Meningococcal meningitis

Rapid response to meningococcal disease cluster in Foya district, Lofa County, Liberia January to February 2018

Introduction

Early detection of disease outbreaks is paramount to averting associated morbidity and mortality. In January 2018, nine cases including four deaths associated with meningococcal disease were reported in three communities of Foya district, Lofa County, Liberia. Due to the porous borders between Lofa County and communities in neighboring Sierra Leone and Guinea, the possibility of epidemic spread of meningococcal disease could not be underestimated.

Methods

The county incidence management system (IMS) was activated that coordinated the response activities. Daily meetings were conducted to review response activities progress and challenges. The district rapid response team (DRRT) was the frontline responders. The case based investigation form; case line list and contacts list were used for data collection. A data base was established and analysed daily for action. Tablets Ciprofloxacin were given for chemoprophylaxis.

Results

Sixty-seven percent (67%) of the cases were males and also 67% of the affected age range was 3 to 14 years and attending primary school. The attack rate was 7/1,000 population and case fatality rate was 44.4 % with majority of the deaths occurring within 24-48 hours of symptoms onset. Three of the cases tested positive for Neisseria Meningitidis sero-type W while six cases were Epi-linked. None of the cases had recent meningococcal vaccination and no health-worker infections were registered.

Conclusion

This cluster of cases of meningococcal disease during the meningitis season in a country that is not traditionally part of the meningitis belt emphasized the need for strengthening surveillance, preparedness and response capacity to meningitis.

Encephalitis hospitalization rates and inpatient mortality in the United States, 2000-2010

Background

Encephalitis rates by etiology and acute-phase outcomes for encephalitis in the 21^st century are largely unknown. We sought to evaluate cause-specific rates of encephalitis hospitalizations and predictors of inpatient mortality in the United States.

Methods

Using the Nationwide Inpatient Sample (NIS) from 2000 to 2010, a retrospective observational study of 238,567 patients (mean [SD] age, 44.8 [24.0] years) hospitalized within non-federal, acute care hospitals in the U.S. with a diagnosis of encephalitis was conducted. Hospitalization rates were calculated using population-level estimates of disease from the NIS and population estimates from the United States Census Bureau. Adjusted odds of mortality were calculated for patients included in the study.

Results

In the U.S. from 2000–2010, there were 7.3±0.2 encephalitis hospitalizations per 100,000 population (95% CI: 7.1–7.6). Encephalitis hospitalization rates were highest among females (7.6±0.2 per 100,000) and those <1 year and >65 years of age with rates of 13.5±0.9 and 14.1±0.4 per 100,000, respectively. Etiology was unknown for approximately 50% of cases. Among patients with identified etiology, viral causes were most common (48.2%), followed by Other Specified causes (32.5%), which included predominantly autoimmune conditions. The most common infectious agents were herpes simplex virus, toxoplasma, and West Nile virus. Comorbid HIV infection was present in 7.7% of hospitalizations. Average length of stay was 11.2 days with mortality of 5.6%. In regression analysis, patients with comorbid HIV/AIDS or cancer had increased odds of mortality (odds ratio [OR]  = 1.70; 95% CI: 1.30–2.22 and OR = 2.26; 95% CI: 1.88–2.71, respectively). Enteroviral, postinfectious, toxic, and Other Specified causes were associated with lower odds vs. herpes simplex encephalitis.

Conclusions

While encephalitis and encephalitis-related mortality impose a considerable burden in the U.S. in the 21^st Century, the reported demographics of hospitalized encephalitis patients may be changing.

Concurrent meningococcal and herpes simplex infection in a non-immunocompromised child

A previously well 11-month-old infant presented with lethargy, a blanching rash, vomiting and diarrhoea. She was diagnosed with suspected gastroenteritis and discharged. The patient deteriorated and re-presented 24 h later with lumbar puncture (LP) confirming Neisseria meningitidis. Following an initial good response to ceftriaxone, the patient then developed a blistering facial rash on day 3 for which topical aciclovir was started with no improvement. She subsequently developed fever and redeveloped a rising C reactive protein (CRP). A CT of the head on day 6 was normal, however a repeat LP on day 7 showed persistently raised cerebrospinal fluid (CSF), white cell count (WCC), high proteins and low CSF glucose. A CSF viral PCR confirmed concurrent herpes simplex virus (HSV) type 1 for which parenteral aciclovir was started. The patient responded well to bacterial and viral anti-infective treatments and was subsequently discharged on day 16 with no neurological sequelae.

Do corticosteroids improve outcome for any critical illness?

PURPOSE OF REVIEW

Corticosteroids have been widely administered in critically ill patients for various indications. Their clinical benefit is broadly investigated but remains controversial. The purpose of this review is to explore the use of corticosteroids in intensive care, their impact on patient outcome and to provide practical guidance for the use of corticosteroids in the ICU.

RECENT FINDINGS

Critical illness is the result of significant tissue damage, due to cellular ischemia, trauma or infection, inducing a systemic inflammatory syndrome. Recent advances in the understanding of the immunologic and molecular mechanisms of inflammation support, in part, the conceptual use of corticosteroids as an adjunct immunomodulatory therapy. But use of corticosteroids carries the risk of severe adverse effects, partly because of their anti-infammatory effects. Recently, clinical research has focused on critical illness-related corticosteroid insufficiency and several trials investigated the role of corticosteroids therapy in septic and critically ill patients with severe systemic inflammation such as acute respiratory distress syndrome, severe community-acquired pneumonia and meningitis. Improved morbidity has been demonstrated in some studies but a clear benefit in term of mortality was not observed.

SUMMARY

Critical illnesses stem from a group of heterogeneous medical conditions. Failure to target subgroups more likely to benefit from the use of corticosteroids may be one explanation for the largely disappointing results in clinical trials, thus, far.

Therapeutic hypothermia for adult viral meningoencephalitis

BACKGROUND

Despite the advances in critical care, severe viral meningoencephalitis continues to impose high rates of morbidity and mortality. Consequently, new treatment strategies are needed and we present therapeutic hypothermia (TH) as one of the possible efficacious treatment tools.

METHODS

We present the case series in an adult intensive care unit of a tertiary care hospital. Eleven patients suffering from severe viral meningoencephalitis were treated with hypothermia. The major indication for TH was severely impaired consciousness associated with carbon dioxide reactivity loss assessed by Transcranial Doppler. Besides from the established treatment, all the patients underwent TH. Mild hypothermia (rectal temperature of 32-34°C) was maintained with continuous veno-venous hemofiltration.

RESULTS

Median Glasgow coma scale score in our patients at admission was 8 (3-10) and median Acute Physiology and Chronic Health Evaluation score was 24 (12-32). The overall mortality rate was 9% (1/11). Among survivors, the outcome was favorable in five patients [Glasgow Outcome Scale score (GOS) 4-5]. Remaining five patients had severe residual neurological deficit (GOS 3). Median GCS at discharge was 15 (8-15). With respect to disease severity, the outcome in presented patients was generally satisfactory.

CONCLUSIONS

Our results suggest that use of mild hypothermia in selected adult patients with viral meningoencephalitis could be a promising treatment tool.