Annals of Tropical Paediatrics International Child Health
ISSN: 0272-4936 (Print) 1465-3281 (Online) Journal homepage: http://www.tandfonline.com/loi/ypch19
Prognostic factors influencing mortality in meningococcal meningitis S. Fakhir, S. H. Ahmad & P. Ahmad To cite this article: S. Fakhir, S. H. Ahmad & P. Ahmad (1992) Prognostic factors influencing mortality in meningococcal meningitis, Annals of Tropical Paediatrics, 12:2, 149-154, DOI: 10.1080/02724936.1992.11747560 To link to this article: https://doi.org/10.1080/02724936.1992.11747560
Published online: 13 Jul 2016.
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Annals of Tropical Paediatrics (1992) 12, 149-154
Prognostic factors inftuencing mortality in meningococcal meningitis S. FAKHIR, S. H. AHMAD & P. AHMAD
Department of Pediatrics,J.N. Medical Co/lege, A.M.U., Aligarh, lndia (Received 4 June 1991)
Summary The clinical features and sorne laboratory parameters of 247 cases of meningococcal meningitis admitted between January 1983 and April1990 to a paediatric ward in Jawahar Lai Nehru Medical Co liege Hospital, India were analyzed retrospectively. A total of 189 (76.5 ~ 0 ) were more than 5 years of age. The maximum number of cases occurred between October and April each year. Complications included bleeding tendencies, neurological deficits, gangrene of limbs, arthritis, uveitis and cataract. The overall mortality rate was 16%. A scoring system based on sorne clinical characteristics correctly predicted a fatal outcome in ali but three children.
Introduction Prior to 1984, N eisseria meningitidis accounted for only a small percentage of cases of purulent meningitis admitted to the paediatric services of J awahar Lal Nehru Medical College Hospital in Aligarh, India. Epidemies of meningococcal sepsis and meningitis seen between October and April each year since 1984, however, have changed the situation. The present communication attempts to identify the factors associated with high mortality, hoping that their earl y recognition and aggressive management may influence the outcome favourably.
Materials and methods This is a retrospective study based on a case note review of 247 consecutive cases of meningococcal meningitis admitted between 1 January 1983 and 30 April 1990. During Reprint requests to: Dr S. Fakhir, Department of Pediatries, J.N. Medical College, A.M.U., Aligarh202002, U.P., India.
the study period, 1865 cases with a diagnosis of meningitis were admitted; 247 of them bad clinical features compatible with a diagnosis of meningococcal meningitis (fever, headache, haemorrhagic rash, hypotension/ shock, signs of meningeal irritation, etc.). Six patients with a dubious diagnosis of meningococcal meningitis were not included in the study. All the patients were given a detailed neurological examination, including coma grading. 1 Hypotension was defined as a systolic blood pressure of less than 70 mmHg, while the patients with a rapid low volume pulse, cold and clammy skin and unrecordable blood pressure were regarded as being in peripheral circulatory failure. A lumbar puncture was done in all cases. Findings in the CSF of predominant polymorphonuclear leucocytes and a reduction of sugar to less than 50% of blood sugar were taken as suggestive of purulent meningitis. An attempt was also made further to substantiate the diagnosis by demonstrating the organism in a Gram-stained smear and by isolating it from the CSF. Blood and throat
150
S. Fakhir et al. TABLE 1. Age, sex distribution and monality in cases of meningococcal meningitis
Age group 29-364days 1-4 yrs 5-9 yrs 10-14 yrs Total
No. of cases (%)
Male(%)
Female(%)
No. of deaths (%)
6 (2.42) 52 (21.05) 92 (37.24) 97 (39.27)
4 (66.66) 41 (78.84) 62 (67.39) 68 (70.10)
2 (33.33) 11 (21.15) 30 (32.60) 29 (29.89)
2 (33.33) 8 (15.38) 19 (20.65) 11 (11.34)
175 (70.85)
72 (29.14)
40 (16.19)
247
Sex
TABLE Il. Salient symptoms and signs in children with meningococcal meningitis No. of cases Signs and symptoms Fever Irritability Altered sensorium Vomiting Meningeal irritation Rashes Refusai of feeds Headache and/or excessive crying Convulsions Hypotension Shock Neurological deficits Papilloedema
(%)
244 (98.78) 203 (82.18) 183 (74.08) 191 (77.32) 209 (84.61) 193 (78.13) 156 (63.15) 160 (64.77) 134 (54.25) 83 (33.60) 65 (26.31) 21 (8.50) 11 (4.45)
cultures were also obtained together with a Gram-stained smear of the skin rash. Meningococcal serotyping was, however, not carried out. Z test of proportion was used to assess statistical significance.
Results Meningococcal meningitis was responsible for nearly 13% of all cases of meningitis admitted during the study period. The majority of the children (76.5%) were more than 5 years of age. The male:female ratio was 2.43:1 (Table 1). Salient clinical features are given in Table Il. The disease showed a
remarkable seasonal predilection as more than 90% of cases each year were admitted during the dry season (October-April). N. meningitidis was cultured in 143 instances. It included 60 isolated from the CSF, 45 from the blood and 38 from the throat. Furthermore, while CSF as well as blood cultures were positive in 34 cases, a positive blood but negative CSF culture was obtained in 11 cases (Table III). In 10 cases, throat culture yielded organisms other than meningococcus (Streptococcus pneumoniae 4, Staphylococcus a/bus 4 and Staphylococcus aureus 2). Seven of these had positive Gram staining and three had a positive CSF culture for meningococcus. Gram-stained CSF and skin rash smears were wrongly interpreted in 10 and 11 cases, respectively: N. meningococcus was isolated from all these cases, either from CSF or blood. Abnormal CSF findings are shown in Table III also. Complications included bleeding tendencies, gangrene of lower limbs below the knee joint, arthritis, uveitis and ca taract in 21, 1, 3, 3 and 1 case, respectively. Residual neurological deficits on discharge were seen in 18 (7.28%) children. Motor deficits were present in 13 (hemiparesis 12, ataxia 1), loss of vision in three and deafness in two patients. The case fatality was 16%. Twenty-eight deaths occurred within the 1st 24 hours of admission. Another eight succumbed during the next 24 hours, while the remaining four of the 40 died after 96 hours of hospitalization.
240 148
Gram-stained smear CSF Petechial rash
175 (72.91) 90 (60.80)
11 (4.82) 38 (26.57) 55 (22.91) 47 (31.75)
95 (66.43)
160 (68.42) 162 (71.05)
Sterile
10 (4.16)** 11 (7.43)**
10 (6.99)*
18 (7.28) 21 (9.21)
Contaminated 235 (95.14)
12 (4.85)
247
Neutrophil % >50 100
ISSN: 0272-4936 (Print) 1465-3281 (Online) Journal homepage: http://www.tandfonline.com/loi/ypch19
Prognostic factors influencing mortality in meningococcal meningitis S. Fakhir, S. H. Ahmad & P. Ahmad To cite this article: S. Fakhir, S. H. Ahmad & P. Ahmad (1992) Prognostic factors influencing mortality in meningococcal meningitis, Annals of Tropical Paediatrics, 12:2, 149-154, DOI: 10.1080/02724936.1992.11747560 To link to this article: https://doi.org/10.1080/02724936.1992.11747560
Published online: 13 Jul 2016.
Submit your article to this journal
Article views: 1
View related articles
Citing articles: 3 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ypch19
Annals of Tropical Paediatrics (1992) 12, 149-154
Prognostic factors inftuencing mortality in meningococcal meningitis S. FAKHIR, S. H. AHMAD & P. AHMAD
Department of Pediatrics,J.N. Medical Co/lege, A.M.U., Aligarh, lndia (Received 4 June 1991)
Summary The clinical features and sorne laboratory parameters of 247 cases of meningococcal meningitis admitted between January 1983 and April1990 to a paediatric ward in Jawahar Lai Nehru Medical Co liege Hospital, India were analyzed retrospectively. A total of 189 (76.5 ~ 0 ) were more than 5 years of age. The maximum number of cases occurred between October and April each year. Complications included bleeding tendencies, neurological deficits, gangrene of limbs, arthritis, uveitis and cataract. The overall mortality rate was 16%. A scoring system based on sorne clinical characteristics correctly predicted a fatal outcome in ali but three children.
Introduction Prior to 1984, N eisseria meningitidis accounted for only a small percentage of cases of purulent meningitis admitted to the paediatric services of J awahar Lal Nehru Medical College Hospital in Aligarh, India. Epidemies of meningococcal sepsis and meningitis seen between October and April each year since 1984, however, have changed the situation. The present communication attempts to identify the factors associated with high mortality, hoping that their earl y recognition and aggressive management may influence the outcome favourably.
Materials and methods This is a retrospective study based on a case note review of 247 consecutive cases of meningococcal meningitis admitted between 1 January 1983 and 30 April 1990. During Reprint requests to: Dr S. Fakhir, Department of Pediatries, J.N. Medical College, A.M.U., Aligarh202002, U.P., India.
the study period, 1865 cases with a diagnosis of meningitis were admitted; 247 of them bad clinical features compatible with a diagnosis of meningococcal meningitis (fever, headache, haemorrhagic rash, hypotension/ shock, signs of meningeal irritation, etc.). Six patients with a dubious diagnosis of meningococcal meningitis were not included in the study. All the patients were given a detailed neurological examination, including coma grading. 1 Hypotension was defined as a systolic blood pressure of less than 70 mmHg, while the patients with a rapid low volume pulse, cold and clammy skin and unrecordable blood pressure were regarded as being in peripheral circulatory failure. A lumbar puncture was done in all cases. Findings in the CSF of predominant polymorphonuclear leucocytes and a reduction of sugar to less than 50% of blood sugar were taken as suggestive of purulent meningitis. An attempt was also made further to substantiate the diagnosis by demonstrating the organism in a Gram-stained smear and by isolating it from the CSF. Blood and throat
150
S. Fakhir et al. TABLE 1. Age, sex distribution and monality in cases of meningococcal meningitis
Age group 29-364days 1-4 yrs 5-9 yrs 10-14 yrs Total
No. of cases (%)
Male(%)
Female(%)
No. of deaths (%)
6 (2.42) 52 (21.05) 92 (37.24) 97 (39.27)
4 (66.66) 41 (78.84) 62 (67.39) 68 (70.10)
2 (33.33) 11 (21.15) 30 (32.60) 29 (29.89)
2 (33.33) 8 (15.38) 19 (20.65) 11 (11.34)
175 (70.85)
72 (29.14)
40 (16.19)
247
Sex
TABLE Il. Salient symptoms and signs in children with meningococcal meningitis No. of cases Signs and symptoms Fever Irritability Altered sensorium Vomiting Meningeal irritation Rashes Refusai of feeds Headache and/or excessive crying Convulsions Hypotension Shock Neurological deficits Papilloedema
(%)
244 (98.78) 203 (82.18) 183 (74.08) 191 (77.32) 209 (84.61) 193 (78.13) 156 (63.15) 160 (64.77) 134 (54.25) 83 (33.60) 65 (26.31) 21 (8.50) 11 (4.45)
cultures were also obtained together with a Gram-stained smear of the skin rash. Meningococcal serotyping was, however, not carried out. Z test of proportion was used to assess statistical significance.
Results Meningococcal meningitis was responsible for nearly 13% of all cases of meningitis admitted during the study period. The majority of the children (76.5%) were more than 5 years of age. The male:female ratio was 2.43:1 (Table 1). Salient clinical features are given in Table Il. The disease showed a
remarkable seasonal predilection as more than 90% of cases each year were admitted during the dry season (October-April). N. meningitidis was cultured in 143 instances. It included 60 isolated from the CSF, 45 from the blood and 38 from the throat. Furthermore, while CSF as well as blood cultures were positive in 34 cases, a positive blood but negative CSF culture was obtained in 11 cases (Table III). In 10 cases, throat culture yielded organisms other than meningococcus (Streptococcus pneumoniae 4, Staphylococcus a/bus 4 and Staphylococcus aureus 2). Seven of these had positive Gram staining and three had a positive CSF culture for meningococcus. Gram-stained CSF and skin rash smears were wrongly interpreted in 10 and 11 cases, respectively: N. meningococcus was isolated from all these cases, either from CSF or blood. Abnormal CSF findings are shown in Table III also. Complications included bleeding tendencies, gangrene of lower limbs below the knee joint, arthritis, uveitis and ca taract in 21, 1, 3, 3 and 1 case, respectively. Residual neurological deficits on discharge were seen in 18 (7.28%) children. Motor deficits were present in 13 (hemiparesis 12, ataxia 1), loss of vision in three and deafness in two patients. The case fatality was 16%. Twenty-eight deaths occurred within the 1st 24 hours of admission. Another eight succumbed during the next 24 hours, while the remaining four of the 40 died after 96 hours of hospitalization.
240 148
Gram-stained smear CSF Petechial rash
175 (72.91) 90 (60.80)
11 (4.82) 38 (26.57) 55 (22.91) 47 (31.75)
95 (66.43)
160 (68.42) 162 (71.05)
Sterile
10 (4.16)** 11 (7.43)**
10 (6.99)*
18 (7.28) 21 (9.21)
Contaminated 235 (95.14)
12 (4.85)
247
Neutrophil % >50 100
