Anyone listening to the radio or watching television this week will be aware that it is National Meningitis Awareness Week. The aim of this is to highlight the risks to health posed by meningitis, and the symptoms and signs of the disease.
The Meningitis Research Foundation provides excellent material for both patients and healthcare professionals about meningitis and I would recommend you look at their website http://www.meningitis.organd the test yourself case histories in the document “doctor’s in training” http://www.meningitis.org/assets/x/50156. The earlier meningitis is diagnosed and treated the better the outcome, so Meningitis Awareness Week is definitely a good thing BUT should meningitis really be compared to meningococcal sepsis?!
The Meningitis Research Foundation provides excellent material for both patients and healthcare professionals about meningitis and I would recommend you look at their website http://www.meningitis.organd the test yourself case histories in the document “doctor’s in training” http://www.meningitis.org/assets/x/50156. The earlier meningitis is diagnosed and treated the better the outcome, so Meningitis Awareness Week is definitely a good thing BUT should meningitis really be compared to meningococcal sepsis?!
Some Doctors get very confused about meningitis and meningococcal sepsis and this leads to missed diagnosis, disability and death. To my mind the confusion comes about for 3 reasons:
Reason 1:
Meningitis and meningococcal sepsis are discussed together and therefore people think they are the same disease – they are not. So why are meningitis and meningococcal sepsis discussed at the same time?
Answer: They can be caused by the same bacteria, Neisseria meningitidis.
However, meningitis and meningococcal sepsis are different types of infection and the conditions present in different ways. In the same way that Staphylococcus aureus can cause cellulitis, septic arthritis, osteomyelitis, pneumonia and infective endocarditis (all different infections caused by the same bacteria), Neisseria meningitis can cause meningitis
and meningococcal sepsis.
Reason 1:
Meningitis and meningococcal sepsis are discussed together and therefore people think they are the same disease – they are not. So why are meningitis and meningococcal sepsis discussed at the same time?
Answer: They can be caused by the same bacteria, Neisseria meningitidis.
However, meningitis and meningococcal sepsis are different types of infection and the conditions present in different ways. In the same way that Staphylococcus aureus can cause cellulitis, septic arthritis, osteomyelitis, pneumonia and infective endocarditis (all different infections caused by the same bacteria), Neisseria meningitis can cause meningitis
and meningococcal sepsis.
Meningitis is inflammation of the meninges (the fibrous layers surrounding the brain and spinal cord) caused by many different micro-organisms not just N. meningitidis. Untreated it leads to brain damage and eventually death,
although this usually takes a number of hours to days.
Meningitis typically presents with fever, headache, photophobia and neck stiffness progressing to seizures and focal neurological signs if untreated.
Meningococcal sepsis is an infection of the blood
stream with N. meningitidis which leads rapidly to multi-organ failure and death in minutes to hours. Meningococcal sepsis typically presents with fever, hypotension, lethargy, reduced consciousness and a rapidly progressive rash.
Symptoms
although this usually takes a number of hours to days.
Meningitis typically presents with fever, headache, photophobia and neck stiffness progressing to seizures and focal neurological signs if untreated.
Meningococcal sepsis is an infection of the blood
stream with N. meningitidis which leads rapidly to multi-organ failure and death in minutes to hours. Meningococcal sepsis typically presents with fever, hypotension, lethargy, reduced consciousness and a rapidly progressive rash.
Symptoms
| Meningitis: • Fever / vomiting • Severe headache • Dislike of bright lights • Stiff neck • Seizures • Rash (there may be NO rash) • Very sleepy / vacant / difficult to wake • Confused / delirious | Meningococcal sepsis: • Fever / vomiting • Limb / joint / muscle pain • Cold hands & feet /shivering • Pale or mottled skin • Breathing fast /breathless • Rash • Very Sleepy / vacant / difficult to wake • Confused / delirious Source: http://www.meningitis.org |
Remember: it is possible to have both types of infection at the same time but this is not necessarily the case.
Reason 2: The infamous rash! The “tumbler test” used to detect a non-blanching rash (which fails to disappear with pressure) is often used as a sign of meningitis – this is incorrect, the non-blanching rash is a sign of meningococcal
sepsis.
The rash is often the most “known” and publicised symptom for concerned parents. The “tumbler test” is advised to detect a non-blanching rash but this is a late sign of disease and is really there to try and help as a backup system for when people have failed to notice how unwell a child is. Doctors need to remember that other bacteria such as Streptococcus pneumoniaeand Haemophilus influenzae
do not present with a rash but do cause meningitis. Doctors waiting for a rash will miss a diagnosis. The rash is occurs in meningococcal sepsis.
Reason 2: The infamous rash! The “tumbler test” used to detect a non-blanching rash (which fails to disappear with pressure) is often used as a sign of meningitis – this is incorrect, the non-blanching rash is a sign of meningococcal
sepsis.
The rash is often the most “known” and publicised symptom for concerned parents. The “tumbler test” is advised to detect a non-blanching rash but this is a late sign of disease and is really there to try and help as a backup system for when people have failed to notice how unwell a child is. Doctors need to remember that other bacteria such as Streptococcus pneumoniaeand Haemophilus influenzae
do not present with a rash but do cause meningitis. Doctors waiting for a rash will miss a diagnosis. The rash is occurs in meningococcal sepsis.
Click for larger image
Confusing the conditions leads to doctors not recognising the signs and this can lead to incorrect diagnosis and treatment. I have seen healthcare staff say a patient with a rapidly progressive rash doesn’t have meningitis because they don’t have headache, photophobia etc and therefore they send the patient home despite a glaring diagnosis of meningococcal sepsis. Conversely I have seen meningitis
“excluded”because a patient with fever, headache and photophobia didn’t have a rash.
Reason 3: People think that a rapidly spreading blanching rash (i.e. disappears with pressure) is not a symptom of meningococcal sepsis – it can be!
The rash of meningococcal sepsis begins as a blanching rash that rapidly spreads over the body. It is caused by bacterial invasion of the capillaries supplying the skin which in turn triggers an inflammatory reaction in the skin supplied by that blood vessel. Inflammation blanches, i.e. it disappears with pressure. After a period of time (from minutes to hours) this bacterial invasion causes necrosis by cutting off the blood supply to the skin and hence the skin lesions become non-blanching. The infamous non-blanching rash is therefore a late sign and its absence should not be used to rule out a diagnosis of meningococcal sepsis by healthcare staff.
So what should you know?
Meningitis and meningococcal sepsis kill rapidly, learn how to recognise each condition separately and know how to treat them.
“excluded”because a patient with fever, headache and photophobia didn’t have a rash.
Reason 3: People think that a rapidly spreading blanching rash (i.e. disappears with pressure) is not a symptom of meningococcal sepsis – it can be!
The rash of meningococcal sepsis begins as a blanching rash that rapidly spreads over the body. It is caused by bacterial invasion of the capillaries supplying the skin which in turn triggers an inflammatory reaction in the skin supplied by that blood vessel. Inflammation blanches, i.e. it disappears with pressure. After a period of time (from minutes to hours) this bacterial invasion causes necrosis by cutting off the blood supply to the skin and hence the skin lesions become non-blanching. The infamous non-blanching rash is therefore a late sign and its absence should not be used to rule out a diagnosis of meningococcal sepsis by healthcare staff.
So what should you know?
- If any patient is unwell then meningitis and sepsis should be part of the differential diagnosis
- Both conditions are medical emergencies and antibiotics should be given as quickly as possible,
definitely within 1 hour of presentation, usually IV Cefotaxime or Ceftriaxone (as they cover N.
meningitidis, S. pneumoniae and H. influenzae) - If meningococcal sepsis is suspected IM Benzylpenicillin should be given immediately (highly
appropriate to be given in primary care) as this can be life saving - Meningitis and meningococcal sepsis are different conditions and therefore they present in different ways even though they are caused by the same bacteria, do not get the symptoms and signs mixed up (but be aware that patients can have
both conditions at the same time) - The rash of meningococcal sepsis starts blanching and then becomes non-blanching, do not be lulled into a
false sense of security by a rapidly progressive rash that is blanching, it is entirely in keeping with meningococcal sepsis - Patients do not have to have a rash to have Meningitis...assess all the patient’s symptoms
Meningitis and meningococcal sepsis kill rapidly, learn how to recognise each condition separately and know how to treat them.
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