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CASE REPORT

CASE REPORT. Vedran Stevanović, MD Branko Miše, MD Ward for preschool and school-aged children Pediatric Infectious Diseases Department University Hospital for Infectious Diseases 16.03.2018. PATIENT HISTORY. 17 year - old male PRESENT ILLNESS:

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CASE REPORT

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  1. CASE REPORT Vedran Stevanović, MD Branko Miše, MD Ward for preschool and school-aged children Pediatric Infectious Diseases Department University Hospital for Infectious Diseases 16.03.2018.

  2. PATIENT HISTORY • 17 year-old male • PRESENT ILLNESS: • 28.05.2017., one hospital in Zagreb = 1st day of illness: • Fever of 40.0 °C with cough • Therapy: two salbutamol inhalations, then discharged • 29.05.2017., one hospital in Zagreb = 2nd day of illness : • FEVER, occipital HEADACHE, soar thorat, LEG PAIN(„like I have no legs”), vomited 3x, diarrhea 3x • PAST MEDICAL HISTORY: asthma; chronic therapy: Flixotide, Ventolin • EPIDEMIOLOGIC INFORMATION: He lives in Zagreb, in a flat with his family, he is a second grade student of an industrial school, sporadic case. No contact with animals, no tick bite. Travelling: Rijeka 10 days ago, occasionally visits family in B&H

  3. PHYSICAL EXAMINATION: weight 115kg, • BP 110/60 mmHg, HR 70/min, RF 15/min, SpO2 100%, Ttymp 37.3 st C, • Somnolence, GCS 13, oriented, afebrile after antipyretic medications, difficulty walking, diminished patient appearance. Meningeal signs positive. Skin: without rash or signs of bleeding, in the scalp area parietally left one hematoma 5x5cm with red outer layer, above skin surface, painless. Mucosas: petechial hemorrhages of the soft palate

  4. LABORATORY AND FURTHER EXAMS • L 29.5 (seg 67, neseg 20, ly 2, mo 6)%; CRP 185 • Consiliary neuropediatrician; Skull X-ray; Consiliary ophthalmologist • Emergency CT head: Arachnoid cyst of the left middle cranial fossa with dimensions 42x20mm (Galassi 1) that compresses left temporal parenchyma. Oedema of the right maxillary sinus mucosa – acute sinusitis.

  5. ARACHNOID CYST • Congenital • Usually located within the subarachnoid space and contain CSF • Usually asymptomatic • Usually discovered by accident (CT, MRI) • 1% of all intracranial masses; 2:1 M:F • TH / surgery if symptoms present

  6. PURULENT MENINGITIS? Our ER 19:20hceftriaxon 1x2g i.v. (1. dose) ADMISSION

  7. 2 BC – Sterile; Throat swab culture – neg;  Nasopharyngeal swab culture – normal flora.Chest X-ray – normal finding.

  8. Diagnosis? Lumbar puncture? Yes or no?Therapy?

  9. 30.05. Lumbar puncture (CSF): • 17 920 st /3 • (poli 78%, mono 22)% • (ne 76, ly 7, mo 8)% • prot 2.66, GUL 1.4, Cl 120, lactate 10.87 • E 1530/3 • CSF culture: Sterile • Blood – PCR Neisseria meningitidis –POSITIVE for serotype Y • Thorax and abdomen US: normal finding • 31.05. Head CT: no change in contrast to the previous CTEEG: diffusely irregular • TH / • ceftriaxone 2x2g i.v. 11 days • phenobarbiton • Flixotide + Ventolin • 10% Manitol for 5 days

  10. Neisseria meningitidis • The main cause of bacterial meningitis in children and young adults • Exclusively infects humans • Transmission: saliva and respiratory secretions during coughing, sneezing, kissing • Winter months Begovac J., Božinović D., Lisić M., Baršić B., Schonwald S. Infektologija. 1. izdanje. Zagreb: Profil International; 2006:672-674; European Centre for Disease Prevention and Control. Invasive meningococcal disease. In: ECDC. Annual epidemiological report for 2015. Stockholm: ECDC; 2017.

  11. European Centre for Disease Prevention and Control. Invasive meningococcal disease. In: ECDC. Annual epidemiological report for 2015. Stockholm: ECDC; 2017.

  12. RISK FACTORS • Nasopharyngeal carriage (about 10% of adults and 15-25% of adolescents are carriers of the bacteria) • Complement component deficiencies (C5-C9, propreridin, factor H ili factor D) • Defect in the membrane attack complex (MAC) • Functional or anatomic asplenia, including sickle cell disease • Patients receiving eculizumab – paroxysmal nocturnal hemoglobinuria (PNH) and atypical hemolytic uremic syndrome (aHUS) Begovac J., Božinović D., Lisić M., Baršić B., Schonwald S. Infektologija. 1. izdanje. Zagreb: Profil International; 2006:672-674; American Academy of Pediatrics Red Book: 2015 Report of the Committee on Infectious Diseases. 30th ed. Elk GroveVillage, IL: American Academy of Pediatrics; 2015:249-252

  13. Serotype B European Centre for Disease Prevention and Control. Invasive meningococcal disease. In: ECDC. Annual epidemiological report for 2015. Stockholm: ECDC; 2017.

  14. Incubation Period: 48-72h ( 1-10 days) • EPIDEMIC AND ENDEMIC MENINGOCOCCAL INFECTION • Mortality rates in patients with meningococcal meningitis = 10-15% despite antibiotic treatment • Mortality rates in patients with meningococcal sepsis = >40% • Sequelae associated with meningococcal disease occud in 11-19% of survivors and include: • Hearing loss, neurologic disability, • Digit or limb amputations, • Skin scarring Begovac J., Božinović D., Lisić M., Baršić B., Schonwald S. Infektologija. 1. izdanje. Zagreb: Profil International; 2006:672-674; American Academy of Pediatrics Red Book: 2015 Report of the Committee on Infectious Diseases. 30th ed. Elk GroveVillage, IL: American Academy of Pediatrics; 2015:249-252

  15. CLINICAL PRESENTATION • 5-15 years • ABNORMAL SKIN COLOUR • COLD HANDS AND FEET • LEG PAIN • HAEMORRHAGIC RASH 81% • NECK STIFFNESS 77% • Headache, photophobia • Fever • Vomiting • <1 year • ABNORMAL SKIN COLOUR • COLD HANDS AND FEET • BREATHING DIFFICULTY • RASH 42% • Irritability • Bulging fontanelle 11-30% • Seizures 8-40% • Drowsiness • Poor appetite or feeding • Vomiting or diarrhoea • Hypothermia or hyperthermia • 1-4 years • ABNORMAL SKIN COLOUR • COLD HANDS AND FEET • LEG PAIN • RASH 81% • NECK STIFFNESS 77% • Confusion (e.g. child does not recognise mother) • Photopohobia • Fever 94% • Vomiting 82% Thompson MJ, Ninis N, Perera R, Mayon-White R, Philips C, Bailey L et al . Clinical recognition of meningococcal disease in children and adolescents. The Lancet 2006; 367:397-403; Begovac J., Božinović D., Lisić M., Baršić B., Schonwald S. Infektologija. 1. izdanje. Zagreb: Profil International; 2006:672-674

  16. 15.02.2018. The same patient • PRESENT ILLNESS : FEVER of 38.8 °C, HEADACHE frontally, LEG PAIN, vomited 1x • PHYSICAL EXAMINATION: BP 120/80mmHg, HR 98/min, RF 16/min, Ttymp 39.7 °C • Conscient, oriented, Meningeal signs negative. Skin erythema of the abdomen and lower legs. Herpes labialis of the upper lip. Trismus (with neck pain upon opening the mouth). Throat: normal finding. WE LOOK FOR HAEMORRHAGIC RASH! WE DO NOT SEE IT! • L 8.2 (ne 94.3, ly 4.8, mo 0.8)%; Trc 178; • HOSPITALIZATION ? • CRP 37.7; PV 0.72. fbg 3.4; Urin - normal • HOSPITALIZATION ? • PCT 15.57, D-dimers 4.51

  17. BC Sterile; • Throat swab culture – neg;  Nasopharyngeal swab culture– normal flora;Nasopharyngeal swab PCR: influenza type A • Blood – PCR Neisseria meningitidis –POSITIVE for serotype W-135 • EEG – normal EEG rhythms • TH / • 15.-22.02.2018. • ceftriaxone 2x2g i.v.

  18. Why vaccinate? Whom to vaccinate? • EU – ECDC (“BEXSERO” since 2013.) • USA • All in between age 11 to 18 years • Age < 11 or age > 18 years, but with high risk • HIV patients • Travelers or persons living in endemic areas • First year college students living in residence halls, military recruits, microbiologists • Individuals with complrement component • Functional or anatomical asplenia • Individuals treated with eculizumab “MENACTRA or MENVEO” „BEXSERO” or „TRUMENBA”

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