Meningococcal infection in children

Meningococcal infection is an acute infectious disease with clinical manifestations ranging from nasopharyngitis and asymptomatic carriage to generalized forms - purulent meningitis, meningoencephalitis and meningococcemia with damage to various organs and systems.

ICD-10 code

• A39.0 Meningococcal meningitis.
• A39.1 Waterhouse-Friderichsen syndrome (meningococcal hemorrhagic adrenalitis, meningococcal adrenal syndrome).
• A39.2 Acute meningococcemia.
• A39.3 Chronic meningococcemia.
• A39.4 Meningococcemia, unspecified (meningococcal bacteremia).
• A39.5 Meningococcal heart disease (meningococcal carditis, endocarditis, myocarditis, pericarditis).
• A39.8 Other meningococcal infections (meningococcal arthritis, conjunctivitis, encephalitis, optic neuritis, postmeningococcal arthritis).
• A39.9 Meningococcal infection, unspecified (meningococcal disease).

Epidemiology

The source of infection is the sick and carriers of bacteria. The sick person is most infectious at the beginning of the disease, especially when there are catarrhal phenomena in the nasopharynx. Healthy carriers without acute inflammatory phenomena of the nasopharynx are less dangerous, the frequency of carriage exceeds the frequency of diseases by 1000 times or more.

The infection is transmitted by airborne droplets (aerosols). Susceptibility is low. The contagious index is 10-15%. There is a family predisposition to meningococcal infection. Periodic increases in incidence are noted every 8-30 years, which is usually explained by a change in the pathogen (most major epidemics were associated with group A meningococcus; in recent years, increases in incidence are often due to group B and C meningococci). A harbinger of an increase in incidence is an increase in the number of meningococcal carriers.

The incidence rate peaks in February-May; 70-80% of all cases occur in children under 14 years of age, and among them the largest number of cases are children under 5 years of age. Children in the first 3 months of life rarely get sick. Cases of the disease have also been described in the neonatal period. Intrauterine infection is possible.

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Causes meningococcal infection

The causative agent of meningococcal infection is meningococcus, from the genus Neisseria - Neisseria meningitidis, a gram-negative diplococcus possesses endotoxin and an allergenic substance. The serological properties of individual strains of meningococcus are heterogeneous. According to the agglutination reaction, meningococci are divided into serogroups N, X, Y and Z, 29E and W135.

The most virulent strains of meningococcus are those from serogroups A, which are particularly invasive. The ability of meningococci to form L-forms has been proven, which can cause a protracted course of meningococcal meningitis.

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Pathogenesis

In the pathogenesis of meningococcal infection, the pathogen, its endotoxin and allergenic substance play a role.

The entry gates for meningococci are the mucous membranes of the nasopharynx and oropharynx. In most cases, no pathological phenomena occur at the site of meningococcal penetration. This is the so-called healthy carriage. In other cases, inflammatory changes in the mucous membrane of the nasopharynx appear - meningococcal naeopharyngitis. In some patients, meningococci overcome local barriers and enter the blood. This may be transient bacteremia, not accompanied by clinical manifestations, or meningococcemia (meningococcal sepsis) occurs. In these cases, the meningococcus is carried by the bloodstream to various organs and tissues: skin, joints, adrenal glands, choroid, kidneys, endocardium, lungs, etc. The meningococcus can overcome the blood-brain barrier and cause damage to the meninges and brain tissue with the development of a clinical picture of purulent meningitis or meningoencephalitis.

Symptoms meningococcal infection

The incubation period is from 2-4 to 10 days.

Acute naesopharyngitis

Acute naeopharyngitis is the most common form of meningococcal infection, accounting for up to 80% of all cases of meningococcal infection. The disease begins acutely, most often with an increase in body temperature to 37.5-38.0 °C. The child complains of headache, sometimes dizziness, sore throat, pain when swallowing, nasal congestion. Lethargy, adynamia, and pallor are noted. When examining the pharynx, hyperemia and swelling of the posterior pharyngeal wall, its granularity - hyperplasia of lymphoid follicles, swelling of the lateral ridges are detected. There may be a small amount of mucus on the posterior pharyngeal wall.

Often the disease occurs with normal body temperature, satisfactory general condition and very weak catarrhal symptoms in the nasopharynx. Moderate neutrophilic leukocytosis is sometimes noted in the peripheral blood. In half of the cases, the blood picture does not change.

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Meningococcemia

Meningococcemia (meningococcal bacteremia, meningococcal sepsis) is a clinical form of meningococcal infection, in which, in addition to the skin, various organs (joints, eyes, spleen, lungs, kidneys, adrenal glands) can be affected.

The disease begins acutely, often suddenly, with a rise in body temperature to high numbers. There may be chills, repeated vomiting, severe headache, which in young children manifests itself as a piercing scream. In more severe cases, loss of consciousness is possible, in young children - convulsions. All clinical symptoms increase over 1-2 days. At the end of the 1st - beginning of the 2nd day of the disease, a hemorrhagic rash appears on the skin. It appears all over the body at once, but more abundantly on the legs and buttocks. The size of the rash elements varies from pinpoint hemorrhages to large hemorrhages of irregular star-shaped form with necrosis in the center. In places of extensive lesions, necrosis is subsequently rejected and defects and scars are formed. In especially severe cases, gangrene of the fingertips, feet, and ears is possible. In these cases, healing is slow. There are hemorrhages in the sclera. conjunctiva, mucous membranes of the oral cavity. Often hemorrhagic rash is combined with roseola or roseola-papular rash.

Joint damage in the form of synovitis or arthritis is possible.

Uveitis and iridocyclochoroiditis develop in the choroid of the eye. With uveitis, the choroid of the eye becomes brown (rusty). The process is usually one-sided. Cases of panophthalmitis have been described. In rare cases, meningococcemia may cause pleurisy, pyelitis, thrombophlebitis, purulent liver lesions, endo-, myo- and pericarditis. With damage to the heart, dyspnea, cyanosis, muffled heart sounds, expansion of its borders, etc. appear.

Renal pathology in the form of focal glomerulonephritis up to the development of renal failure is also detected; hepatosplenic syndrome is clearly defined.

Changes in the peripheral blood during meningococcemia are manifested by high leukocytosis, a neutrophilic shift to young and myelocytes, aneosinophilia and an increase in ESR.

There are mild, moderate and severe forms of the disease. The so-called fulminant form of meningococcemia (super-acute meningococcal sepsis) is particularly severe.

Meningococcal meningitis

The disease begins acutely with a rise in body temperature to 39-40 °C, severe chills. Older children complain of severe headache, usually diffuse, without clear localization, but the pain can be especially strong in the forehead, temples, back of the head. Children groan, clutch their heads, become very restless, scream, their sleep is completely upset. The headache intensifies with movement, turning the head, strong light and sound stimuli. In some patients, excitement is replaced by inhibition, indifference to the environment. Painful sensations along the spine are possible, especially distinct when pressing along the nerve trunks and nerve roots. Any, even light touch causes sharp anxiety in the patient and an increase in pain. Hyperesthesia is one of the leading symptoms of purulent meningitis.

An equally characteristic initial symptom of meningitis is vomiting. It begins on the first day and is not associated with food intake. Most patients experience repeated vomiting, sometimes multiple, more frequent in the first days of the disease. Vomiting is the first manifest sign of incipient meningitis.

An important symptom of meningococcal meningitis in young children is convulsions. They are usually clonic-tonic, and often occur on the first day of illness.

Meningeal symptoms are noted on the 2nd-3rd day, but can be distinct from the 1st day of the disease. Most often, rigidity of the occipital muscles, Kernig's sign and Brudzinsky's upper sign are determined.

Tendon reflexes are often increased, but in severe intoxication they may be absent, often determining clonus of the feet, a positive Babinski symptom, muscle hypotonia. Rapidly passing damage to cranial nerves (usually III, VI, VII, VIII pairs) is possible. The appearance of focal symptoms indicates edema and swelling of the brain.

Changes in the cerebrospinal fluid are of great importance for diagnosis. On the first day of illness, the fluid may still be transparent or slightly opalescent, but quickly becomes cloudy and purulent due to the high content of neutrophils. Pleocytosis reaches several thousand in 1 μl. However, there are cases when pleocytosis is small, the amount of protein is increased, and the content of sugar and chlorides is reduced.

Meningococcal meningoencephalitis

Meningococcal meningoencephalitis occurs mainly in young children. In this form, encephalitic symptoms appear and predominate from the first days of the disease: motor agitation, impaired consciousness, convulsions, damage to the III, VI, V, VIII, and less often other cranial nerves. Hemi- and monoparesis are possible. Bulbar paralysis, cerebellar ataxia, oculomotor disorders and other neurological symptoms may occur. Meningeal phenomena in the meningoencephalitic form are not always clearly expressed. The disease is particularly severe and often ends unfavorably.

Meningococcal meningitis and meningococcemia

Most patients have a combined form of meningococcal infection - meningitis with meningococcemia. In the clinical symptoms of mixed forms, manifestations of both meningitis and meningoencephalitis, as well as meningococcemia, may dominate.

Forms

The following forms are distinguished:

• localized form - acute naesopharyngitis;
• generalized forms - meningococcemia, meningitis;
• mixed form - meningitis combined with meningococcemia;
• rare forms - meningococcal endocarditis, meningococcal pneumonia, meningococcal iridocyclitis, etc.

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Diagnostics meningococcal infection

In typical cases it does not present any difficulties. Meningococcal infection is characterized by acute onset, high body temperature, headache, vomiting, hyperesthesia, symptoms of irritation of the meninges, hemorrhagic stellate rash.

Spinal tap is crucial in diagnosing meningococcal meningitis. However, the fluid may be transparent or slightly opalescent, pleocytosis within 50 to 200 cells with a predominance of lymphocytes. These are the so-called serous forms of meningococcal meningitis, they usually occur with early treatment. In these cases, antibiotic therapy interrupts the process at the stage of serous inflammation.

The most important is the bacteriological examination of cerebrospinal fluid and blood smears (thick drop) for the presence of meningococcus. Of the serological methods, the most sensitive are RPGA and the counter immunoelectroosmophoresis reaction. These reactions are highly sensitive and allow detecting insignificant levels of specific antibodies and minimal concentrations of meningococcal toxin in the blood of patients.

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Differential diagnosis

Meningococcal infection, which occurs as meningococcemia, should be differentiated from infectious diseases accompanied by a rash (measles, scarlet fever, yersiniosis), hemorrhagic vasculitis, sepsis, thrombopenic conditions, etc.

Forms of the disease with damage to the central nervous system are differentiated from toxic influenza, other acute respiratory viral infections that occur with meningeal and encephalitic symptoms, as well as other infectious diseases (severe dysentery, salmonellosis, typhoid fever, etc.) accompanied by meningeal symptoms.

Treatment meningococcal infection

All patients with meningococcal infection or suspected of it are subject to mandatory and immediate hospitalization in a specialized department or diagnostic box. Comprehensive treatment is carried out taking into account the severity of the disease.

Antibacterial therapy for meningococcal infection

In the case of generalized meningococcal infection, penicillin therapy with massive doses is still effective. Benzylpenicillin potassium salt is administered intramuscularly at a rate of 200,000-300,000 U/kg per day. For children under 3-6 months, the dose is 300,000-400,000 U/kg per day. The daily dose is administered in equal parts every 4 hours without a night break. For children in the first 3 months of life, the intervals are recommended to be shortened to 3 hours.

In severe meningoencephalitis, and especially in ependymatitis, intravenous administration of benzylpenicillin is indicated. A distinct clinical effect is determined already after 10-12 hours from the start of penicillin treatment. It is not recommended to reduce the penicillin dose until the full course is completed (5-8 days). By this time, the general condition improves, body temperature normalizes, and meningeal syndrome disappears.

While recognizing the effectiveness of treating meningococcal infection with penicillins, it is still necessary to give preference to the cephalosporin antibiotic ceftriaxone (rocephin), which penetrates well into the cerebrospinal fluid and is slowly excreted from the body. This allows limiting its administration to 1, maximum 2 times a day at a dose of 50-100 mg/kg per day.

To control the effectiveness of antibiotic treatment, a lumbar puncture is performed. If the fluid cytosis does not exceed 100 cells per 1 mm3 ^and it is lymphocytic, the treatment is stopped. If pleocytosis remains neutrophilic, the antibiotic should be continued at the same dose for another 2-3 days.

Combining two antibiotics is not recommended, as it does not increase the effectiveness of treatment. Combined antibiotic use can only be used when a bacterial infection (staphylococcus, proteus, etc.) occurs and purulent complications occur - pneumonia, osteomyelitis, etc.

If necessary, sodium succinate levomycetin can be prescribed at a dose of 50-100 mg/kg per day. The daily dose is administered in 3-4 doses. Treatment continues for 6-8 days.

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Symptomatic therapy of meningococcal infection

Simultaneously with etiotropic therapy for meningococcal infection, a set of pathogenetic measures is carried out to combat toxicosis and normalize metabolic processes. For this purpose, patients are provided with an optimal amount of fluid in the form of drinking and intravenous infusions of 1.5% reamberin solution, rheopolygluczhin, 5-10% glucose solution, plasma, albumin, etc. The fluid is administered intravenously by drip at a rate of 50-100-200 mg/kg per day depending on age, severity of the condition, water-electrolyte balance, and renal function. The introduction of donor immunoglobulin is indicated, probiotics (acipole, etc.) are prescribed.

In very severe forms of meningococcemia, occurring with acute adrenal insufficiency syndrome, simultaneously with the use of antibiotics, treatment should be started with intravenous jet fluid administration (hemodez, rheopolyglucin, 10% glucose solution) until a pulse appears and hydrocortisone (20-50 mg) is administered. The daily dose of glucocorticoids can be increased to 5-10 mg/kg of prednisolone or 20-30 mg/kg of hydrocortisone. After a pulse appears, it is necessary to switch to drip fluid administration.

Prevention

In the system of preventive measures, early isolation of the patient or carrier is of crucial importance. Patients with meningococcemia and purulent meningitis are immediately hospitalized. An emergency notification is sent to the SES about each case of the disease. Groups where cases of the disease have been identified do not accept new people for 10 days and prohibit the transfer of children from one group to another. Bacteriological examination of contacts is carried out twice with an interval of 3 to 7 days.

Hospitalization of patients with nasopharyngitis is carried out according to clinical and epidemiological indications. Such patients are treated with chloramphenicol for 5 days. If a patient with nasopharyngitis is not hospitalized, then persons who have been in contact with him/her are not allowed into preschools and other closed institutions until a negative result of a bacteriological examination of mucus from the nasopharynx is received. Healthy carriers of meningococcus are not subject to hospitalization. Persons who have been in contact with a patient with a generalized form of the disease or nasopharyngitis in the family or apartment are not allowed into the above-mentioned institutions until a single negative result of a bacteriological examination of mucus from the nasopharynx is received.

Discharge of convalescents after generalized meningococcal infection is permitted upon clinical recovery and a two-time negative result of bacteriological examination of nasopharyngeal mucus. Bacteriological examination is started after the disappearance of clinical symptoms, not earlier than 3 days after the end of antibiotic treatment with an interval of 1-2 days. Patients with nasopharyngitis are discharged from the hospital after clinical recovery and a single negative result of bacteriological examination, conducted not earlier than 3 days after the end of treatment.

General hygiene measures are of great preventive importance: breaking up children's groups, frequent ventilation of rooms, treatment of household items with chlorine-containing solutions, ultraviolet irradiation of rooms, boiling toys, dishes, etc. The question of the effectiveness of gamma globulin prophylaxis requires additional study.

Killed and polysaccharide vaccines are proposed to create active immunity. In our country, two vaccines are approved for use: meningococcal group A polysaccharide dry vaccine and polysaccharide meningococcal vaccine A+C from Sanofi Pasteur (France).

Vaccination against meningococcal infection is used for persons over 1 year of age in foci of infection, as well as for mass vaccination during an epidemic. The vaccination course consists of 1 injection. The resulting immunity provides reliable protection for at least 2 years.

For post-exposure prophylaxis of meningococcal infection, normal human immunoglobulin can be used once in children from a meningococcal infection site aged under 7 years no later than 7 days after contact in doses of 1.5 ml (for children under 2 years) and 3 ml (over 2 years). Carriers of meningococcus are given chemoprophylaxis with ampicillin or rifampicin for 2-3 days.

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Forecast

With timely treatment, the prognosis for meningococcal infection is favorable. However, even now, mortality remains high and averages about 5%. The prognosis depends on the child's age and the form of the disease. The younger the child, the higher the mortality. The prognosis worsens with meningococcal meningoencephalitis.

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