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A better categorisation of meningococcal rash
- oscar,m jolobe (29 September 2006)
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Letter concerning the article “Meningococcal disease and its management in children”
- Thomas Krasemann (2 October 2006)
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Regarding "Meningococcal disease and its management in children"
- Sanjaya N Senanayake (4 October 2006)
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Vaccine for B Strain is available
- Ivor Cammack (6 October 2006)
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Advances to the care of Paediatric Critical Care patients should be applied to the care of children with meningococcal disease
- Asrar Rashid, Harish Vyas (7 October 2006)
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¿Because Septicaemia?
- guillermo montalvan (8 October 2006)
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Might fundoscopy be useful in diagnosing meningococcal disease?
- Roger H Armour (9 October 2006)
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oscar,m jolobe, retired geriatriacian 1 The Lodge, 842 Wilmslow Road, Didsbury, Manchester, M20 2RN
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It is potentially misleading to dichotomise meningococcal rash as either non-blanching or maculopapular(1). It is less ambiguous simply to say that in some cases it may be non-blanching, but others it may be blanching in character, in the latter instance with or without some non- blanching elements(2). The presence of non-blanching elements would justify urgent admission, but their absence would not unless there were associated features such as cold extremities and skin mottling, the latter two features probably being indicative of peripheral circulatory failure. Even in the absence of cold extermities and skin mottling an exclusively blanching rash would, however,require periodic review to see whether it evolved to include non-blanching elements, which it might well do over a period of several hours(3). References (1) Hart CA., Thomson APJ Meningococcal disease and its management in children British Medical Journal 2006:333:685-90 (2) Marzouk O., Thomson APJ., Sillis JA., Hart CA., Harris F Features and outcome in meningococcal disease presenting with maculopapular rash Archives of Disease in Childhood 1991:66:485-7 (3)Thompson MJ., Ninis N., Perera R., et al Clinical recognition of meningococcal disease in children and adolescents Lancet 2006:367:397-403 Competing interests: None declared |
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Thomas Krasemann, Consultant Paediatric Cardiologist Evelina Children's hospital, Guy's & St Thomas Hospital, Lambeth Palace road, London SE1 7EH
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Dear Sir, The article by Hart and Thomson gives a good overview over common findings in meningococcal disease in children. They even mention atypical presentations like arthritis, osteomyelitis and others. Unfortunately they missed a potentially life-threatening manifestation, which is meningococcal endocarditis. This rare presentation has been described in adults (1) as well as in children (2). The onset might be acute, or complicate the course of septicaemia (3). If endocarditis is the leading manifestation one wouldn’t wait until the PCR-result is back, but initiate treatment. Luckily, the commonly used antibiotics for the treatment of endocarditis of unknown origin will cover neisseria meningitides. References: 1) Benes J, Dzupova O, Kabelkova M, Krizova P, Gabrielova A: Infective endocarditis due to Neisseria meningitidis: two case reports. Clin Microbiol Infect. 2003 Oct;9(10):1062-4 2) Briassoulis G, Kalabalikis P, Thanopoulos V, Hatzis T: Non-Q wave acute myocardial infarction in acute meningococcemia in a 10-year-old girl. Pediatr Emerg Care. 2000 Feb;16(1):33-8 3) Odegaard A: Unusual manifestations of meningococcal infection. A review. NIPH Ann. 1983 Jun;6(1):59-63 Competing interests: None declared |
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Sanjaya N Senanayake, Staff Specialist in Infectious Diseases The Canberra Hospital, Garran, ACT 2604, Australia
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I read with interest the article on meningococcal disease in children;[1] however, some points need to be clarified. With regard to laboratory diagnosis, the authors only briefly mentioned the role of serology and aspirates/ punch biopsies, stating that they weren’t routinely used. While the sensitivity of Gram staining and/or culture of aspirates or biopsies from haemorrhagic skin lesions is only around 60%, the positive predictive value is high in clinically suspected meningococcal disease. In the acute setting, a positive Gram stain of an aspirate from a skin lesion can provide a diagnosis within minutes; also, both cultures and Gram stains of skin lesions will be positive many hours after administrating empiric antibiotic therapy.[2] Serology is also a very useful test: the diagnosis can be made on a single high IgM titre or on a rise between acute and convalescent sera. Furthermore, serology has a sensitivity of almost100% and a specificity of 93%, its only limitation being that a serological diagnosis can’t be made until at least Day 5 of illness.[3, 4] The authors are correct in stating that making a microbiological diagnosis of meningococcal disease should not delay the initiation of antibiotic therapy, especially with the advent of polymerase chain reaction (PCR) assays.[1] PCR assays are not as readily affected by antibiotics as conventional blood and cerebrospinal fluid (CSF) cultures. In fact, the sensitivity of blood cultures for meningococcal disease after antibiotics have been given is only 5%.[5, 6] But despite the relatively superior sensitivity of PCR to cultures in the antibiotic-treated patient, it is important to remember that even PCR assays are not 100% sensitive. The sensitivity of PCR in blood is much lower than in CSF (62-76% versus 89%);[4] therefore, meningococcal infection shouldn’t be excluded solely on the basis of a negative PCR in those with a high clinical suspicion of the disease. The role of immunization in the patient with meningococcal disease was not discussed. It is thought that the immunity generated by immunization with the conjugate C vaccine is superior to that generated by the infection itself. This is particularly so for children; therefore, guidelines do recommend that patients with even serogroup C disease should subsequently receive the conjugate C vaccine. [7, 8] References [1] Hart CA, Thomson AP. Meningococcal disease and its management in children. BMJ 2006;333:685-90. [2] van Deuren M, van Dijke BJ, Koopman RJ, Horrevorts AM, Meis JF, Santman FW, et al. Rapid diagnosis of acute meningococcal infections by needle aspiration or biopsy of skin lesions. BMJ 1993;306:1229-32. [3] Robertson PW, Reinbott P, Duffy Y, Binotto E, Tapsall JW. Confirmation of invasive meningococcal disease by single point estimation of IgM antibody to outer membrane protein of Neisseria meningitidis. Pathology 2001;33:375-8. [4] Munro R. Meningococcal disease: treatable but still terrifying. Intern Med J 2002;32:165-9. [5] Cartwright K, Reilly S, White D, Stuart J. Early treatment with parenteral penicillin in meningococcal disease. BMJ 1992;305:143-7. [6] Hoyne A, Brown R. Meningococcic cases, an analysis. Ann Intern Med 1948;28:248-59. [7] Public Health Laboratory Service, Public Health Medicine Environmental Group, Scottish Centre for Infection and Environmental Health. Guidelines for public health management of meningococcal disease in the UK. Commun Dis Public Health. 2002;5:187-204. [8] Australian Immunisation Handbook. 8th ed. Canberra: National Health and Medical Research Council, 2003. Competing interests: None declared |
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Ivor Cammack, Medical Student Otago University, New Zealand
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The article stated that a vaccine for the group B strain of Neisseria meningitidis is not available. In fact, it is. The MenzB vaccine has been available in New Zealand for some time and was developed specifically for this country's epidemic of group B meningococcal disease. See http://www.menzb.com/menzb-vaccine.htm for more details. Competing interests: None declared |
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Asrar Rashid, Consultant Paediatric Intensivist University Hospital Queens Medical Centre, Derby Road, Nottingham, NG7 2UH, Harish Vyas
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We thank Dr’s Hart and Thomson for their review of meningococcal disease (MD) and its management in children. We stress the need for a rapid multidisciplinary team effort in the resuscitation of these children. A ‘shock team’ should ideally involve anaesthetists, paediatricians and intensivists. A focused approach within the ‘golden hour’ may allay the immunological storm termed systemic inflammatory response syndrome (SIRS) that may be responsible for the ensuing morbidity and mortality associated with this condition. The macro and micro vascular effects in meningococcal are complex. Aggressive fluid therapy resuscitation in the early stages is focused on restoring macrovascular disruption. Interestingly early high fluid infusion is associated with a lower incidence of acute respiratory distress syndrome (ARDS) [1]. Early haemofiltration may be useful if oliguria is present. The use of plasmapheresis has been shown to be anecdotally beneficial[2], however clinical trials are lacking. Early inotrope use should be considered via the intraossous route if access is difficult. It may offset the risk of hypotension associated with the use of anaesthetic agents prior to intubation. Early intubation has been shown to be advantageous in a canine model of septic shock.[3] Serum lactate or the mixed venous saturation may be used in evaluating the effectiveness of microvascular perfusion. Our experience has shown that serum lactate measurements may be useful in following either clinical deterioration or efficacy of treatment. Lactate measurements are now readily available on most blood gas machine modules and should be made available to all acute clinical areas. Mixed venous saturation that assesses the degree of oxygen demand and delivery to the tissues can be obtained from a large venous access. The International Surviving Sepsis campaign [4] was introduced in 2004 and strives to focus attention on improving clinical care to septic patients based on sound clinical and scientific principles that are goal directed. The protocols are simple but emphasize a quick and controlled response with fluids, inotropes and steroids all within the first hour of resuscitation. We wait in anticipation genomic research that may help us to pre-empt vascular responses to sepsis and aid in modifying generic protocols that are applied to a heterogeneous population. 1. Carcillo, J.A., A.L. Davis, and A. Zaritsky, Role of early fluid resuscitation in pediatric septic shock. Jama, 1991. 266(9): p. 1242-5. 2. Pearson, G., P.C. Khandelwal, and N. Naqvi, Early filtration and mortality in meningococcal septic shock? Arch Dis Child, 2000. 83(6): p. 508-9. 3. Aubier, M., et al., Respiratory muscle contribution to lactic acidosis in low cardiac output. Am Rev Respir Dis, 1982. 126(4): p. 648-52. 4. Dellinger, R.P., et al., Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Intensive Care Med, 2004. 30(4): p. 536-55. Competing interests: None declared |
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guillermo montalvan, doctor UTIP matanzas cuba
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Doctor: Two points that I would wish to clarify exist, the first if exists vaccinates against the Neisseria meningitidis of the group the B, at its country is produced by the Institute Finlay (VA-MENGOC-BCR), ), cash at the same time for the immunization of the disease menigocócica caused for the group C, see: http://www.finlay.sld.cu/cartera/Vamengocbc.htm, The another main issue would be in terminology used in relation to Septicaemia, because in the light of present-day knowledge, and in between the The International Surviving Sepsis campaign, the term proves to be ambiguous and contradictory, because according to SIRS classification, would isolated bacterias presence be an infection, now ¿What that it means septicemia?, If you want defining as the organism's answer to infection, we are talking about SRIS, but if he refers to dysfunction of at least one organ then we are referring to the severe sepsis or septic shock. Dr.Guillermo Montalván González. UTIP Matanzas Cuba. guillermo.montalvan@infomed.sld.cu Referentes: - Brahm Goldstein, MD; Brett Giroir, MD; Adrienne Randolph, MD; and the Members of the International Consensus Conference on Pediatric Sepsis: International pediatric sepsis consensus conference: Definitions for sepsis and organ dysfunction in pediatrics. I wait know dispensing my English Competing interests: None declared |
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Roger H Armour, Honorary Consultant Surgeon (retired consultant surgeon) Lister Hospital, Stevenage SG1 4AB
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The otherwise masterly account of meningococcal disease in children by Anthony Hart and Alistair Thomson does not mention fundoscopy. Might not this simple non-invasive examination show retinal haemorrhages and cotton wool spots even before the cutaneous manifestations of the disease? As the authors dramatically illustrate (Figure 4), the child may deteriorate within minutes. It is now well known that another equally lethal blood-borne disease in children, namely cerebral malaria, usually shows characteristic fundal changes(1). Have the authors examined the fundi of the children they admit? Reference. Lewallen S, Harding SP, Ajewole J et al. A review of the spectrum of clinical ocular findings in P. falciparum malaria in African children with a proposed classification and grading system. Trans Roy Soc Trop Med Hyg, 1999;93:619-622 Competing interests: I am one of the directors of Ophthalmos Ltd, a company that makes ophthalmoscopes |
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