Sunday, September 22, 2013

Four and a Half Years is not Enough: Neisseria Meningitides Takes a Child

It’s been years, but Nona (name altered to protect privacy) still remembers it vividly. It was 2005. The clinic in Israel served mostly Ultra-Orthodox Jews, families with multiple children living in very close quarters and hence very susceptible for infections transferring from one to another. The child in question was four and a half, and has been to the clinic only once before. “A cute kid,” Nona says. “Pale face, I think on the tall and skinny side for a girl her age, dark long hair in  a ponytail.” That day, however, she was not doing well.
It was in the second half of June 2005. Nona was seeing a patient, and her secretary came in and told her there was a very sick looking little girl outside. Nona and her patient understood the urgency and finished their session, and the child’s mother wheeled her in in a stroller.
Nona says: “You know when a girl past the toddler stage is being brought in a stroller, it's serious. The mother told me her daughter was fine until last night, when she developed a high fever and vomited a few times. Then she seemed to settle down and sleep, but this morning was hard to wake up. She put the little girl on the examining table and we undressed her. The girl was in a semicomatose state, she responded a bit to pain stimulus but not much else, her neck was stiff as a board, and I noticed some odd markings on her legs. It wasn't the classic bleeding under the skin you see in more established cases. Still, I knew immediately what it was.”
The markings, said Nona, looked like this or like this.

At a later stage, it probably developed into something like this:

Picture taken from the Public Health Image Library, Courtesy of CDC/Mr. Gust

Nona had seen a full-blown case as a student. It was very, very memorable. Nona whispered to the nurse that they had a little girl with meningitis, probably meningococcemia, and asked her to bring an IV set. She also told the secretary to call and ask for a mobile ICU unit and to write down the names of all the patients in the waiting room. Nona knew they may have to put all the patients on antibiotics. In the event, the instruction from the public health authority was that given the short duration of the exposure, only the nurse, Nona herself and the little girl’s family – including her mother, pregnant at the time -  needed the antibiotics.
She went back to her patient, and put in an IV. The little girl was “fully comatose by then and made no protest at all to the painful stimulus.” The rash turned more purple on the legs climbed up to chest level – although it had only been ten minutes or less. Nona says: “I'd never seen ANY infectious disease progress that fast.”
Nona went searching for the appropriate antibiotics, ceftriaxone. She explains that it’s a “very broad-spectrum antibiotic. A good thing to give if you don't know what you're dealing with for sure.” She couldn’t get them: on Tuesday, the pharmacy was only open in the evening, and this was morning… and only the pharmacist had the key. The Mobile ICU showed up; Nona showed the doctor the rash and he understood immediately what was this was. Nona said “I asked if he had any antibiotics for the way, I seemed to think he did but ultimately found out the ambulances don't carry it (or didn't at the time).” Since that episode, the doctors at the clinic bought privately their own supply of cefrtriaxone and kept it in the resuscitation cart. “Luckily,” says Nona, “we never had to use it again.”
The Mobile ICU took the little girl away. Later, Nona called the hospital’s PICU and talked to the chief. The Chief told her that the little girl arrived at the hospital intubated. She’d lost consciousness before the arrival of the Mobile ICU, before she was taken away, but Nona explains that this suggests that her situation had continued to deteriorate in the ambulance, or that they put the tube in a s a precautionary measure, something often done for unconscious patients expected to be on life support. The ambulance called ahead, and a full team was waiting for the child as she arrived. She was given antibiotics immediately upon arrival. Since she was in such a bad condition, the diagnosis was based on her clinical signs: they did not wait for a lab culture.
The little girl “hung on in the PICU for 9 days without ever regaining consciousness.”
Then she died.

There’s a vaccine available against meningococcal, though it does not cover all the common strains. It is recommended for teen-agers and college students, though it is not routinely recommended for infants in the United States  (it is in Australia). The National Meningitis Association summarizes:
Meningococcal disease, sometimes called bacterial meningitis, is a potentially fatal bacterial infection that may cause death or disability within hours. However, it can be potentially prevented through vaccination.” 

Would the vaccine have helped this little girl? We don’t know; it would depend which strain she had (and there’s always a slight risk of vaccine failure). But it can prevent other children from having the disease, with its dangers and complications. 

For a long, long time, Nona felt guilty, on top of the pain and distress at losing the child. To some degree she still does, though she had since realized that she and her colleagues did the best they could in the circumstances. She blamed herself for not immediately giving antibiotics, not having the necessary antibiotic available, though eventually she realized the antibiotics in question was not standard issue for clinics, not something usually available, because it was so rarely needed. The child’s family did not blame or criticize them: they  “thanked us profusely”, and are still with the clinic. But she remembers, vividly, the little girl lost to the disease.

Acknowledgements: I'm grateful to Karen Ernst and Alice Warning Wasney for their help with the draft, and to Nona for sharing her story. 

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