Meningococcal and Pneumococcal Meningitis by Melissa Watrous and Amy Buss

Pneumococcal Meningitis
Melissa Watrous
May 15, 2009

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Figure 1.1 Streptococcus pneumoniae


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Abstract:
Pneumococcal Meningitis is a gram positive, spherical bacterium. The pathogen form of this bacterium is Streptococcus pneumoniae, which can be transmitted through aerosols. It is a type of bacterial meningitis that affects the nasopharyngeal region and is prevalent in young children. Viral meningitis is more common, however bacterial meningitis is less invasive. Infection is rare, however mortality rates are high in those with compromised immune systems. Conjugated vaccines are available to help prevent infection for children below the age of two, however at the moment no treatment is available. Despite all that is known, scientists are having difficulties creating antibiotics for each of the newly discovered serovars. Those who survive this infection normally experience issues with neurological damage.

Bacterial meningitis and pneumonia are two of the main complications caused by this bacterium. It can also lead to otitis media, more commonly known as an earache. Several epidemiologic factors have been discovered that lead to pneumococcal diseases, which include age, gender, race, season, breastfeeding and predisposing factors. Researchers are working on learning more about the optimal method of diagnosis and are attempting to discover all possible serovars so that they can be added to the pneumococcal vaccine. It is crucial that scientist continue to work hard to find a way to diagnose specific bacteria that cause pneumococcal diseases. If this goal is achieved, antibiotic treatments can be administered and mortality rates for these types of infections may decline.

Introduction:
My perseverance to become a registered nurse has developed throughout the years due to various hardships within my family. When I was five years old, my sister was diagnosed with Type One diabetes, but we learned how to take care and support my sister adapt to her new lifestyle. Again, when my mother was diagnosed with breast cancer, my family came together to support each other and made sure my mother received the utmost care. Most recently, when my grandfather was receiving dialysis treatments, my family would drive an hour to his weekly appointments and made sure he laughed at least once during the day. I am fortunate to have experienced growing up in a large family with constant health related issues because we have overcome many obstacles that have taught me many lessons in life. I have found that my main purpose in life is to help others. With a nursing degree, I will have the opportunity to help children thrive and give them the chance to appreciate their lives. I chose to write about
Pneumococcal Meningitis because it pertains to my future field of work. Through my research, I found that this bacterium is prevalent in children one month to four years of age. This bacterium is also commonly found in hospitalized patients (Tortora, 2007,667 pp.).

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Many are unaware that they are carriers of its pathogen form,
Streptococcus pneumoniae, and about 70% of the U.S. population are healthy carriers (Tortora, 2007, 646 pp.). Despite these alarming results, the mortality rate for this type of infection is rare in those who are healthy. However, those with compromised immune systems experience a high mortality rate at about 30% for young children and about 80% for the elderly (Tortora, 2007, 646 pp.). The few who are fortunate enough to survive commonly experience seizures, neurological damage or complete mental impairment.

One important issue that researchers are dealing with today is determining the bacterial causes in the early stages of meningitis, which makes it difficult for scientists to treat infected patients. As a nurse, I hope to able to help research and diagnose the specific bacteria that cause meningitis so that antibiotic treatments can be administered promptly.

II. Discussion:

Terms:

Meningitis: an inflammation of the meninges, which are the three membranes covering the spinal cord (Tortora, 2007, 922 pp.).

Pneumonia: an inflammation of the lungs (Tortora, 2007, 924 pp.).

Streptococci: cocci that remain attached in chains after cell division. It is a gram positive, catalase negative bacteria (Tortora, 2007, 927 pp.).


Overview:
Streptococcus pneumoniae are gram-positive encapsulated diplococcus(Tortora, 2007, 665 pp.). The capsule portion of the cell helps the bacterium protect itself from phagocytosis. S. pneumoniae is most commonly found in the nasopharyngeal region of the body, which includes: the glottis, the epiglottis, the pharynx, the larynx and the nasal turbinates, which collectively affect the respiratory tract (Tortora, 2007, 665 pp.). There are about 3,000 cases of meningitis each year (Tortora, 2007, 646 pp.).There are around 91 strains of Pneumococcal bacteria that have been found, however not all of them are dangerous (Beil, 2009). Researchers are working on creating a new vaccine that will include all serovars.

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Transmission:
Most humans are healthy carriers, however not all strains of S. pneumoniae are compatible with the human immune system. S. penumoniae is able to replicate rapidly in the blood stream, which then allows it to enter the cerebrospinal fluid, eventually infecting tissues of the brain and causing inflammation (Altrock, 1973, 164 pp.). Researchers have found that adult carrier rates are highest in dormitories and can be transmitted by aerosols(Quie and Kass,1982, 52 pp.). Aerosols are solid or liquid particles that are able to diffuse in air and other gaseous substances. Due to these findings, it is now a requirement that students receive the meningococcal vaccine before attending college due to the fact that it is highly contagious and can cause severe complications.

Symptoms and Prevention:
Symptoms vary from mild, fever, headache, stiff neck and nausea, to severe, convulsions and the body can even induce comas ( Tortora, 2007, 644 pp.). A polysaccharide vaccine is used to prevent exposure to this bacterium. Death from bacterial meningitis is quick due to shock and inflammation caused by the release of cell wall fragments. A conjugated vaccine is available that has been modeled after the Hib vaccine (Tortora, 2007, 646 pp.). This vaccine is recommended for children under the age of two years. The toxicity of the pneumococcal vaccine is slight however it can lead to mild pain and tenderness at the injection site (Quie and Kass, 1982, 383 pp.). It is rare that severe symptoms such as erythema, fever and leukocytosis will occur.

Diagnosis:
About 500,000 cases of pneumonia and millions of otitis media, earache, are caused each year (Tortora, 2007, 646). Pneumococcus is the most common bacterial cause of pneumonia, otitis media and bacterimia in infants in children. S. pneumonia infects the middle ear after organisms are present in the respiratory tract and pass through the Eustachian tube. It is important that physicians test for otitis media by testing middle ear fluid because it provides the most accurate diagnosis (Quie and Kass, 1982, 67 pp.). Pneumonia on the other hand is extremely difficult to diagnose because it can be caused by multiple sources and can be viral or bacterial. Meningitis can be accurately diagnosed if cerebrospinal fluid is collected before any antimicrobial therapy begins. Several epidemiologic features are factors of Pneumococcal disease, including, but not limited to age, sex, race, season, breast feeding and predisposing factors. Young infants are highly susceptible to pneumococcal diseases becaue their immune systems have not been fully developed and are considered to be compromised. It has also been found that rates of pneumococcal bacteremia or meningitis are the highest in the first year of a child (Austrian, 1985, 56 pp.). As far as gender, males are more susceptible to bacteremia, pneumonia and otitis media. It has also been found that blacks and those who live in certain socioeconomic areas have a higher rate of infection. Season is an important factor because it mimics the pattern of other respiratory tract infections and is highly contagious in winter and spring months. Breastfeeding prevents gastrointestinal infection, however researchers are unsure of how it affected the respiratory tract. Studies show that breastfeeding did not lessen the amount of outbreaks, however it shortened their duration. Some of the most crucial predisposing factors are children with anatomic or immunoloigic defects as well as those who have a defect in the cribiform plate of their skull (Quie and Kass, 1982, 68-69 pp.).

The Future of Pneumococcal Vaccines:
Predominant pneumococcal serotypes change due to several factors, age, time and geographic location to name a few. Scientists are working on keeping up with each new serotype in an effort to put them into a vaccine. The vaccines that are available for pnumococcal diseases contain about 85-97% of strains that cause disease (Quie and Kass,1982, 64 pp.). There are multiple serotypes of pneumococcus, which makes it difficult to develop vaccines for each strain. The most recent conjugated vaccine has been approved and is able to prevent 97.4% of invasive serotypes that lead to pneumococcal diseases in children. After this vaccine was administered, there has been decline in infant Pneumoccoccal meningitis (Gil Prieto, 2009, 2667 pp.).


Current Events Involving Pneumococcal meningitis:

"Worrisome Infection Eludes a Leading Children's Vaccine"



American toddlers have been immunized against S.pneumoniae since the year 2000. Those who survive Pneumococcal meningitis often experience complications such as deafness or neurological problems. The rates of infection form these bacteria dropped 80% due to an increase in vaccinations by the year 2002. Today, a new strain of infection, Serotype 19A, is increasing and doctors are finding that the only way to cure this type of infection is by implanting tubes or prescribing adult medication to children, which could lead to future problems. Aside form otitis media, Serotype 19A is also increasing meningitis, pneumonia and bloodstream infections. Prevnar, a vaccine to prevent seven types of predominant disease causing Pneumococcal strains, are being reevaluated. Manufacturers are currently working on developing a new vaccine that will include Serotype 19A along with five other pneumococcal strains. Even if manufacturers develop a new vaccine, it will have be approved for effectiveness and safety before it can be licensed. One issue that researchers are dealing with is determinig whether or not it is necessary to revaccinate children who have been vaccinated with the old Prevnar so that they may be protected from Serotype 19A (Beil, 2009).

Literature Cited:

Altrock, B. 1973. The Role of Peritoneal Macrophages in Immunity and Immunological "Paralysis" To Type III Diplococcus Pneumoniae, CA, 164 pp.


Austrian, R. 1985. Life with the Pneumococcus: Notes from the Bedside, Laboratory, and Library. University of Pennsylvania Press, PA, 56p.

Beil, Laura. "Worrisome Infection Eludes a Leading Children’s Vaccine". The New York Times. May 5, 2009 <http://www.nytimes.com/2008/10/14/health/14vacc.html?_r=1>.

Gil Prieto, R.. "Epidemiology of pneumococcal meningitis hospitalizations in pediatric population in Spain (1998–2006)".Vaccine May 5, 2009: 2667.

Quie, P.G., Kass, E.H. 1982.
The Pneumococcus and the Pneumococcal Vaccine. The University of Chicago Press, IL, 52, 64, 67, 68-69 pp.

Tortora, G.J., Funke B.R., Case C.L. 2007.
Microbiology: An Introduction. Benjamin Cummings, CA, 644, 646, 665-667, 922, 924, 927 pp.




Title: Meningococcal meningitis
Author: Amy Buss
Date: May 15, 2009


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Abstract
Meningococcal meningitis is a type of bacterial meningitis. The types of bacteria that cause meningitis are typically gram- negative cocci. It is common in young children and adults that live or are frequently in crowded conditions. It can be spread by sharing drinks or by respiratory droplets from an infected individual. Many incidences in where people come in contact with someone infected with Meningococcal meningitis, they become carriers of the disease. The disease could be caused by a number of different bacteria and viruses, for example Neisseria meningitides is a common bacteria that can cause the infection. The bacterium enters the body through the Nasopharynx to the bloodstream into the cerebrospinal fluid where they release endotoxins that cause inflammation of the meninges in the central nervous system.

A spinal tap is one of the ways to diagnose Meningococcal meningitis. They receive cerebrospinal fluid from the lower back and inoculate the culture to see which bacteria is causing the infection, so that the doctors can prescript antibiotics. Antibiotics are given intravenously so that treatment can be effective as so as possible. Meningococcal meningitis symptoms can begin with headaches, stiff neck, or vomiting. As the infection proceeds, it can lead to neurological damage, loss of hearing, coma, or even death. Since the disease is contagious, that is why vaccines for serotype A, C, Y, and W-135 are required before living in the dorms when students go to college.

Introduction

I am interested in medicine and health care, and etiology and pathology. Another reason why I am interested in Meningococcal meningitis is that one of my good friends got Meningococcal meningitis her sophomore year of college. She was complaining about being sore and her neck was stiff. We all thought that she was just stressed out from finals and moving out, because it was the end of the school year. Then four days after she started to first feel the early symptoms she got really sick, could not put sentences together, and incoherent. They took her to the hospital, gave her antibiotics through her vein in her arm so that it would work immediately. They took a spinal tap to find out what type of bacteria was causing her illness. It was very scary to know that her brain was swelling and I came close to losing one of my good friends. Now she is fine and I wanted to research more on the disease that almost killed her. I thought it would be interesting to learn about a common disease that is well known for causing infections in people in my age group.

There were a few significant findings I came across during my research. One being that about a 10% of the population are carriers for Meningococcal meningitis and carriers do not always show symptoms of the disease. Another is that the disease was highly contagious and there are a number of different types of bacteria and viruses that can cause it. Also, that the bacteria enters the nose and throat, then goes into the bloodstream, and ends up of in the central nervous system that consists of the brain and spinal cord and causes inflammation of the meninges surrounding the central nervous system.

Discussion

History/background

Meningococcal meningitis can either be viral or bacterial. Some of the bacteria that can cause the disease are Haemophilus influenzae, Escherichia coli, Streptococcus pneumoniae, Streptococcus pyogenes, Staphylococcus aureus, and Neisseria meningitides (Todar, 2006). There are five common serotypes of Meningococcal meningitis, which are A, C, Y, and W-135 (Tortora, 2007). This disease often occurs in adolescents and young adults (NMA, 2008). It is also commonly found in children around two years old and younger due to the weaken passive immunity they received from their mother after birth and can result in deafness (Tortora, 2007). The type of Meningococcal that is common in college students is Sporadic Meningococcal (Tortora, 2007). Before vaccines, the outbreak of Meningococcal meningitis caused trouble for U.S military (Tortora, 2007). The first observation of gram-negative diplococci in cerebrospinal fluid was in 1884 by Marchiafara and Celli after taking fluid from a corpus that died from meningitis and later they isolated the species that were proven to cause meningitis (Todar, 2006). Meningococcal meningitis can be either sporadic or become an epidemic (Todar, 2006). Late winter and early spring is usually when the most incidences occur (Todar, 2006). Meningococcal meningitis is a world wide disease, a example is that in several countries in West Africa, there has been more than 40,000 Meningococcal meningitis cases that have been recorded and the epidemic continues to grow rapidly even though international humanitarion is trying to get the epidemic under control (Odigwe, 2009).

Neisseria meningitides

One of the pathogens that cause Meningococcal meningitis is Neisseria meningitides, which are aerobic, gram-negative bacteria that are a oxidase-positive diplococci (Todar, 2006) with a polysaccharide capsule, which is important for the bacterium’s virulence (Tortora, 2007). The capsule is also anti-phagocytic, which is another important factor that contributes to the in the virulence of meningococcal diseases (Todar, 2006). The environments that N. meningitides is commonly found in are the nose and throat of the infected (Tortora, 2007). N. meningitides enters the cytoplasm of neutrophil and this type of infection is called pyogenic (pus-forming) (Todar, 2006). Meningococcemia (skin lesions and acute bacterial meningitis) is a disease caused by N. meningitides. The bacterium can be grown in a peptone- blood medium, with a moisten chamber that is 5-10% carbon dioxide, and then the media needs to be at 37°C before inoculating the bacterium (Todar, 2006). N. meningitides undergoes autolysis rapidly after death and then they release endotoxins that cause inflammation (Todar, 2006). Humans are the only known host for N. meningitides (Todar, 2006). N. meningitides seem to infect people who lack serum bacterial antibodies that are suppose to be against the antigens of the invading meningitis strains (Todar, 2006).



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Neisseria meningitides scanning EM from Kenneth Todar


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Gram-stain of a pure culture, Kenneth Todar
How it spreads

Meningococcal meningitis is a contagious disease that can be acquired through respiratory droplets and contact with an infected person (NMA, 2008). The people that are at risk for getting the disease lives in crowded conditions, move to a new residence, or attend a new school (NMA, 2008). Meningococcal meningitis can be spread by going to crowded areas, for example going to bars or irregular sleeping patterns can also increase the probability for getting get the disease (NMA, 2008). The disease starts in the nose or throat and spreads to the bloodstream to the central nervous system, however it is still unknown exactly how the meningococcus enters the central nervous system (Todar, 2006). Then the bacteria enter the cerebrospinal fluid and cause an infection by releasing their endotoxins, which causes the inflammation of the meninges (HCN, 2001-9). The bacteria attaches to the epithelial cells of the nasopharyngeal and oropharyngeal mucosa (Todar, 2006).Even though Meningococcal meningitis is contagious, it is not as contagious as the flu or common colds (CDC, 2008). The average incubation for the disease ranges from two to ten days (WHO, 2003). Most people that come into contact with someone that has Meningococcal meningitis become a carrier (Todar, 2006). A few carriers can actually develop the disease (Todar, 2006). If serotype A is introduced in a population, it is common for the number incidences for Meningococcal meningitis to increase (Todar, 2006).

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Symptoms

Meningitis is inflammation of the meninges, which are three membranes that surround the brain and spinal cord (Todar, 2006). Meningococcal septicemia is a common symptom of Meningococcal meningitis that consists of a rash that when pressed on, it does not fade and can cause circulatory collapse (WHO, 2003). Some times the disease begins as a throat infection that leads to bacteromia, which can result into meningitis (Tortora, 2007). A mild case of the disease consists of a fever and malaise (Todar, 2006). A more severe case of Meningococcal meningitis consists of chills, fever, stiff neck, malaise, neurological problems and meningeal irritation such as the spine being rigid or hamstring spasms (Todar, 2006). Seizures and comas can also result from Meningococcal meningitis (HCM, 2001-9). If any brain nerves are damaged, it could cause the patient to lose their hearing, develop learning disabilities, cause motor impairment, or even the possibility to develop mental retardation (HCM, 2001-9). The disease can cause mental alterations with headaches during early stages and later it can proceed to more severe symptoms (Todar, 2006). Infants that are infected with Meningococcal meningitis do not so any evident signs of irritation, but if they are irritable, refuse to eat, or vomiting are symptoms that are common (Todar, 2006). However, it is not common for young children under two months to get a fever (Todar, 2006).

Another symptom is gram-negative sepsis, which can be is deadly, that is caused by the bacterium proliferating in the bloodstream and cause tissue damage. Since the bacteria enter the bloodstream, other diseases can occur such as arthritis, heart infections, and pneumonia (HCM, 2001-9). Death can occur after a fever within a few hours, but with antibiotics the mortality rate can be decreased to 9 to 10% and without chemotherapy, morality rate increases 80% (Tortora, 2007). Some times people die 24-48 hours after the first symptom signs (WHO, 2003).

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Skin rash of meningococcal septicemia that is caused by Neisseria meningitides (Todar, 2006)

Diagnose

It is common to misdiagnosed Meningococcal meningitis; because early symptoms are flu like and without proper treatment it can turn to a more serious illness (NMA, 2008). It is recommended to see a doctor immediately if any symptom signs appear (CDC, 2008). One of the ways to diagnose Meningococcal meningitis is by growing bacteria from a sample of cerebrospinal fluid taken from a spinal tap and observe white blood cells and protein along with the bacteria (HCM, 2001-9). A spinal tap is when an anesthetic is injected into the lower back of the patient to numb it and then a hollow needle receives cerebrospinal fluid from the lower part of the spinal canal (HCM, 2001-9). Observing cerebrospinal fluid is not the only way to detect Meningococcal meningitis, looking at blood, sputum, and urine are alternatives (HCM, 2001-9). Doctors may request the patient to get chest films or a CT scan of the brain to see if there is another cause to the infection (HCM, 2001-9).

Treatments

Meningococcal meningitis is a medical emergency and if the infected person fails to get treatment, it can lead to shock, serious complications, or death (NMA, 2008). When a patient is omitted into the hospital, intravenous antibiotics (penicillin or cefriaxone) should be given to the patient immediately and the antibiotic treatment can be used for 7-10 days (HCM, 2001-9). From a spinal tap result, doctors can determine which antibiotics to use (CDC, 2008). Penicillin is usually used and it enters the blood-brain barrier where the meninges are inflamed (Todar, 2006). A few other types of antibiotics that are used are ampicillin, chloramphenicol, and ceftriaxone (WHO, 2003). However, if someone is allergic to penicillin, antibiotics such as cefotaxime or ceftriaxone are given to the patient (Todar, 2006). Cephalosporin is one of the treatments for the disease (Tortora, 2007). A delay of the antibacterial/antibiotics treatment actually increases the risk of neurological damage (HCM, 2001-9). A person that came in close contact with a infected person are told by health professionals to take antibiotics (rifampicin, ceftriaxone, or ciprofloxacin) within 24 hours as soon as the infected is diagnosed with meningococcal meningitis (HCM, 2001-9).

Prevention

Vaccines were introduced in 1982 for serotypes A, C, Y, and W-135, however it is not effective against serotype B and some other types, because there are different variations of proteins in the surfaces of the bacteria such as N. meningtidis (Todar, 2006). The vaccines cause the body to produce antibodies against Meningococcal meningitis bacteria (HCM, 2001-9). College students have to get those vaccines before entering college, but the vaccines are not very effective for very young children (Tortora, 2007). A few ways to prevent Meningococcal meningitis are good hygiene, not sharing drinks, or sharing something that had been in someone else’s mouths (NMA, 2008).


Literature cited

< Centers for Disease Control and Prevention (CDC). Department of Health and Human services. 2008. Meningococcal Disease: Frequently Asked Questions. www.cdc.gov/meningitis/bacterial/faqs.htm

< Odigwe, Chibuzo. 2009. Meningitis Toll Rises as West Africa face its Worst Epidemic. British Medical Journal, 2009, vol. 338 issue 7701, p. 973.
< The HealthCentral Network (HCM). 2001-2009. Meningococcal meningitis. The HealthCentral Network, Inc. www.healthscout.com/ency/68/354/main.html#DescriptionofMeningococcalMeningitis

< The National Meningitis Association, Inc (NMA). 2008. What is Meningitis.
www.nmaus.org/meningits/

< Todar, Kenneth. 2006. Meningococcal meningitis. The Microbial World. Bacteriology at University of Wisconsin – Madison. http://bioinfo.bact.wisc.edu/themicrobialworld/mmeningitis.html

< Tortora, Gerard J., Berdell R. Funke, and Christine L. Case. 2007. Microbiology. Ninth edition. Pearson Education, Inc., publishing as Benjamin Cummings, San Francisco, 645-646 pp.

< World Health Organization (WHO). 2003. Meningococcal meningitis. www.who.int/mediacentre/factsheets/fs141/en/index.html