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"Child`s Health" 7 (50) 2013

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Rare Forms Of Meningococcal Disease In Children (clinical observation)

Authors: N.V. Banadyha - Ternopil State Medical University by I.Ya Horbachevsky

Categories: Pediatrics/Neonatology

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Keywords

meningococcal disease, carditis, polyarthritis, pneumonia.

Summary. The article presents two examples of rare forms of meningococcal disease - carditis, polyarthritis, pneumonia, diagnosed in children on the background of generalized forms.

The problem of meningococcal disease in children is not only relevant, but also so that deserving topic for discussion in which is the importance of diagnosing and treating different clinical forms.

Boy V. 14 years old entered the intensive care unit of children's hospital with complaints of headache, drowsiness, sleepiness, involuntary head position. From the history of the disease: sick 4 days, the disease began acutely with fever up to 39.4 ° C, later there was  vomiting. On the 2nd day of the disease he was worried by headache, drowsiness, repeated vomiting, there was a haemorrhagic rash, and still pyrexia. Delivered to the infectious disease clinic hospital. On the 2nd day of the disease worried headache, drowsiness, repeated vomiting, there was a haemorrhagic rash and pyrexia too. Delivered to the infectious disease clinic hospital. At admission the general condition is heavy, the boy was unconscious, took a forced position, involuntary head position, positive meningeal symptoms, rigid of neck muscles - 5 cm. On the skin of the abdomen, hips, shoulders was rare irregular hemorrhagic rash, Heart rate -98 beats /min, BH - 20 for 1 min., blood pressure -80/50 mmHg Full clinical and laboratory examination gave reason to diagnose: meningococcal disease, generalized, combined form: meningococcal, purulent meningitis. Intended therapy protocol, which showed the logical regression of hemorrhagic rash and neurological symptoms. On the 4th day of the disease in the child's complaints were: retrosternal pain, intensified by coughing, trouble. On examination: border of relative cardiac shortness was not changed, the rhythmic activity of the heart, tones weakened. Heart rate 64-72 beats / min.,  -90-60 mm.  blood pressure -90-60 mm mHg The next day the child was transferred to the department of anesthesiology and reanimation in infection profile of children's hospital.

The condition of a child was hard at admission. Skin was pale, existing single petechial rash on the abdomen, back, buttocks. Rigid of neck muscles 4 cm. Symptoms Kernig, Brudzinsky - negative. The limits of relative cardiac dullness due to the age. Rhythmic activity of the heart, sonorous tone is reduced, and the tone at the top is weakened. Heart rate: 64 beats/min, blood pressure: 90/60 mm Hg.  ECG: sinus bradycardia, the phenomenon of premature ventricular repolarization. Plain radiography of the chest: unchanged. Have been continued to take etiopathogenetical and symptomatic therapy. Over the next three days  bradycardia that after 8 days of disease varied tachycardia, late child's condition worsened. There were pains in the heart of tight character heart rate 112 beats/min , blood pressure, 90/60 mm Hg. century. On examination, the child was difficult. The situation forced to worse, sparing the left half of the chest. Skin was pale, no new lesions. Rigid of neck muscles 1 cm. Drew attention to itself smoothing intercostal spaces on the left. BH - 26 for 1 min., HR-96 for 1 min., BP-85/60 mm Hg. . Percussion of the lungs in the lower left-shortening percussion. Auscultation in the lungs at the left edge of the sternum in the range II-IV intercostal space was listened pleural friction, over the another part of the lungs- relaxed breathing. Percussion border of relative cardiac dullness: right - 1 cm from the right edge of the sternum outward, top - the second intercostal space, left - the left front axiall line. Rhythmic activity of the heart, moderately easing tone, short apical systolic murmur. Abdominal palpation: liver + 3 cm, painless, elastic. Spleen at the edge of the arc. No edema. Diuresis decreased during the last day (was - 970 ml).

 Re-examination: in blood - leukocytosis with a shift to the left;   X-ray of the chest (the ninth day of illness) - polysegmental left-sided pneumonia, complicated by exudative pleuritis. Exudative pericarditis. ECG: left ventricular is overload. The phenomenon of premature ventricular repolyaryzation. Echocardioscopia: interventricular membrane-paradoxical movement vertically during normal thickness. Heart is enlarged in diameter by the right and left ventricle. The presence of free fluid in the pericardium - up to 15 mm.It means that the child has rare forms: pericarditis, pneumonia complicated by pleuritis. The correction treatment:the combination antibiotic therapy (ceftriaxone + amikacin), anti-inflammatory steroid (prednisolone), which later changed with nonsteroidal, anticoagulants, diuretics, drugs potassium. Attack of pain in the heart area was not repeated, but for several days bothered low-intensity shaking pain. During treatment is gradually being upgraded, in 3 days decreased percussion border hearts after 4 days of speaker echocardiogram characteristics (amount of free fluid decreased to 4.5 mm).

The following case: Girl P., aged 4 years, 3 months, was admitted to the intensive care unit for 10 days of disease. Complaints at the time of admission: fever in a child up to 39 ° C, once vomiting, headache, rash on hands, malaise. Medical history revealed that the child is receiving outpatient treatment for: chicken pox, typical form, uncomplicated. Morning of admission (the tenth day of illness) the child's condition worsened: the body temperature reaches 38 ° (or more) C, vomiting, approximately 10-11 hours hemorrhagic rash appeared on his left forearm. Objective inspection: general condition of the child difficult due to severe intoxication syndrome. She was consciousness, sleepy. Skin pale, throughout the body were multiple crusts and pigmented spots and hemorrhagic petechial rash-spotted character, sometimes confluent (usually the legs), localized in the upper and lower limbs, feet, buttocks, in the region of the left elbow and right foot drain haemorrhagic rash in diameter than 1.0-1.5 cm, with necrosis in the center, on the face, petechial haemorrhagic rash. The  mucous of throat pink, clean. Tongue coated and white.  Meningeal signs are negative. HR - 170-180 beats per minute., BH - 40 ', t - 37 ° C, BP ​​= 80/40 mm Hg. The limits of relative cardiac dullness extended to the left (left - 0.5 cm outwards from the left midclavicular line). Rhythmic activity of the heart, tones weakened, and tachycardia. Percussion over lungs: clear lung sounds, auscultatory: vesicular breathing. Abdomen soft, smooth, liver appears from under the edge of the arc of 1.5 cm, elastic, painless. Free urination.

Due to the history a history and objective examination, initial laboratory examination on admission it was diagnosed  meningococcal disease, generalized form, meningococcemia, severe course. chickenpox, residual period.

On the third day of hospitalization she began to complain of pain in the legs. Examination: ankle swelling-speed, knee, radiation - wrist joint, active movements are limited, painful skin over the joints hot to the touch. Changes indicated the appearence of arthritis. To antibiotic (ceftriaxone) was added nonsteroidal anti-inflammatory therapy-a dose ibuprofen due to the age. Notwithstanding the dynamics of meningococcal skin syndrome (regression of lesions on the trunk, extremities, face, separating dry necrosis in the region of the left elbow and right leg), the decreasing intoxication syndrome, cardiac examination held: tachycardia and decreased cardiac sonorous tones. Further positive results indicators of acute inflammation. Although designed ibuprofen, articular syndrome kept the child refused to stand on his feet. On the tenth - eleventh day stay during the evening hours was observed re-fever to febrile digits. On the eleventh day of hospitalization were recorded polyarthritis, negative dynamics of the cardiovascular system: tachycardia maintained - 120-126 beats for 1 min, expanding the boundaries of the heart by percussion of the left (left border of relative cardiac dullness - the left front axiall line) rhythmic activity of the heart auscultation, heart sounds weak, systolic murmur in the in point. Conducted survey radiography of the chest, which confirmed the enlargement of the heart shadow across

In child was diagnosed  meningococcal disease: carditis, acute course, NDT II A c., Arthritis, functional insufficiency 2 stage. It was made correction treatment (designated benzylpenicillin). The future health of the child improved: one day the body temperature returned to normal. Pain in the joints and limit moves the child disappeared after 4 days. Dynamics of cardiovascular changes was as follows: normalization of heart rate occurred after 5 days, the relative normalization of cardiac activity after 8 days from the date of diagnosis of carditis

Attention is drawn to the fact that the occurrence of carditis and arthritis, carditis and pneumonia were observed on the background of meningococcal disease average course, in children who have no chronic disease, foci of chronic infection. Among the possible triggering factors of this course are: puberty and  combined infection (earlier - chicken pox). Early diagnosis of rare forms are the key to successful treatment.


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