1. Mortality & Morbidity Conference
Presented by R4 李軒慶
Supervisor: Dr. 吳孟書
Moderator: Dr. 邱德發

2. Patient Profile 14 year-old boy 到院時間: 2008/03/19 15:58 檢傷主訴: 頭痛, 重度疼痛
T/P/R: 36.7/107/ BP:
GCS: E4V5M6
PH: No significant disease before

3. Symptoms Vomiting noted this noon Fever yesterday Headache(+)
No diarrhea or abdominal pain
No dysuria or cough
No BW loss

4. Physical Examination General appearance: ill
Conscious: clear, E4V5M6 Pupil: 3+/3+
Neck: supple, no Kernig sign or Brudzinski sign
HEENT: not anemic, not icteric
no JVE, no LAP
throat: not injected; no pus
tonsil: not swelling; no pus
Chest: BS: clear HS: RHB without murmur
Abdomen: soft & flat, no tenderness
no rebounding pain
bowel sound: normoactive
Extremity: free movable

5. Initial Impression
URI?
Sepsis?
Meningitis?
Malinger?

6. Initial Order (16:08) CBC/DC BUN/Cr, ALT, Na/K, CRP, F/S B/C CXR U/A
IVF: N/S run 150ml/hr
Ketorolac 1amp IM stat
Check BP stat  122/67

7. What else do you want to know about history taking & physical examination?

8. Further Information Obtained…
校護: 2~3 週前校內有一流行性腦膜炎個案，但病人和他無明確接觸病史
病患為住校生

9. Picture of skin lesion on 3/19

11. Laboratory Data BUN 11 Creatinine 0.8 Na 135 K 3.7 ALT 16 CRP 157.38
F/S
137
WBC
22400
Seg/Band
91.5/0.5
Lym 5%
Mono 3% Hb
13.8
MCV
85.4
Platelet
219K

12. CXR

13. U/A Color Yellow Turbidity Clear SP.Gravity 1.013 pH 6.0 Leukocyte
Negative
Nitrite
Protein
Glucose
Negative
Ketone
Urobilinogen
0.1
Bilirubin
Blood
Trace
RBC/WBC
3/5
Epithelial cell

14. What’s your impression now?
What will you do next?

15. Following Course in ER (Turbid fluid; Pressure: 160/140 mmH2O)
Ciprofloxacin 2# po stat at (17:02)
Lumbar puncture performed (17:26)
(Turbid fluid; Pressure: 160/140 mmH2O)
On critical
Penicillin 1PC IVF stat
Rocephin 4PC IV stat
Admission to PICU

16. CSF Routine ( reported at 19:12)
Color
Yellow
Appearance
Turbid
Sugar
< 5
Protein
332
RBC 12
RBC (fresh:old)
80:20
WBC
9070
Neurtrophil
99%
Monocyte 1%
Lymphocyte
GNDC 2+
Cryptococcus
Negative
AFB
India Ink

17. What are you supposed to do next?

18. 傳染病通報 & 隔離 & 消毒 第二類法定傳染病 通報時限: 24 小時 呼吸道隔離至開始投予抗生素24小時後
病人之鼻腔、喉嚨分泌物和受其污染的物品實施消毒

19. Culture (Reported on 3/20)
B/C: Neisseria meningitidis
CSF culture: Neisseria meningitidis
藥敏試驗
Ceftriaxone S
Meropenem
Penicillin

20. Following Course after Admission
Activity improved without fever under antibiotic treatment (Rocephin + Penicillin G)
Transferred to general ward 24 hours after
Discharge on 3/30

21. Discussion Meningeal signs in meningococcal meningitis
Meningococcal disease

22. How to perform meningism test?

23. Meningeal Signs Kernig sign  Brudzinski sign 
Patients in the supine position with the hip and knee flexed at 90o, cannot extend the knee more than 135o and/or there is flexion of the opposite knee
Brudzinski sign 
Patients in the supine position, flexes the lower extremities during attempted passive flexion of the neck

24. Clinical recognition of meningococcal disease in children and adolescents. [Lancet. 367(9508): , 2006 Feb 4.]

25. Bacterial meningitis without clinical signs of meningeal irritation-- Southern Medical Journal. 75(4):448-50, 1982 April
1,064 cases of bacterial meningitis beyond the neonatal period reviewed
16 (1.5%) patients had none of meningeal signs during the entire hospitalization ( despite CSF pleocytosis) [8 patients were ≧ 2 y/o]
Neisseria meningitidis : 7
Hemophilus influenzae: 6
Streptococcus pneumoniae: 2
Salmonella enteritidis: 1

26. Meningococcal Disease
傳染途徑: 飛沫; 接觸病患鼻咽分泌物
好發季節: 春,冬
潛伏期: 2~10 天
好發年齡: 50%  < 2 y/o
25%  > 30 y/o
Mortality rate: 10% generally
(Highest among 15~24 y/o)
Risk Factor: Viral infection(especially influenza)
Smoking and smoke exposure
Crowded living conditions
Underlying chronic diseases
Low socioeconomic status

27. Clinical Pattern Common: 1.Bacteremia without sepsis:
fever & URI signs, without other typical signs
resolve spontaneously without ABx
2. Sepsis
3. Meningitis
4. Combine sepsis & meningitis (Most common)
Uncommon: endocarditis, purulent pericarditis, pneumonia, endophthalmitis, mesenteric lymphadenitis, osteomyelitis, sinusitis, otitis media, and periorbital cellulitis

28. Clinical Manifestation
Non-specific:
sudden onset of fever
nausea/vomiting
headache
decreased ability of concentrate
myalgia
sorethroat
coryza
Classic late signs:
Meningismus
Hemorrhagic rash
Conscious disturbance
Worrisome signs (Early sepsis signs):
Leg pain
Cold hands & feet
Skin palor or mottling

29. Clinical recognition of meningococcal disease in children and adolescents. [Lancet. 367(9508): , 2006 Feb 4.]

30. Typical Meningococcal Skin Rash American Academy of Pediatrics: Red Book: 2006 Report of the Committee on Infectious Diseases, 27th ed. Elk Grove Village, IL, American Academy of Pediatrics, 2006, Atlas 7

31. Diagnosis & Treatment CSF study & Blood culture
Antibiotic: (5~7 days for hospitalized patients)
1. Penicillin G
(250,000–400,000 U/kg/day divided every 4–6 hr IV)
2. Cefotaxime (200 mg/kg/day)
3. Ceftriaxone (100 mg/kg/day)

32. Prevention
Antibiotic prophylaxis
Vaccination

33. Antibiotic Prophylaxis- Candidates
1.Household, daycare, and nursery school contacts
2.Those who have had contact with the patient's oral secretions during the 7 days before onset of illness
3.Medical personnel with intimate exposure (mouth-to-mouth resuscitation, intubation, or suctioning before antibiotic therapy was begun)
 Those without intimate exposure do not need
routine ABx prophylaxis
4. Patients treated with penicillin before hospital discharge (Because Penicillin does not eradicate nasopharyngeal carriage)

34. Antibiotic Prophylaxis - Choices
1. Rifampin
(10 mg/kg orally every 12 hr for a total of 4 doses; maximum dose 600 mg; 5 mg/kg/dose for infants <1 mo of age)
2. Ceftriaxone
(125 mg in a single dose IM for children <12 yr of age; 250 mg in a single dose IM for those >12 yr of age
3. Ciprofloxacin
(500 mg orally as a single dose; may be given to persons >18 yr of age)

35. Vaccination (approved by FDA)
MCV4 (2005 Jan. 開始臨床使用)
--> for 11~55 y/o
MPSV4
--> for 2~10 & > 55 y/o
接種時機: 前往流行地區七天前辦理接種 (免疫效果約在接種七天以後產生)
大流行發生時
流行地區:
亞洲地區
沙烏地阿拉伯、尼泊爾、印度、蒙古共和國。
      非洲地區
塞內加爾、甘比亞、幾內亞比索、幾內亞、馬利、象牙海岸、布吉納法索、
迦納、多哥、貝南、尼日、奈及利亞、查德、喀麥隆、中非、蘇丹、衣索比
亞、吉布地、索馬利亞、浦隆地、薩伊、盧安達。
[資料來源: 衛生署疾病管制局]