Meningococcal and ECHO-9 meningitis. Report of an outbreak

Patterns of Kingella kingae Disease Outbreaks

BACKGROUND

Kingella kingae outbreaks occur sporadically in childcare centers but remain poorly understood and difficult to identify.

METHODS

To provide the basis of a better knowledge of K. kingae outbreaks patterns that may help to guide identification and management strategies, we collected epidemiological, clinical and laboratory data from all reported K. kingae outbreaks, and those from 2 new Israel outbreaks in 2014.

RESULTS

Nine outbreaks were identified in the USA, Israel and France from 2003 to 2014. Twenty-seven children with a median age of 14 ± 4.1 months were affected, male:female ratio of 1.4:1. Outbreaks demonstrated seasonal patterns from the 10th to the 45th weeks, a mean duration of 13.1 ± 8.4 days, a mean attack rate of 17.3 ± 5.1% and a case-fatality rate of 3.7% (1/27). Seventy-four percentage of children had fever (20/27), and the mean values of white blood cell count and C-reactive protein level were 14.6 ± 4.5 × 10/L and 23.8 ± 24.1 mg/L, respectively. Osteoarticular infections accounted for 88.9% of cases (24/27), bacteremia 7.4% (2/27), endocarditis 3.7% (1/27) and meningitis 3.7% (1/27). Specific real-time polymerase chain reaction demonstrated higher performance than culture methods in the diagnosis of case patients and investigations of oropharyngeal K. kingae carriage among close contacts, and multilocus sequence typing methods revealed that ST-6 and ST-25 invasive strains were responsible for multiple country-dependent outbreaks. Coviral infections were identified in the majority of K. kingae outbreaks, notably those causing oral ulcers.

CONCLUSIONS

K. kingae outbreaks displayed severe K. kingae diseases that were poorly confirmed with culture methods. We argue for the use of genomic technologies to investigate further K. kingae outbreaks.

Update on meningococcal disease with emphasis on pathogenesis and clinical management

The only natural reservoir of Neisseria meningitidis is the human nasopharyngeal mucosa. Depending on age, climate, country, socioeconomic status, and other factors, approximately 10% of the human population harbors meningococci in the nose. However, invasive disease is relatively rare, as it occurs only when the following conditions are fulfilled: (i) contact with a virulent strain, (ii) colonization by that strain, (iii) penetration of the bacterium through the mucosa, and (iv) survival and eventually outgrowth of the meningococcus in the bloodstream. When the meningococcus has reached the bloodstream and specific antibodies are absent, as is the case for young children or after introduction of a new strain in a population, the ultimate outgrowth depends on the efficacy of the innate immune response. Massive outgrowth leads within 12 h to fulminant meningococcal sepsis (FMS), characterized by high intravascular concentrations of endotoxin that set free high concentrations of proinflammatory mediators. These mediators belonging to the complement system, the contact system, the fibrinolytic system, and the cytokine system induce shock and diffuse intravascular coagulation. FMS can be fatal within 24 h, often before signs of meningitis have developed. In spite of the increasing possibilities for treatment in intensive care units, the mortality rate of FMS is still 30%. When the outgrowth of meningococci in the bloodstream is impeded, seeding of bacteria in the subarachnoidal compartment may lead to overt meningitis within 24 to 36 h. With appropriate antibiotics and good clinical surveillance, the mortality rate of this form of invasive disease is 1 to 2%. The overall mortality rate of meningococcal disease can only be reduced when patients without meningitis, i.e., those who may develop FMS, are recognized early. This means that the fundamental nature of the disease as a meningococcus septicemia deserves more attention.

Update on meningococcal disease with emphasis on pathogenesis and clinical management

The only natural reservoir of Neisseria meningitidis is the human nasopharyngeal mucosa. Depending on age, climate, country, socioeconomic status, and other factors, approximately 10% of the human population harbors meningococci in the nose. However, invasive disease is relatively rare, as it occurs only when the following conditions are fulfilled: (i) contact with a virulent strain, (ii) colonization by that strain, (iii) penetration of the bacterium through the mucosa, and (iv) survival and eventually outgrowth of the meningococcus in the bloodstream. When the meningococcus has reached the bloodstream and specific antibodies are absent, as is the case for young children or after introduction of a new strain in a population, the ultimate outgrowth depends on the efficacy of the innate immune response. Massive outgrowth leads within 12 h to fulminant meningococcal sepsis (FMS), characterized by high intravascular concentrations of endotoxin that set free high concentrations of proinflammatory mediators. These mediators belonging to the complement system, the contact system, the fibrinolytic system, and the cytokine system induce shock and diffuse intravascular coagulation. FMS can be fatal within 24 h, often before signs of meningitis have developed. In spite of the increasing possibilities for treatment in intensive care units, the mortality rate of FMS is still 30%. When the outgrowth of meningococci in the bloodstream is impeded, seeding of bacteria in the subarachnoidal compartment may lead to overt meningitis within 24 to 36 h. With appropriate antibiotics and good clinical surveillance, the mortality rate of this form of invasive disease is 1 to 2%. The overall mortality rate of meningococcal disease can only be reduced when patients without meningitis, i.e., those who may develop FMS, are recognized early. This means that the fundamental nature of the disease as a meningococcus septicemia deserves more attention.

Changing pattern of neonatal meningitis in Sweden. A comparative study 1976 vs. 1983

A nationwide retrospective epidemiological survey of neonatal meningitis in Sweden was performed in order to estimate possible changes in incidence, etiology and mortality. The total number of newborns with meningitis was 137 and 40 (29%) were preterm (less than 37 gestational weeks) infants and 27 of these preterm boys (20%). Meningitis from group B streptococci and Escherichia coli, the two major causative organisms in 1976, had decreased markedly in 1983. The identification rate of viral origin was more frequent during 1983 compared to 1976. The total incidence of meningitis was 8.9/10,000 livebirths in 1983 vs. 5.6/10,000 in 1976 but the rate of verified bacterial meningitis had decreased from 3.6/10,000 (1976) to 1.9/10,000 (1983). The total outcome was improved significantly since the combined mortality and handicap rates decreased from 34% in 1976 to 15% in 1983.

Unusual aspects of Salmonella meningitis

Two cases of salmonella meningitis that demonstrate unusual clinical and epidemiologic features are reported. The first case was a two-month-old infant with relapsing salmonella meningitis in whom ECHO 2 virus and S. enteritidis grew in mixed culture from cerebrospinal fluid. The second case was a five-month-old with typhoid meningitis. Although this patient eventually responded to chloramphenical, repeated CSF cultures grew S. typhi despite his receiving high dose parenteral therapy with ampicillin and chloramphenicol. Stool cultures disclosed that the patient's mother was an asymptomatic carrier of S. typhi. Nine days after the positive stool culture, the mother developed S. typhi bacteremia.

Relationship of serogroups of Neisseria meningitidis. II. R variants of Neisseria meningitidis

Meningococci isolated in primary cultures from nasopharyngeal carriers occasionally consisted of mixtures of smooth (S) and rough (R) strains. The R strains were separated from the S strains and their morphological and serological characteristics were studied. Some of these R strains reverted spontaneously to S strains which subsequently produced group-specific polysaccharide. Several R strains, grown in the presence of deoxyribonucleic acid from either an R strain of known parentage or an S strain, formed recombinants with serological group specificity.