with 100 episodes of acute infections. The aim of the study was to evaluate the possible correlation between the tests, separately and in combination, and the outcome of the patients. The prognostic value was found to be dubious (0.05 greater than P greater than 0.01) as regards both a low platelet count and a decreased level of P&P and very low (P greater than 0.2) as regards factor V. On the other hand, the demonstration of a raised S-FDP as well as the presence of more than one pathological test was of distinct prognostic value (P less than 0.001). It is concluded that coagulation tests are useful as supportive aids in the prognostic evaluation of patients with acute infectious diseases.

An epidemic due to sulphonamide-resistant group A meningococci in the Helsinki area (Finland). Epidemiological and clinical observations

An epidemic due to sulphonamide-resistant group A meningococci started in Finland in January 1973. By the end of 1974 the number of cases exceeded 1300. This report describes epidemiological and clinical observations in 370 patients treated in Helsinki 1973-1974. The incidence was about 65 per 100 000 per year in children under 7 years of age and about 10 per 100 000 in adults. More than one case occurred in 3.8% of the families and in 36% of the lodging-houses of the lowest social group. The fatality rate of patients treated in hospital was 4.1%. Persistent neurological damage was noticed in 4.6%.