Meningitis: far more than a pain in the neck
Meningitis has been very topical recently for a variety of reasons so I thought I’d write a little about it. Firstly, there was the saddening coroner's report indicating that an emergency service call handler caused a treatment delay for a 5 year old who ultimately had meningitis. Secondly was the news that the combined meningitis A,C,W and Y vaccine is to be offered to teenagers and university-goers this September, and incorporated into the UK vaccination schedule as standard from January 2016. Finally, there was the not so recent (but fantastic) news that the meningitis B vaccine is also to be incorporated into the UK schedule from September 2015. It won’t be available to everyone though – only those babies aged 4 months or under at the time of its rollout – but its inclusion is a really positive step forward.
About two weeks ago a lady in her late thirties came to see me, and was actually my last patient of the day. She came in rather gingerly, carrying her 7 month old daughter with her. As soon as she walked in I could tell this lady was not well. One of the great strengths of being a GP is a result of the sheer volume of people we see – you quickly get an initial sense of who is well and who is not, and there was something about this lady that my mind categorised as the latter. She told me that she’d woken up that morning with an awful headache, one of the worst of her life and she was not prone to them. It had not improved despite some paracetamol and ibuprofen, and she had felt feverish throughout the day. She had a touch of neck stiffness, but no sensitivity to light, and apart from feeling generally dreadful she had no other symptoms to speak of. I got the impression she was not the sort of person who came to the GP lightly – and she herself said this without me vocalising it.
She had a temperature of 38.3C when I examined her, but there was little else to find, and notably, no rash.
On the face of it, it seems like there isn’t much – a few hours’ worth of headache and a fever, but I think this neatly demonstrates why medicine is very much not an exact science. The combination of these symptoms, their severity, and taken in conjunction with her evidently rather stoic nature was enough for us to have the conversation about meningitis. I was as frank as I could be without trying to be scary that there was a very real possibility this was meningitis. This lady had three other children at home and was not keen to leave them for the evening. We compromised that she monitor her symptoms for a few hours, and that if her symptoms did not improve within 2 to 3 hours that she go immediately to hospital with a letter I had written for her. I called her the next day to follow up – things had not improved, and she had indeed gone to hospital and been admitted. I spoke to the medical registrar running the ward who had performed the necessary tests, which had all but confirmed this was bacterial meningitis, and she was receiving intravenous antibiotics. Needless to say, she was feeling much better after a few doses.
This was a rather sobering patient for me for a number of reasons, mainly: a) she was not a child and b) she had so few of the “classic” signs and symptoms we are all taught about.
So what is meningitis?
We as a medical profession often do not explain this very well on the whole. Meningitis means infection and swelling of the meninges – the protective layer that covers your brain and spinal cord. Broadly speaking, there are two classes of meningitis – viral and bacterial. Either can be spread by prolonged, close contact with affected individuals, and I think it’s really important to note that it does not just affect toddlers and children – last year 34% of bacterial cases were in the over 25s – like my patient.
Whilst both have similar symptoms, viral meningitis is rarely fatal, unlike bacterial meningitis. This is because if the bacteria enter the bloodstream they can cause septicaemia, or blood poisoning, which can be rapidly disastrous. I don’t wish to scaremonger at all here – let’s not lose sight of the fact that bacterial meningitis is in the grand scheme of things rare (a GP will only see one or two cases in a 35 year career). However, prompt diagnosis and action is so important because it can be fatal, have debilitating lasting effects and we can prevent this.
What are those signs and symptoms?
A lot of the signs and symptoms of meningitis, when taken individually, might not seem of much significance and happen with almost any other illness. But when present in certain combinations they may indicate the possibility of meningitis:
· Fever (i.e. temperature above 38C)
· A severe headache
· Notable sensitivity to bright light
· Neck stiffness/pain
· Vomiting
· Cold hands and feet, pale skin
· Drowsiness, difficulty in waking, confusion
· Convulsions or seizures
There are also a few other symptoms slightly more specific to babies and toddlers, and the picture below is a nice illustration of most of these:
· Not wanting to be held, very irritable
· Off their food and milk
· Inconsolable high-pitched crying
· The fontanelle (soft gap between the skull bones over the top of the head) may be bulging outwards
Signs of meningitis in babies and toddlers (taken from firstaidforlife.com)
The one thing I’ve not mentioned thus far is the rash. Whilst many childhood viruses and infections can be associated with a mild pinky-red rash, the rash of bacterial meningitis is very characteristic. The reason I have not mentioned this until later on is simple, and cannot be stressed strongly enough: YOU SHOULD NOT WAIT FOR A RASH TO DEVELOP BEFORE SEEKING HELP. Some cases of bacterial meningitis don’t even develop a rash – again, like my patient. If the rash is present, get help immediately, but it’s risky to assume that this is not bacterial meningitis because there is no rash. The rash can also be much harder, or almost impossible to see in darker skinned people. If you have any concerns or suspicions, don’t wait for a rash to develop before seeking help.
The non-blanching rash of bacterial meningitis does not change colour when pressed
As you can see from the above picture, the rash of bacterial meningitis does not “blanche” when pressed, i.e. the colour does not drain from it, and it stays a dusky red/purple. The best way to check this is to press a clear glass against it. The rash can be anywhere on the body, usually in clusters of little spots. The reason for no colour change is that the rash is essentially bleeding underneath the skin from very small blood vessels. If the bacteria get into the blood and spread, they cause the blood vessels to get leaky, and the rash results. Thus, if the rash is present, the infection is likely in the blood and spreading, so prompt treatment is even more paramount.
Bacterial meningitis is not always fatal, but can leave people with life changing disabilities, ranging from loss of fingers/toes to loss of limbs and changes in their mental functioning such as a reduction in IQ, learning difficulties and personality changes.
Ultimately, if you feel there is something not quite right then get it checked out like my patient did. Don’t ignore that feeling you get, because from my experience it’s usually a deeply important one.
Vaccination
There are currently no vaccines specifically for viral meningitis, but thankfully, all the vaccinations mentioned above protect against bacterial meningitis. There are 6 different strains of the Neisseria meningitides bacterium that cause meningitis – A, B, C, W135, X and Y. The fact there are so many has made it hard to produce a single effective vaccine to date.
The men C vaccine, introduced in 1999, was the first meningitis vaccine given routinely as part of the UK schedule. It has been so effective that confirmed cases of men C have fallen from around 1,000 per year pre-1999, to 27 in 2013/14 according to Public Health England (PHE) figures. Alongside this however, there has been a rise in the number of confirmed cases of men W, which can be even more serious and aggressive. There were 30 cases in 2011, 117 cases in 2014 and more expected this year – it is this steep rise in cases that is behind the decision to roll out nationwide vaccination.
The graph below, taken from PHE, shows a breakdown of cases by each strain over the last few years in the UK. The standout fact here is that men B is the leading culprit of bacterial cases (around 80-85% of cases), and this is precisely why it’s fantastic news for us all that it’s going to be part of the routine schedules for babies from September 2015. Despite the B strain causing so much mortality it took considerable time to manufacture an effective vaccine (first coming into general use in Europe in 2013). However, we can expect cases to fall steadily over the coming years with widespread vaccination. This will also apply to men W cases, with vaccination reversing their current rising trend in the near future.
UK cases of bacterial meningitis by strain since 2004 (taken from Public Health England)
All in all, this is great news for the public, and the entire population will benefit from this move to vaccinate more. My take home message from my personal experience is that this terrible disease can present with lots, some or even very few of the “classic” symptoms – such as with my patient. If there’s any doubt – get it checked out by a medical professional. The worst case scenario is that you’ve taken some time out of the day to get some reassurance. The best? You’ve saved a life.
For those of you who would like to know more, there are some fantastic websites about meningitis, and some very heartfelt stories on them. Take, for instance, Charlotte Nott – a brave little girl left without hands and legs after battling meningitis B in 2010. You can watch her incredibly moving story here - Charlotte's Story.
The meningitis B vaccine Bexsero is currently administered by myself to anyone over the age of 2 months old, and I strongly recommend it to all children. Men ACWY can also be given over the age of 1 year old. Please contact me if this is something you’d be interested in.
Useful further information and resources:
Meningitis Research Foundation: http://www.meningitis.org/
Public Health England: https://www.gov.uk/government/collections/meningococcal-disease-guidance-data-and-analysis#data-collection
First Aid For Life: http://www.firstaidforlife.org.uk/men-b-vaccine-important/
