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Mortality & Morbidity
Conference
Presented by R4 李軒慶
Supervisor: Dr. 吳孟書
Moderator: Dr. 邱德發
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: 36.7/107/21
BP:
GCS: E4V5M6
 PH: No significant disease before

Symptoms
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Vomiting noted this noon
Fever yesterday
Headache(+)
No diarrhea or abdominal pain
No dysuria or cough
No BW loss
Physical Examination
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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
Initial Impression
URI?
 Sepsis?
 Meningitis?
 Malinger?

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

What else do you want to know about
history taking & physical examination?
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
Picture of skin lesion on 3/19
Laboratory Data
BUN
11
WBC
22400
Creatinine
0.8
Seg/Band 91.5/0.5
Na
135
Lym
5%
K
3.7
Mono
3%
ALT
16
CRP
157.38
Hb
13.8
F/S
137
MCV
85.4
Platelet
219K
CXR
U/A
Color
Yellow
Glucose
Negative
Turbidity
Clear
Ketone
Negative
SP.Gravity
1.013
Urobilinogen
0.1
pH
6.0
Bilirubin
Negative
Leukocyte
Negative
Blood
Trace
Nitrite
Negative
RBC/WBC
3/5
Protein
Negative
Epithelial cell
0
What’s
your impression now?
What will you do next?
Following Course in ER


Ciprofloxacin 2# po stat at (17:02)
Lumbar puncture performed (17:26)
(Turbid fluid; Pressure: 160/140 mmH2O)
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
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On critical
Penicillin 1PC IVF stat
Rocephin 4PC IV stat
Admission to PICU
CSF Routine ( reported at 19:12)
Color
Yellow
Appearance Turbid
Neurtrophil 99%
Monocyte
1%
Lymphocyte
0
GNDC
2+
Cryptococcus
Negative
Sugar
<5
Protein
332
RBC
12
RBC
80:20
AFB
Negative
WBC
9070
India Ink
Negative
(fresh:old)
 What
are you supposed to do next?
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

Culture (Reported on 3/20)


B/C: Neisseria meningitidis
CSF culture: Neisseria meningitidis
藥敏試驗
Ceftriaxone
S
Meropenem
S
Penicillin
S
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

Discussion
 Meningeal
signs in
meningococcal meningitis
 Meningococcal disease
How to perform meningism test?
Meningeal Signs

Kernig 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
Clinical recognition of meningococcal disease in children and adolescents. [Lancet.
367(9508):397-403, 2006 Feb 4.]
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
Meningococcal Disease
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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
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
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
Clinical recognition of meningococcal disease in children and adolescents. [Lancet.
367(9508):397-403, 2006 Feb 4.]
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
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)
Prevention
 Antibiotic
prophylaxis
 Vaccination
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)
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)
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]