Meningitis

Question 1

… refers to inflammation of the meninges, which are the outer membranes covering the brain and spinal cord.

Answer 1

Meningitis refers to inflammation of the meninges, which are the outer membranes covering the brain and spinal cord.

Question 2

Epidemiology of bacterial meningitis

Answer 2

The annual incidence of bacterial meningitis in developed countries is estimated at 2-5 per 100,000 population.

Question 3

Meningitis has been reported to be … times more common in developing countries due to less well developed preventative programmes (e.g. vaccination).

Answer 3

Meningitis has been reported to be ten times more common in developing countries due to less well developed preventative programmes (e.g. vaccination).

Question 4

The meninges are composed of … individual layers.

Answer 4

The meninges are composed of three individual layers.

The meninges form the outer membranes covering of the brain and spinal cord. These are divided into three structures.

Dura mater: tough outer membrane. Lies directly beneath the skull. Composed of two layers: outer periosteal layer and inner meningeal layer.
Arachnoid mater: avascular layer of connective tissue that sits beneath the dura mater. Beneath the arachnoid mater is the subarachnoid space that contains cerebrospinal fluid.
Pia mater: thin inner membrane. Tightly adherent to the brain and spinal cord.

Question 5

The meninges are composed of three individual layers - list these

Answer 5

The meninges form the outer membranes covering of the brain and spinal cord. These are divided into three structures.

Dura mater: tough outer membrane. Lies directly beneath the skull. Composed of two layers: outer periosteal layer and inner meningeal layer.
Arachnoid mater: avascular layer of connective tissue that sits beneath the dura mater. Beneath the arachnoid mater is the subarachnoid space that contains cerebrospinal fluid.
Pia mater: thin inner membrane. Tightly adherent to the brain and spinal cord.

Question 6

…: thin inner membrane. Tightly adherent to the brain and spinal cord.

Answer 6

Pia mater: thin inner membrane. Tightly adherent to the brain and spinal cord.

Question 7

Arachnoid mater: … layer of connective tissue that sits beneath the dura mater. Beneath the arachnoid mater is the … space that contains cerebrospinal fluid.

Answer 7

Arachnoid mater: avascular layer of connective tissue that sits beneath the dura mater. Beneath the arachnoid mater is the subarachnoid space that contains cerebrospinal fluid.

Question 8

Dura mater: … outer membrane. Lies directly beneath the skull. Composed of two layers: outer … layer and inner meningeal layer.

Answer 8

Dura mater: tough outer membrane. Lies directly beneath the skull. Composed of two layers: outer periosteal layer and inner meningeal layer.

Question 9

Meningitis may be caused by a series of infectious and non-infectious aetiologies.

List some non-infectious casues

Answer 9

Non-infectious causes include malignancy, systemic inflammatory conditions (e.g. systemic lupus erythematous, Behçet’s disease), head injury, medications (e.g. NSAIDs, co-trimoxazole) or surgery.

Question 10

Bacterial meningitis usually occurs acutely (< 1 day) and can lead to profound sepsis and subsequent complications.

Commonly implicated organisms include:
(5)

Answer 10

Commonly implicated organisms include:

Neisseria meningitidis
Streptococcus pneumoniae
Haemophilus influenzae
Listeria monocytogenes
Escherichia coli

Question 11

Bacterial meningitis usually occurs acutely (< 1 day) and can lead to profound sepsis and subsequent complications.

The table summarises the likely organisms based on age.

Answer 11

Question 12

Several viruses are implicated in meningitis - list them

Answer 12

Enteroviruses (most common): examples include echovirus and Coxsackieviruses
Herpes simplex virus (HSV)
Human immunodeficiency virus (HIV)
West Nile virus (WNV)
Varicella-zoster virus (VZV)

Question 13

Several viruses are implicated in meningitis

What are the most common?

Answer 13

Enteroviruses (most common): examples include echovirus and Coxsackieviruses

Question 14

Cryptococcus neoformans is a particularly devastating meningitis that is usually seen in patients with poorly controlled HIV. It is a …-like … that is a major cause of HIV-associated mortality worldwide.

Answer 14

Cryptococcus neoformans is a particularly devastating meningitis that is usually seen in patients with poorly controlled HIV. It is a yeast-like fungus that is a major cause of HIV-associated mortality worldwide.

Question 15

Fungal - meningitis

Fungal infections usually occur in the setting of HIV or signifiant immunosuppression.

Answer 15

Cryptococcus neoformans
Coccidioides immitis
Candida species
Histoplasma capsulatum
Blastomyces dermatitidis

Question 16

TB - meningitis

Answer 16

Mycobacterium tuberculosis (TB) should always be considered in patients who are immunosuppressed. In addition, have a low threshold for suspecting TB meningitis in patients with aseptic meningitis (initial bacterial cultures negative), chronic meningitis (> 7 days duration), or from high prevalence area.

Question 17

…. meningitidis can cause a rapidly progressive, and devastating meningitis with profound bacteraemia.

Answer 17

N. meningitidis can cause a rapidly progressive, and devastating meningitis with profound bacteraemia.

Question 18

N. meningitidis is a gram … diplococci. It is found as a commensal organism in the upper respiratory tract of 5-11% of the adult population. Around 25% of adolescents are asymptomatic carriers.

Answer 18

N. meningitidis is a gram negative diplococci. It is found as a commensal organism in the upper respiratory tract of 5-11% of the adult population. Around 25% of adolescents are asymptomatic carriers.

Question 19

N. meningitidis is a gram negative …. It is found as a commensal organism in the upper respiratory tract of 5-11% of the adult population. Around 25% of adolescents are asymptomatic carriers.

Answer 19

N. meningitidis is a gram negative diplococci. It is found as a commensal organism in the upper respiratory tract of 5-11% of the adult population. Around 25% of adolescents are asymptomatic carriers.

Question 20

N. meningitidis is a gram negative diplococci.

The organism typically causes meningitis in patients of all ages, except the very young (< … months). The incubation period for infection is usually ..-… days and the spectrum of disease is wide. Some patients may develop a mild self-limiting illness, whereas others may present with fulminant meningococcal disease characterised by septic shock and multi-organ failure.

Answer 20

The organism typically causes meningitis in patients of all ages, except the very young (< 3 months). The incubation period for infection is usually 2-7 days and the spectrum of disease is wide. Some patients may develop a mild self-limiting illness, whereas others may present with fulminant meningococcal disease characterised by septic shock and multi-organ failure.

Question 21

N. meningitidis is a gram negative diplococci.

The majority of cases are caused by 6 serogroups, which are categorised according to its polysaccharide capsule. These include A, B, C, W, X and Y. More than 95% of cases of meningitis are caused by serogroups …

Answer 21

The majority of cases are caused by 6 serogroups, which are categorised according to its polysaccharide capsule. These include A, B, C, W, X and Y. More than 95% of cases of meningitis are caused by serogroups B, C and Y.

Question 22

The UK currently offers …s vaccinations to children and young adults as part of the UK vaccination programme. This includes the MenB and MenACWY vaccines.

Answer 22

The UK currently offers N. meningitidis vaccinations to children and young adults as part of the UK vaccination programme. This includes the MenB and MenACWY vaccines.

Question 23

… pneumoniae is commonly implicated in cases of meningitis, pneumonia, and ear infections.

Answer 23

Streptococcus pneumoniae is commonly implicated in cases of meningitis, pneumonia, and ear infections.

Question 24

S. pneumoniae is a gram positive ….

Answer 24

S. pneumoniae is a gram positive diplococci.

Question 25

S. … is a gram positive diplococci.

Answer 25

S. pneumoniae is a gram positive diplococci.

Question 26

S. pneumoniae is a gram positive diplococci. It is a very common cause of … and usually transmitted by close contacts through droplet or direct contact with secretions from the respiratory tract. It colonises 5-10% of asymptomatic adults and up to 40% of children.

Answer 26

S. pneumoniae is a gram positive diplococci. It is a very common cause of pneumonia and usually transmitted by close contacts through droplet or direct contact with secretions from the respiratory tract. It colonises 5-10% of asymptomatic adults and up to 40% of children.

Question 27

The UK currently offers S. pneumoniae vaccination to children as part of the UK vaccination programme. It also offers the vaccine to patients with significant co-morbidities (e.g. diabetes mellitus) and all adults > … years old.

Answer 27

The UK currently offers S. pneumoniae vaccination to children as part of the UK vaccination programme. It also offers the vaccine to patients with significant co-morbidities (e.g. diabetes mellitus) and all adults > 65 years old.

Question 28

Routes of infection Bacteria cause meningeal inflammation by two major routes:

Answer 28

Invasion of bloodstream: subsequent haematogenous spread to meninges (commonly seen with N. meningitidis and S. pneumoniae) Direct contiguous spread: usually as a result of ear, nose or throat infections (e.g. sinusitis, otitis media). Alternatively trauma.

Question 29

Once bacteria penetrate the blood-brain barrier (BBB), they spread quickly within the meninges and can eventually damage underlying brain tissue. Mild vs severe cases?

Answer 29

Once bacteria penetrate the blood-brain barrier (BBB), they spread quickly within the meninges and can eventually damage underlying brain tissue. Mild cases: infection usually confined to the subarachnoid space. Severe cases: brain parenchyma underlying pia mater can be affected leading to widespread destruction.

Question 30

Once bacteria penetrate the blood-brain barrier (BBB), they spread quickly within the meninges and can eventually damage underlying brain tissue. As the immune system is activated, there is infiltration of immune cells and release of inflammatory cytokines. The combination of inflammatory cell infiltration, cytokine-mediated damage and replicating bacteria can perpetuate the infectious process. This leads to a number of complications:

Answer 30

``` Damage to cranial nerves Obstructive hydrocephalus (disruption of CSF flow, leading to fluid accumulation) Local ischaemia (local inflammatory reactions causes vessel inflammation and thrombophlebitis) Cerebral oedema: secondary to interstitial oedema (due to altered CSF and venous flow), cytotoxic oedema (due to inflammation reaction) and vasogenic oedema (due to increased BBB permeability) ```

Question 31

If left untreated, progressive cerebral oedema leads to diffuse neuronal injury. This is usually combined with systemic complications due to bacteraemia, which include … … and …

Answer 31

If left untreated, progressive cerebral oedema leads to diffuse neuronal injury. This is usually combined with systemic complications due to bacteraemia, which include septic shock and multi-organ failure.

Question 32

Meningitis is characterised by meningism, which describes a triad of …, … … and ….

Answer 32

Meningitis is characterised by meningism, which describes a triad of headache, neck stiffness and photophobia.

Question 33

… meningitis is more likely to present with a sudden onset illness (up to 50% within 24 hours of symptom onset) and systemic upset (e.g. signs of sepsis). … meningitis has a slightly longer prodrome and usually less severe symptoms. Meningism is characteristic of both, which describes a triad of headche, neck stiffness and photophobia.

Answer 33

Bacterial meningitis is more likely to present with a sudden onset illness (up to 50% within 24 hours of symptom onset) and systemic upset (e.g. signs of sepsis). Viral meningitis has a slightly longer prodrome and usually less severe symptoms. Meningism is characteristic of both, which describes a triad of headche, neck stiffness and photophobia.

Question 34

Over 95% of cases of meningitis present with at least two of the following symptoms: …, fever, neck stiffness, and altered … ….

Answer 34

Over 95% of cases of meningitis present with at least two of the following symptoms: headache, fever, neck stiffness, and altered mental status.

Question 35

Symptoms of meningitis (9)

Answer 35

``` Neck stiffness Photophobia: dislike for bright lights Headache (>80%) Fever (>70%) Nausea & vomiting Fatigue Confusion Irritable or unsettled behaviours: particularly in children Altered mental status (>70%) ```

Question 36

Signs of meningitis (8)

Answer 36

``` Tachycardia Hypotension Marked neck stiffness Photophobia Non-blanching rash: concerning sign of meningococcal septicaemia from ‘leaky’ blood vessels. May be seen with other organisms. Seizures Focal neurological deficits Reduced consciousness and coma ```

Question 37

Classic signs in meningitis ?

Answer 37

Kernig's sign: inability to fully extend at the knee when the hip is flexed at 90º due to pain Brudzinski's sign: spontaneous flexion of the knees and hips on active flexion of the neck due to pain

Question 38

… sign: inability to fully extend at the knee when the hip is flexed at 90º due to pain

Answer 38

Kernig's sign: inability to fully extend at the knee when the hip is flexed at 90º due to pain

Question 39

… sign: spontaneous flexion of the knees and hips on active flexion of the neck due to pain

Answer 39

Brudzinski's sign: spontaneous flexion of the knees and hips on active flexion of the neck due to pain

Question 40

Both Kernig’s and … are classical signs of meningeal irritation. However, absence of these signs does not exclude meningitis.

Answer 40

Both Kernig’s and Brudzinski’s are classical signs of meningeal irritation. However, absence of these signs does not exclude meningitis.

Question 41

The diagnosis of meningitis can be challenging. Why?

Answer 41

Due to the potentially life-threatening nature of meningitis (esp. bacterial meningitis), a diagnosis is initially made on clinical suspicion and treatment instigated whilst further investigations are organised. Definitive diagnosis of an infectious meningitis (e.g. bacterial meningitis) is by isolation of a pathogen from a CSF sample following a lumbar puncture (LP). However, it may be difficult to isolate an organism, especially with administration of antibiotics prior to LP. Given this, a confident diagnosis of bacterial meningitis may be made in patients with a bacterial pathogen isolated from blood cultures with a CSF sample suggesive of infection (e.g. raised WCC), even if cultures are negative

Question 42

Clinical assessment in meningitis Prompt clinical assessment should focus on: (4)

Answer 42

ABCDE assessment: if critically unwell Focused history: important to determine any preceeding illnesses that increase risk of meingitis (e.g. sinusitis, otitis media, contact with an affected patient) Allergy status Formal examination: assess for meningeal irritation, look for non-blanching rash and signs of sepsis (e.g. hypotension, tachycardia).

Question 43

A … rash refers to identification of petechiae (<2mm red lesions) or purpura (>2mm), which are both a sign of abnormal vessel integrity. In meningitis, it is indicative of … and is most commonly seen in meningococcal infection. Importantly, the disease may already be quite advanced before the rash develops.

Answer 43

A non-blanching rash refers to identification of petechiae (<2mm red lesions) or purpura (>2mm), which are both a sign of abnormal vessel integrity. In meningitis, it is indicative of septicaemia and is most commonly seen in meningococcal infection. Importantly, the disease may already be quite advanced before the rash develops.

Question 44

A non-blanching rash refers to identification of … (<2mm red lesions) or … (>2mm), which are both a sign of abnormal vessel integrity. In meningitis, it is indicative of septicaemia and is most commonly seen in meningococcal infection. Importantly, the disease may already be quite advanced before the rash develops.

Answer 44

A non-blanching rash refers to identification of petechiae (<2mm red lesions) or purpura (>2mm), which are both a sign of abnormal vessel integrity. In meningitis, it is indicative of septicaemia and is most commonly seen in meningococcal infection. Importantly, the disease may already be quite advanced before the rash develops.

Question 45

NOTE: in the early stages of meningitis and septicaemia, the rash may be …. Important to regularly reassess.

Answer 45

NOTE: in the early stages of meningitis and septicaemia, the rash may be blanching. Important to regularly reassess.

Question 46

Patients with a suspected meningitis and a non-blanching rash should be given prompt parenteral (intravenous or intramuscular) antibiotics and referred urgently to hospital. Unless there is a clear penicillin allergy, the choice is …..

Answer 46

Patients with a suspected meningitis and a non-blanching rash should be given prompt parenteral (intravenous or intramuscular) antibiotics and referred urgently to hospital. Unless there is a clear penicillin allergy, the choice is benzylpenicillin. Paramedics can administer benzylpenicillin for suspected meningococcal meningitis.

Question 47

Paramedics can administer … for suspected meningococcal meningitis.

Answer 47

aramedics can administer benzylpenicillin for suspected meningococcal meningitis.

Question 48

Benzylpenicillin dosing for suspected meningococcal meningitis prior to transfer to hospital:

Answer 48

Children 1-11 months: 300 mg Children 1-9 years: 600 mg Child 10-17 years: 1200 mg Adults: 1200 mg

Question 49

Patients with suspected meningitis undergo a series on investigations including blood tests, …, neuroimaging (if indicated) and …

Answer 49

Patients with suspected meningitis undergo a series on investigations including blood tests, cultures, neuroimaging (if indicated) and LP.

Question 50

If there is concern about a non-blanching rash, sepsis, or rapidly-progressive disease, patients should be given urgent intravenous antibiotics (e.g. … 2 g STAT or chloramphenicol if severe penicillin allergy) whilst awaiting further tests.

Answer 50

If there is concern about a non-blanching rash, sepsis, or rapidly-progressive disease, patients should be given urgent intravenous antibiotics (e.g. ceftriaxone 2 g STAT or chloramphenicol if severe penicillin allergy) whilst awaiting further tests.

Question 51

Bedside tests for suspected meningitis

Answer 51

Throat swab | Respiratory viral screen (nasopharyngeal swab)

Question 52

Blood tests in suspected meningitis

Answer 52

``` Full blood count Urea & electrolytes Liver function tests Bone profile Coagulation C-reactive protein Blood cultures Venous blood gas Meningococcal PCR ```

Question 53

A CT head is often completed as part of the work-up for meningitis. This is predominantly to look for any contraindications to lumbar puncture instead of being used as a diagnostic tool. Not all patients require a CT head. In general, the main indications include:(6)

Answer 53

Immunocompromised patient History of CNS disease (e.g. tumour, stroke, abscess) New-onset seizures (within a week of illness) Swollen optic discs: assess with direct ophthalmoscope or slit-lamp Abnormal conscious level Focal neurological deficit (e.g. limb weakness, cranial nerve palsy)

Question 54

Not all patients require a CT head. In general, the main indications include: Immunocompromised patient History of CNS disease (e.g. tumour, stroke, abscess) New-onset seizures (within a week of illness) Swollen optic discs: assess with direct ophthalmoscope or slit-lamp Abnormal conscious level Focal neurological deficit (e.g. limb weakness, cranial nerve palsy) Why do we do this?

Answer 54

The reason to perform a CT head in these situations is because of the small, but increased, risk of brain herniation with lumbar puncture with raised intracranial pressure (ICP). On CT, features of raised ICP include effacement of the ventricles, basal cisterns and/or other CSF areas, brain herniation or loss of grey-white matter differentiation. Effacement refers to obliteration of a cavity or space by mass effect (e.g. raised ICP or tumour). In addition, neuroimaging is useful at looking for an alternative diagnosis or complication of meningitis (e.g. abscess). These would be suggested by the clinical situations described above.

Question 55

Why do we perform a CT head in some individuals with suspected meningitis?

Answer 55

The reason to perform a CT head in these situations is because of the small, but increased, risk of brain herniation with lumbar puncture with raised intracranial pressure (ICP). On CT, features of raised ICP include effacement of the ventricles, basal cisterns and/or other CSF areas, brain herniation or loss of grey-white matter differentiation. Effacement refers to obliteration of a cavity or space by mass effect (e.g. raised ICP or tumour). In addition, neuroimaging is useful at looking for an alternative diagnosis or complication of meningitis (e.g. abscess). These would be suggested by the clinical situations described above.

Question 56

Lumbar puncture with analysis of the … is the key investigation in the work-up of meningitis.

Answer 56

Lumbar puncture with analysis of the CSF is the key investigation in the work-up of meningitis.

Question 57

Every patient with suspected meningitis should undergo …

Answer 57

Every patient with suspected meningitis should undergo LP and CSF evaluation. Ideally, an LP should be performed before the administration of antibiotics to improve the diagnostic yield of CSF culture. However, in ‘real-life’ clinical practice this is often difficult and therefore antibiotics have usually already been administered.

Question 58

An LP involves the insertion of a spinal needle into the … space and taking a sample of CSF. It is important to determine the opening pressure with the patient lying on their side in a lateral position. This is a surrogate marker of ICP.

Answer 58

An LP involves the insertion of a spinal needle into the subarachnoid space and taking a sample of CSF. It is important to determine the opening pressure with the patient lying on their side in a lateral position. This is a surrogate marker of ICP.

Question 59

CSF samples should be sent to biochemistry and microbiology for the following tests: (meningitis) - 7

Answer 59

Cell count and differential Protein Glucose (paired with serum glucose) Microscopy, cultures & sensitivity (MC&S) Viral PCR Save sample (can subsequently be used to run other tests) Others (if indicated): cryptococcal antigen (paired with serum), TB PCR

Question 60

Interpretation - CSF sample in suspected meningitis

Answer 60

Isolation of a pathogen on MC&S (e.g. bacteria) or PCR (e.g. virus) will confirm the diagnosis. However, this may take time to come back, especially if the initial gram stain for a bacterial pathogen is negative. Therefore, the general appearance, opening pressure, cell count, protein and glucose concentration are used in combination to determine the suspected diagnosis.

Question 61

Isolation of a pathogen on MC&S (e.g. bacteria) or PCR (e.g. virus) will confirm the diagnosis. However, this may take time to come back, especially if the initial gram stain for a bacterial pathogen is negative. Therefore, the general appearance, opening pressure, cell count, protein and glucose concentration are used in combination to determine the suspected diagnosis. (CSF)

Answer 61

Question 62

In bacterial meningitis, the prompt administration of … is the principle treatment.

Answer 62

In bacterial meningitis, the prompt administration of antibiotics is the principle treatment.

Question 63

The first-line antibiotic for bacterial meningitis is …, which is a 3rd generation cephalosporin. This should be given as 2 grams twice daily. It should be used with caution in patients with penicillin allergy due to cross-reactivity. If there is a severe penicillin allergy (e.g. anaphylaxis) it should be avoided. Further choice antibiotic choices depends on the suspected, or isolated, bacterial pathogen (e.g. amoxicllin if concern about L. monocytogenes.

Answer 63

The first-line antibiotic for bacterial meningitis is ceftriaxone, which is a 3rd generation cephalosporin. This should be given as 2 grams twice daily. It should be used with caution in patients with penicillin allergy due to cross-reactivity. If there is a severe penicillin allergy (e.g. anaphylaxis) it should be avoided. Further choice antibiotic choices depends on the suspected, or isolated, bacterial pathogen (e.g. amoxicllin if concern about L. monocytogenes.

Question 64

The second line antibiotic in bacterial meningitis after ceftriaxone is … (~25 mg/kg, max dose 1 gram QDS). This should be given to those with a severe penicillin allergy. In these situation it is usually recommended to discuss with microbiology.

Answer 64

The second line antibiotic is chloramphenicol (~25 mg/kg, max dose 1 gram QDS). This should be given to those with a severe penicillin allergy. In these situation it is usually recommended to discuss with microbiology.

Question 65

… can be considered as a treatment adjunct in patients highly suspected of having bacterial meningitis, especially pneumococcal meningitis. It may reduce development of neurological complications. It should be given in close association with the initial antibiotic dose for maximal effect. It can be continued in confirmed S. Pneumoniae meningitis.

Answer 65

Dexamethasone can be considered as a treatment adjunct in patients highly suspected of having bacterial meningitis, especially pneumococcal meningitis. It may reduce development of neurological complications. It should be given in close association with the initial antibiotic dose for maximal effect. It can be continued in confirmed S. Pneumoniae meningitis.

Question 66

Management of viral meningitis

Answer 66

Supportive treatment with rest, hydration, analgesia and antipyretic can be considered. If there is concern about encephalitis or HSV infection then aciclovir can be considered.

Question 67

Acute meningitis is a … disease.

Answer 67

Meningitis is a notifiable disease and many pathogens that cause meningitis (e.g. N. meningitidis, invasive S. pneumoniae) are notifiable organisms. This means PHE, usually via notification of the ‘proper officer’ at a local council or local health protection unit, need to be informed once the disease is confirmed or organism isolated.

Question 68

Contact tracing and … should be considered in close contacts following a case of acute meningitis.

Answer 68

Contact tracing and chemoprophylaxis should be considered in close contacts following a case of acute meningitis.

Question 69

Contact-tracing in meningitis

Answer 69

This involves identifying individuals who have come into close contact with the patient affected by meningitis. This is usually close household contacts. Contact-tracing is orchestrated by the local health protection team.

Question 70

Examples of close contacts:

Answer 70

Prolonged contact within 7 days of illness onset (e.g. household member, sharing halls of residence, partner) Transient close contact but exposed to large respiratory secretions (usually around time of hospital admission)

Question 71

Chemoprophylaxis

Answer 71

This is the administration of antibiotic prophylaxis in at-risk close contacts to prevent the risk of developing acute meningitis in case they have asymptomatic carriage of the pathogen This should be completed following confirmed cases of meningococcal meningitis regardless of vaccination status. Antibiotic choices in adults: Ciprofloxacin: 500 mg single dose Rifampicin: 600 mg twice daily for two days

Question 72

The UK vaccination programme is important for prevention of bacterial meningitis. The programme includes vaccines against H. …, N…. S. pneumoniae.

Answer 72

The UK vaccination programme is important for prevention of bacterial meningitis. The programme includes vaccines against H. influenza, N. meningitidis, S. pneumoniae.

Question 73

… vaccine: protects against H. influenzae type B. Given as part of childhood vaccination programme, in patients with complement deficiency and hyposplenism

Answer 73

Hib vaccine: protects against H. influenzae type B. Given as part of childhood vaccination programme, in patients with complement deficiency and hyposplenism

Question 74

… and MenACWY vaccines: protects against different serogroups of N. meningitidis. Given as part of childhood vaccination programme, in patients with complement deficiency and hyposplenism

Answer 74

MenB and MenACWY vaccines: protects against different serogroups of N. meningitidis. Given as part of childhood vaccination programme, in patients with complement deficiency and hyposplenism

Question 75

Pneumococcal conjugate vaccine: protects against 13 serogroups of S. …. Given as part of childhood vaccination programme, to all adults > 65 years old and those with major co-morbidities (including complement deficiency and hyposplenism).

Answer 75

Pneumococcal conjugate vaccine: protects against 13 serogroups of S. pneumoniae. Given as part of childhood vaccination programme, to all adults > 65 years old and those with major co-morbidities (including complement deficiency and hyposplenism).

Question 76

Vaccination against encapsulated bacteria is important in patients with hyposplenism. Why?

Answer 76

Vaccination against encapsulated bacteria is important in patients with hyposplenism. This is because encapsulated bacteria are poorly opsonised (i.e. attachment of complement) and reliant on removal by resident splenic phagocytes. Without a spleen, patients are at risk of overwhelming infections.

Question 77

Immediate complications of bacterial meningitis

Answer 77

Severe sepsis and multi-organ failure Seizures (20-30% of adults) Cerebral oedema Death

Question 78

Chronic complications of meningitis

Answer 78

``` Hearing loss and deafness Seizure disorder Focal paralysis Cranial nerve defects Hydrocephalus Cognitive impairment Gait disturbance Peripheral gangrene Blindness ```

Question 79

Waterhouse–Friderichsen syndrome - what is this?

Answer 79

This describes a classical syndrome causing primary adrenal insufficiency (Addison's disease) due to bilateral adrenal gland haemorrhage. It usually occurs in association with severe bacterial infection such as meningococcal septicaemia.