meningitis “In an acute bacterial meningitis, a delay in the diagnosis and in the beginning of the antibiotic treatment can imply serious sequels and even the death”, affirms Marta Fernández Matarrubia, specialist in Neurology of the Clinic University of Navarra (CUN). “In meningitis, especially in bacterial menses, every minute counts,” says Roi Piñeiro Pérez, head of the Pediatric Service of the General Hospital of Villalba (Madrid) and member of the Medicines Committee of the Spanish Association of Pediatrics (AEP). Hence the importance of detecting this disease in time.
Signs that warn of a meningitis
Piñeiro describes the symptoms of meningitis according to the stage of the disease:
The initial signs and symptoms of meningitis are common to many other common pediatric diseases: fever, vomiting, headache, diarrhea, chills, malaise, muscle aches … The very unspecific symptoms in its initial phases make this serious disease almost indistinguishable from any other current clinical picture.
Subsequently, as meningitis develops, classic meningeal signs appear, fundamentally expressed by a stiff neck with intense pain to its mobilization, and vomiting ‘in shotgun’, that is, projective and without previous nausea. “The best way to explain it to families is that the patient would vomit like the El Exorcista girl would.”
Progressively, lethargy, stupor, severe involvement of the general state and seizures may appear. The famous petechiae, tiny reddish spots that do not disappear when the skin is stretched, are not specific to meningitis. In fact, the most frequent cause of the appearance of these small spots is a viral infection. However, if these lesions increase in size rapidly, they are suggestive of the development of bacterial meningitis.
Fernández Matarrubia adds other clinical manifestations that can alert us to meningitis, such as photophobia (excessive sensitivity to light), altered level of consciousness, epileptic seizures and other neurological symptoms and signs.In infants (children under two years of age), the clinical manifestations may be high fever, excessive drowsiness or irritability, inactivity, constant crying and rejection of food.Elderly people may present only altered level of consciousness, without fever or neck stiffness.
Infectious meningitis can be viral, bacterial and fungal
“Meningitis is an inflammation of the membranes (meninges) that surround the brain and spinal cord. Usually, although not always, they have an infectious cause, “says the specialist in Neurology.
Within the meningitis of infectious cause we can distinguish between those produced by viruses, those of bacterial origin and those caused by fungi (more rare). Viral meningitis is benign and usually resolves spontaneously in a matter of days, leaving, in general, a lower rate of complications. “Everything depends on the virus that causes the infection and, above all, the immune response of the host,” Piñeiro points out.
Bacterial meningitis is serious and requires urgent antibiotic treatment. Those that enter the bloodstream and travel to the brain and spinal cord can cause acute bacterial meningitis. Meningitis can also manifest itself when bacteria directly invade the meninges from a focus located in the vicinity, such as an infection of the ear or sinuses, a skull fracture or, in rare cases, after some surgeries.
“Pneumococcus and meningococcus are the bacteria responsible for more than half of acute meningitis in Spain. Pneumococcus is the most common cause of bacterial meningitis in infants, young children and adults. Meningococcal meningitis is a highly contagious infection that mainly affects adolescents and young adults. It can cause a local epidemic in schools, residences, boarding schools and similar centers “, describes Fernández Matarrubia.
“The prognosis of bacterial meningitis also depends on the causative bacteria and the response of the host, but the overall mortality and morbidity figures are high, in many cases regardless of the treatment used. Depending on the age of the child, mortality can vary between 10 and 30 percent, and the sequelae among survivors can be as serious as, for example, limb amputation, neurological problems or kidney failure, “says the head of Pediatrics of the General Hospital of Villalba.
The importance of detecting a meningitis in time
In the case of acute bacterial meningitis, a delay in the diagnosis and the initiation of antibiotic treatment can involve serious sequelae and even death. That is why, “when we suspect an acute meningitis of bacterial origin, we must start urgent intravenous antibiotic treatment, even before performing the diagnostic lumbar puncture. At first, broad-spectrum antibiotics are used and, later, when the results of the culture and antibiogram are available, the treatment is adjusted to the agent identified, “specifies the neurologist.
As Piñeiro explains, meningitis is a difficult disease to diagnose in its initial stages -where treatment would be much more effective-, and easy to diagnose once it has developed -the moment when the therapy is less effective- . In meningitis, especially bacterial meningitis, every minute counts.
For this reason, continues the pediatrician, are so important vaccines that exist today, which are the most effective preventive measure to prevent the development of bacterial meningitis. Among them, the ones financed in Spain stand out: pneumococcus, Haemophilus influenzae and meningococcal C. In addition, “there are others not financed that pediatricians will never tire of recommending and struggling to be included in the funded calendar. The latter would be the vaccine that protects against meningococcus B and a tetravalent vaccine that protects against four other meningococcal serotypes: A, C, W and Y. None of them has shown a hundred percent protection, but they are currently the measure more effective preventive “.
Risks and complications of a delay in diagnosis
“Bacterial meningitis is serious and can be fatal in a few days without adequate antibiotic treatment. The delay in the diagnosis and treatment increases the risk of permanent brain damage or death, “says the neurologist at the Clínica Universidad de Navarra.
Complications of meningitis include cerebral edema, hydrocephalus, venous sinus thrombosis, cranial nerve palsy, epileptic seizures, septic shock, kidney failure, among others.With appropriate treatment, administered on time, even patients with potentially serious meningitis can have a good recovery without sequelae.
In this regard, Pineiro makes the following reflection: “The fundamental problem of bacterial meningitis is that during the first hours of the disease the child can present excellent general condition and simulate any banal disease. However, in a matter of hours, the clinical picture worsens sharply, developing a serious illness. Early diagnosis is complex, even by the best pediatricians in our country. These paintings are called fulminants because they are so, of sudden and unexpected evolution. And nobody is usually to blame; nor the pediatrician who did not know how to see it in time, nor the family who consulted too late. ”
With what other diseases can it be confused?
“The first symptoms of meningitis can be nonspecific and confused with those that can occur at the onset of influenza, for example. However, the appearance of intense headache -distinct to the usual-, vomiting ‘in shotgun’ and the rigidity of the neck muscles should alert us that it may be a meningitis. Before the appearance of these symptoms we should consult in the Urgencies of our nearest center “, says Fernández Matarrubia.Pineiro adds that in the early stages of meningitis can be confused with any: upper respiratory infection (cold), influenza, gastroenteritis … In advanced stages, the diagnosis usually offers no doubt.
Measures to avoid contagion
Do we have to follow measures of some kind in the family or at school to avoid contagion when a case of meningitis is diagnosed? “Only in the case of bacterial meningitis. Depending on the number of cases diagnosed and whether or not they belong to the same class, there are a series of prophylaxis guidelines with antibiotics to try to avoid the contagion or the development of the disease. In cases of viral meningitis, the only possible preventive measure is hand washing. For the viral ones, there are no vaccines available either, clarifies the pediatrician.
“The prevention of bacterial meningitis is done through two main measures: vaccination and chemoprophylaxis,” says the neurologist.With vaccination, the individual is immunized against a germ and thus is prevented from acquiring the infection. The inclusion of conjugate vaccines against pneumococcus, meningococcus C and Haemophilus influenzae type b in routine immunization schedules has caused a significant decrease in the incidence of these diseases.
Chemoprophylaxis is the administration of an antibiotic for short periods of time to people who have been in contact with a patient diagnosed with meningitis. Not all types of meningitis require antibiotic prophylaxis for contacts, specifically pneumococcal meningitis (the most common type of meningitis) does not require chemoprophylaxis. However, close contacts of patients with invasive meningococcal disease are more likely to contract the disease within seven days, so chemoprophylaxis will be indicated in certain cases.
In the event that a case of meningococcal meningitis has been diagnosed, all persons who have had close contact with the “index case” in the previous seven days should take antibiotic prophylaxis.
What is meant by close contact?
Have had prolonged contact (eight hours or more) and also close (90 cm is the general limit established for the dissemination of large droplets) with the case of meningococcal meningococcus or who have been directly exposed to the patient’s oral secretions (for example, when kissing in the mouth, carrying out mouth-to-mouth resuscitation maneuvers, etc.) during the week prior to the onset of symptoms and up to 24 hours after the start of antibiotic treatment.
This group would include all members of the household (or similar contexts such as shared apartments), roommates, members and staff of the nursery classroom or early childhood centers.”It would not be justified, however, to administer chemoprophylaxis to all students who attend the same class or center of primary, secondary and university education, unless they have had close contact with the case,” concludes Fernández Matarrubia.