Invasive meningococcal disease without meningitis: a forgotten diagnosis

Occurrence of influenza and bacterial infections in cancer patients receiving radiotherapy in Ghana

Background

Influenza co-infection with bacteria is a leading cause of influenza-related deaths and severe respiratory infections, especially among high-risk groups like cancer patients undergoing treatment. However, acute respiratory infection (ARI)-like symptoms developed by upper-torso cancer (UTC) patients receiving radiotherapy are considered as side-effects of the radiation. Hence influenza and bacterial pathogens implicated in ARI are not investigated.

Methods

This prospective cohort study examined 85 in-patients with upper-torso cancers undergoing radiotherapy at the National Radiotherapy, Oncology and Nuclear Medicine Centre (NRONMC) of Korle-Bu Teaching Hospital (KBTH) in Accra, Ghana. Eligible patients who consented were recruited into the study from September 2018 to April 2019. Influenza viruses A and B in addition to the following bacteria species Streptococcus pneumonia, Haemophilus influenzae, Neisseria meningitidis and Staphylococcus aureus were detected from oropharyngeal and nasopharyngeal swab specimens collected at three different time points. Presence of respiratory pathogens were investigated by influenza virus isolation in cell culture, bacterial culture, polymerase chain reaction (PCR) and next generation sequencing (NGS) assays.

Results

Of the 85 eligible participants enrolled into the study, 87% were females. Participants were 17 to 77 years old, with a median age of 49 years. Most of the participants (88%) enrolled had at least one pathogen present. The most prevalent pathogen was N. meningitidis (63.4%), followed by H. influenzae (48.8%), Influenza viruses A and B (32.9%), S. pneumoniae (32.9%) and S. aureus (12.2%). Approximately, 65% of these participants developed ARI-like symptoms. Participants with previous episodes of ARI, did not live alone, HNC and total radiation less than 50 Gy were significantly associated with ARI. All treatment forms were also significantly associated with ARI.

Conclusion

Data generated from the study suggests that ARI-like symptoms observed among UTC patients receiving radiotherapy in Ghana, could be due to influenza and bacterial single and co-infections in addition to risk factors and not solely the side-effects of radiation as perceived. These findings will be prime importance for diagnosis, prevention, treatment and control for cancer patients who present with such episodes during treatment.

Invasive meningococcal disease in older adults in North America and Europe: is this the time for action? A review of the literature

BACKGROUND

Neisseria meningitidis is an encapsulated Gram-negative diplococcus that asymptomatically colonises the upper respiratory tract in up to 25% of the population (mainly adolescents and young adults). Invasive meningococcal disease (IMD) caused by Neisseria meningitidis imposes a substantial public health burden,. The case fatality rate (CFR) of IMD remains high. IMD epidemiology varies markedly by region and over time, and there appears to be a shift in the epidemiology towards older adults. The objective of our review was to assess the published data on the epidemiology of IMD in older adults (those aged ≥ 55 years)in North America and Europe. Such information would assist decision-makers at national and international levels in developing future public health programmes for managing IMD.

METHODS

A comprehensive literature review was undertaken on 11 August 2020 across three databases: EMBASE, Medline and BIOSIS. Papers were included if they met the following criteria: full paper written in the English language; included patients aged ≥ 56 years; were published between 1/1/2009 11/9/2020 and included patients with either suspected or confirmed IMD or infection with N. meningitidis in North America or Europe. Case studies/reports/series were eligible for inclusion if they included persons in the age range of interest. Animal studies and letters to editors were excluded. In addition, the websites of international and national organisations and societies were also checked for relevant information.

RESULTS

There were 5,364 citations identified in total, of which 76 publications were included in this review. We identified that older adults with IMD were mainly affected by serogroups W and Y, which are generally not the predominant strains in circulation in most countries. Older adults had the highest CFRs, probably linked to underlying comorbidities and more atypical presentations hindering appropriate timely management. In addition, there was some evidence of a shift in the incidence of IMD from younger to older adults.

CONCLUSIONS

The use of meningococcal vaccines that include coverage against serogroups W and Y in immunization programs for older adults needs to be evaluated to inform health authorities' decisions of the relative benefits of vaccination and the utility of expanding national immunization programmes to this age group.

A Double Whammy Pneumonia: The First Reported Case of Concurrent Neisseria meningitidis and SARS-CoV-2 Pneumonia

Meningococcal pneumonia (MP) is a rare manifestation of meningococcal disease. The MP was first described in 1907 when Neisseria meningitidis (NM) isolates were identified in sputum samples obtained from soldiers with pneumonia. Preceding and concurrent viral infections constitute a major risk for MP. During the 1918-1919 influenza pandemic, a significant increase in MP cases were reported in patients with preceding influenza infection. Despite the end of the last H1N1 influenza pandemic in 2010, seasonal influenza infections still pose a risk for simultaneous MP. History appears to be repeating itself with concomitant bacterial and viral coinfection amid the current SARS-CoV-2 pandemic. Herein presented is a unique case of an elderly woman who presented with, to the best of our knowledge, the first reported case of possible concurrent SARS-CoV-2 and MP infections.

Neisseria meningitidis pneumonia with bacteremia without meningitis: An atypical presentation

Neisseria meningitidis remains the most important cause of bacterial meningitis worldwide. The second most common and potentially severe end-organ manifestation of invasive meningococcal disease is meningococcal pneumonia. It occurs between 5 % and 15 % of all patients with invasive meningococcal disease. N. meningitidis sepsis and meningitis continue to be associated with high morbidity and mortality, however, meningococcal pneumonia is uncommon and often underreported. We describe a case of sepsis secondary to pneumonia with N. meningitidis bacteremia, without any evidence of meningitis. This case reports aims at highlighting pneumonia as a presentation of N. meningitidis bacteremia, and the need for a high level of clinical suspicion to establish the diagnosis.

Meningococcal pneumonia: a review

Background

Although Neisseria meningitidis is one of the major causes of meningitis, meningococcal pneumonia is the most common non-neurological organ disease caused by this pathogen.

Methods

We conducted a review of the literature to describe the risk factors, pathogenesis, clinical features, diagnosis, treatment and prevention of meningococcal pneumonia.

Results

Meningococcal pneumonia was first described in 1907 and during the 1918–1919 influenza pandemic large numbers of cases of meningococcal pneumonia occurred in patients following the initial viral infection. A number of publications, mainly case series or case reports, has subsequently appeared in the literature. Meningococcal pneumonia occurs mainly with serogroups Y, W-135 and B. Risk factors for meningococcal pneumonia have not been well characterised, but appear to include older age, smoking, people living in close contact (e.g. military recruits and students at university), preceding viral and bacterial infections, haematological malignancies, chronic respiratory conditions and various other non-communicable and primary and secondary immunodeficiency diseases. Primary meningococcal pneumonia occurs in 5–10% of patients with meningococcal infection and is indistinguishable clinically from pneumonia caused by other common pathogens. Fever, chills and pleuritic chest pain are the most common symptoms, occurring in > 50% of cases. Productive sputum and dyspnoea are less common. Diagnosis of meningococcal pneumonia may be made by the isolation of the organism in sputum, blood, or normally sterile site cultures, but is likely to underestimate the frequency of meningococcal pneumonia. If validated, PCR-based techniques may be of value for diagnosis in the future. While penicillin was the treatment of choice for meningococcal infection, including pneumonia, prior to 1991, a third generation cephalosporin has been more commonly used thereafter, because of concerns of penicillin resistance. Chemoprophylaxis, using one of a number of antibiotics, has been recommended for close contacts of patients with meningococcal meningitis, and similar benefits may be seen in contacts of patients with meningococcal pneumonia. Effective vaccines are available for the prevention of infection with certain meningococcal serogroups, but this field is still evolving.

Conclusion

Meningococcal pneumonia occurs fairly frequently and should be considered as a possible cause of pneumonia, particularly in patients with specific risk factors.