Saturday, July 11, 2009

A Disease You Don't Want To Get

If you want to get people in my office to jump, say the words Meningococcal Meningitis. Meningococcal meningitis is bad, bad, bad.

First, a little background. A lot of people freak when they hear the word meningitis. We spend a lot of time calming people down when someone they know if diagnosed with meningitis. Meningitis is simply an inflammation of the meninges, a protective layer that goes around the spinal cord and brain. The most common symptom is headache, and a lot of unexplained severe headaches are diagnosed as meningitis. Lots of things can cause meningitis. Viruses. Bacteria. I once investigated a case where a guy had meningitis due to mold growing in his cerebral-spinal fluid (not good). Fungus can cause it. Sometimes the docs aren't able to isolate the cause, and they call it aseptic. To decipher the cause of the meningitis, a spinal tap is taken. The CSF is typically then run through a variety of bacterial panels -- bacterial generally being the most deadly. If that comes up negative, or if the doc strongly suspects another cause, it can be tested for viruses or other bugs. West Nile can cause viral meningitis. The most common menigitis we see is caused by enterovirus, we see that a lot in little kids, especially in the summer.

For most cases of meningitis, there is no public health response. This is confusing for some people who have heard about people getting shots after exposure to meningitis. Meningococcal meningitis is another story though. Meningococcal meningitis can be really, really bad.

So here is a case that I worked not long ago. Identifying details have been changed out of respect to the patient.

It is a Friday afternoon (because all bad things happen on Friday afternoons -- more so if it is a holiday weekend, but this wasn't). I get a call from one of the hospitals. They have a patient with a presumptive positive (this is a preliminary and not confirmatory -- it later was confirmed) meningococcal test in the CSF. The patient came in to the ER complaining of high fever, headache, and stiff neck.

An interruption -- when we say stiff neck, we don't mean sore. We mean STIFF. Like, it hurts to touch your chin to your chest and/or you can't hardly move your neck at all.

He also had a petiacial rash. The rash is a bad sign. If you have all these things, you need to get to the ER FAST. These are the patients who are healthy in the morning and dead in the evening.

So. The patient had been infused with a ton of antibiotics and moved to the ICU, where he was on a ventilator. His wife was in the ICU with him. The doctors at the hospital had already started the wife on cipro as a precautionary measure, and healthcare workers who had had close contact with him had also taken a dose.

Meningococcal meningitis is spread through saliva. Actually, a fair percentage of people are carriers. They carry it in their nasal passages. It's transient -- so it's not like they will always be carriers. But they don't get sick.

Why? That I can't tell you. Why does one person carry the bacteria with no illness whatsoever, and another die from it? That is the hard question I am always asked.

When someone is diagnosed with meningococcal meningitis, our job here in public health is to identify others who may have been exposed within the 2 weeks before the person showed symptoms, so that we can get them on preventive meds. All household members and sexual contacts are given antibiotics. Then we look for anyone else who may have kissed the person, shared a cigarette, drank after the person, shared other food, maybe that person coughed in their face? Any way that someone could have come in contact with that person's spit. For babies, we will medicate the whole daycare class, we're not taking any chances there. We've found some interesting ones: a girl who had attended a sex party with at least 30 other people, a tuba player who had shared his new mouthpiece with other members of the band, a developmentally disabled woman who liked to spit at people. It takes a lot of interviews to find these people, I can assure you.

In this case, it was only his wife. Of course, I could not talk to the patient. Sometimes other people will come out of the woodwork, lovers and whatnot, but none in this case. I did speak with his work place -- no one could come up with any exposures there, but I had to do a lot of education (including giving a lunch-time presentation to the frightened employees with a Q&A session).

The patient developed multi-system organ failure and we located the death forms. And we all felt really bad for him. And for his wife.

But then. That guy was a fighter. He fought and fought. And every day we called the hospital to check on him to find he was still alive. And after a while, we put the death forms away. He was going to make it.

After two months in the hospital, he was discharged to a long-term care hospital. The doctor who told me about this was very excited. All the folks at the hospital who cared for him were. They saved him! Even they didn't think he would make it.

I requested a copy of his chart for the record. At discharge, he was off the vent but required oxygen. His kidneys were fried -- he would be on dialysis from now on. One leg was amputated due to necrosis. He had necrotic tissue on his face and arms, and was under the treatment of a burn specialist. Three fingers on one hand had been amputated. He was fed through a GI tube.

Two days later, he was in the ER of another hospital. He had spiked a fever -- he had a bloodstream infection, likely from his wounds. They admitted him. He stayed another two months in this hospital. He lost the other leg, and one of his arms (the one with this missing fingers). He was on high doses of anti-depressants. He had significant scaring on his face, to the point of being virtually unrecognizable. He was again discharged to a long-term care facility.

There is a vaccine against meningococcal meningitis. It is recommended for people in group settings, especially college students (all that spit-swapping, something's bound to be transmitted).

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