Meningitis Basics: What you need to know.

Meningitis occurs when a virus or bacteria causes inflammation of our brain or spinal cord. We use several different vaccines to prevent a few types of meningitis, but it’s all very confusing. Recent commercials have raised questions about what these vaccines are and if they’re needed.

Today we’ll go over what meningitis is and what types of germs cause it. Next time I’ll discuss some of the new meningitis vaccines in more detail.

What is meningitis?

Symptoms of MeningitisBoth viruses and bacteria can cause meningitis, but not everyone with these germs gets meningitis. Most people have less severe symptoms when they get these infections.

Not everyone gets all the symptoms listed below when they have meningitis. Some of these symptoms are common to many less serious infections, but if your child has these symptoms and appears more sick than normal, he or she should be evaluated immediately.

Symptoms of meningitis include:
  • fever
  • stiff neck
  • body aches and pains
  • sensitivity to light
  • mental status changes
  • irritability
  • confusion
  • nausea
  • vomiting
  • seizures
  • rash
  • poor feeding

Viral meningitis

Viruses are the most common cause of meningitis. Thankfully viral meningitis tends to be less severe than bacterial meningitis.

Most people recover on their own from viral meningitis. As with many infections, young infants and people who have immune deficiencies are most at risk.

There are many types of viruses that can cause meningitis. It’s likely that you’ve had many of these or have been vaccinated against them.

Non-polio enterovirus

The most common virus to cause meningitis is one from the non-polio enterovirus family.

Fever, runny nose, cough, rash, and blisters in the mouth are all symptoms that kids can get from this type of virus.

Most kids are infected with this type of virus at some point. Adults are less susceptible, and can even have the virus without symptoms.

There is no routine vaccine given for non-polio virus strains.

MM(R)V

Measles, mumps and chicken pox viruses can cause meningitis.

We vaccinate against these typically at 12-15 months of age, so it is uncommon to see these diseases. The MMR and varicella vaccines can be given separately or as MMRV. (Rubella is the “R” and can lead to brain damage in a fetus, but does not cause meningitis.)

Influenza

Influenza can cause meningitis, which is one of the reasons we recommend vaccinating yearly against flu starting at 6 months of age.

Herpesviruses

Herpesviruses can cause meningitis. Despite the name, most of these are not sexually transmitted.

This family of viruses includes Epstein-Barr virus,which leads to mono most commonly. Cold sores from herpes simplex viruses are also in this group. Chicken pox (or varicella-zoster virus) is another of these blistering viruses.

Bacterial meningitis

Bacteria that lead to meningitis can quickly kill, so prompt treatment is important. If you’ve been exposed to bacterial meningitis, you may be treated as well, but remember that most people who get these bacteria do not get meningitis.

Most people who get bacterial meningitis recover, but some have lasting damage. Hearing loss, brain damage, learning disabilities, and loss of limbs can result from various types of meningitis.

Causes of bacterial meningitis vary by age group:

Newborns

Newborns can be infected during pregnancy and delivery as well as after birth. They tend to get really sick very quickly, so this is one age group we take any increased risk of infection very seriously.

Bacteria that tend to infect newborns include Group B Streptococcus, Streptococcus pneumoniae, Listeria monocytogenes, and Escherichia coli.

Mothers are routinely screened for Group B Strep during the last trimester of pregnancy. They are not treated until delivery because this bacteria does not cause the mother any problems and is so common that it could recur before delivery if it’s treated earlier. This could expose the baby at the time of delivery. If a mother does not get adequately treated with antibiotics before the baby is born, the baby may have tests run to look for signs of infection or might be monitored in the hospital a bit more closely.

Once the mother’s water breaks, we time how long it has been because this opens the womb up for germs to infect the baby. If the baby isn’t born during the safe timeframe, your delivering physician or midwife might suggest antibiotics. After delivery your baby might have tests done to look for signs of infection or might be monitored more closely in the nursery.

It is very important that sick people stay away from newborns as much as possible. Everyone should wash their hands well before handling a newborn.

Babies and children

As children leave the newborn period, their risks change. Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae type b (Hib) are the bacteria that cause disease in this age group.

Thankfully we have vaccines against many of these bacteria. Infants should be vaccinated against S. pneumoniae and H. influenzae starting at 2 months of age. (Note: H. influenzae is not related at all to the influenza virus.)

Vaccines against N. meningitidis are available, but are not routinely given to infants at this time. High risk children should receive the vaccine starting at 2 months of age, but it is generally given at 11 years of age in the US.

Teens and young adults

Neisseria meningitidis and Streptococcus pneumoniae are the risks in this age group.

Thankfully most teens in the US have gotten the S. pneumoniae vaccine as infants so that risk is lower than in years past.

Tweens and are routinely given a vaccine against A, C, W, and Y strains of N. meningitis. A vaccine against meningitis B is recommended for high risk people and can be given to lower risk teens. This will be discussed further in my next blog.

Older adults

Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae type b (Hib), group B Streptococcus and Listeria monocytogenes affect the elderly

Talk to your parents to be sure they’re vaccinated and follow the vaccine recommendations for yourself too. Vaccines are not just for kids!

‘NI, Leptomeningitis purulenta cerebralis. Alfred Kast’ . Credit: Wellcome Collection. CC BY

 

Summer Penile Syndrome

Did you know there’s a name for the super swollen male parts from bug bites? Actually two names: Summer Penile Syndrome and Lion Mane’s Penis. Doctors might even call it seasonal acute hypersensitivity reaction. If you’ve ever seen it, you know it can be quite impressive.

What is summer penile syndrome?

Summer penile syndrome is a fairly common concern during the summer months. It’s usually due to a chigger bite on the sensitive skin of the penis or scrotum. You can often find a small bug bite near the center of the swelling.

They can itch like crazy, but usually don’t interfere with urinating.

Despite the significant swelling, there isn’t usually much pain, only itching. Unless there’s a secondary infection, there won’t be any fever.

What is a chigger?

Chiggers are a type of mite, which is an arachnid in the same family as spiders and ticks. They are also called harvest mites, harvest bugs, harvest lice, mower’s mites, or red bugs. Chiggers are so small they often go unnoticed until several hours after they attach to our skin. They can attach even under clothing, and the most common places that we notice chigger bites are in the areas of our pants.

Chiggers live in moist, grassy and wooded areas. They are commonly found in the warm summer months.

Adult chiggers don’t bite. It’s the larvae that cause itchy problems. The larvae are red, orange, yellow, or straw-colored, and no more than 0.3 millimeters long.

File-Chigger bite
Chigger. Source: https://commons.wikimedia.org/wiki/File:File-Chigger_bite.svg 
After crawling onto the skin, the larvae inject digestive enzymes into the skin that break down skin cells. They do not actually bite the host even though the bumps are called chigger bites. They form a hole in the skin called a stylostome. Their saliva goes into deep skin layers, which results in severe irritation and swelling.

People usually start to itch within a few hours and often scratch the feeding chiggers away. A hot shower with plenty of soap will kill chiggers and prevent them from finishing their meal, so showering after being in grassy or wooded areas can help prevent deeper reactions.

The good news is that in the US, chiggers are not known to carry diseases.

Prevention

Even though they don’t cause disease, chigger bites are something to avoid because they can cause significant itching for weeks.

Bug sprays with DEET will deter the chiggers. DEET is approved for use in children over 2 months of age.

Clothing can be treated with permethrin to avoid ticks and chiggers. Permethrin can be purchased at sporting goods stores to pre-treat your clothing. It should not be used directly on skin. Once dried into the clothing, permethrin will last for about six washings. You can also treat your shoes, which makes a lot of sense since chiggers are usually found in the grass and crawl up onto your skin.

Even untreated clothing can help a little if you don’t have time to pre-treat with permethrin. Wear long sleeves and long pants. Be sure to tuck the pant legs into your socks so they can’t enter from the bottom leg hole.

For more on bug sprays, including citronella, picaridin, oil of lemon eucalyptus and more, see the EPAs information on registered and unregistered products. You can even use this handy tool to find the right product for your needs.

How do you treat chigger bites?

Much like any bug bite, control of the itch is important. If kids scratch any itch, it can become secondarily infected from the break in the skin allowing germs in.

Antihistamines

Antihistamines are used for allergic reactions. We commonly use them for seasonal allergies, but they can help most allergy reactions.

Bug bites itch when our bodies react to the saliva injected into our skin with histamine. Histamine is our body’s allergic response and it itches. If you aren’t allergic to the bite, you won’t itch from it. This is the way we react to allergies, which is why we get itchy eyes and noses with allergies to pollen.

Diphenhydramine (Benadryl) is a short acting antihistamine that can help control allergic reactions, but tends to make kids tired or wired. It also only lasts a few hours, which can require frequent dosing.

I don’t like topical antihistamines, which are often sold to treat bug bites. I worry that kids will get too much of the medicine when it is applied to each bite. It’s a low risk, but still a risk. Just because they aren’t taking it by mouth doesn’t mean it isn’t absorbed. Children using a topical antihistamine for an extended time over large areas of the skin (especially areas with broken skin) may be at higher risk, especially if they also are using other diphenhydramine products taken by mouth or applied to the skin.

I am a fan of using an oral long-acting antihistamine, such as cetirizine or loratadine, to treat bug bites. Most kids with one bug bite have many. One dose of an oral antihistamine helps to control the overall histamine reaction, making each bite itch less.

Antibiotics

Despite the significant swelling, these usually do not require prescription antibiotics.

If your child has open areas from scratching the skin, you should keep the area clean and consider using a topical antibiotic ointment to help prevent infection.

Steroids

Over the counter topical hydrocortisone is a very low dose steroid. It can be used on insect bites to help stop the itch.

Stronger steroids that require prescriptions are occasionally used, but you will need to see your physician to discuss the risks and benefits of prescription steroids.

Oatmeal baths

Soaking in an oatmeal bath might help the itching. It works very well for dry skin conditions and sunburn relief as well.

You can buy commercially made oatmeal bath products or you can grind regular plain oats to make it fine enough that it dissolves in bath water. Test a small amount in a cup of water to see if it’s finely ground enough before putting 1 cup of oats into the bath water.

Some people have even made a paste of oats and applied it directly to the itchy skin for relief.

Baking soda

Another kitchen remedy for bug bite itch relief is baking soda. Mix a pinch of baking soda with a few drops of water to make a paste. Put this paste on the bites. Reapply as needed.

Ice or cool cloth

One more kitchen treatment is ice. Many kids won’t tolerate this one, but if they can’t tolerate an ice pack placed over clothing, you can try applying a cool wet washcloth directly to the skin.

When should you see your doctor?

If your child has any of the following symptoms, talk with your doctor.

  • Trouble urinating.
  • Pain or itch not controlled with the above measures.
  • Fever.
Fear has big eyes
By Robbie Grubbs from Houston (What????) [CC BY-SA 2.0 (https://creativecommons.org/licenses/by-sa/2.0)], via Wikimedia Commons

Measles Outbreaks: What can you do to protect your family?

Any area can be affected by measles. My county is in the middle of an measles outbreak right now. This is despite relatively high MMR vaccine rates above 95% for at least 1 MMR by 3 years of age. There are a lot of questions about measles outbreaks, so I thought I’d tackle a few. Like most pediatricians, I’ve never seen measles and I hope to not miss it if I do. We all need to be aware of its symptoms so we can recognize it when we see it!

What is measles?

Measles is a viral illness that includes fever, cough, fatigue, red eyes, and a characteristic rash. The rash spreads from head to trunk to lower extremities.

Measles rash PHIL 4497 lores
Source: https://commons.wikimedia.org/wiki/File%3AMeasles_rash_PHIL_4497_lores.jpg

RougeoleDP
Source: https://commons.wikimedia.org/wiki/File%3ARougeoleDP.jpg
Measles is usually a mild or moderately severe illness. It can lead to pneumonia, encephalitis, and even death (risk of 2-3 per 1000).

One rare complication of measles infection that occurs many years after the illness appears to resolve is subacute sclerosing panencephalitis (SSPE). It is a fatal disease of the central nervous system that usually develops 7–10 years after infection.

 

 

 

Koplik spots, measles 6111 lores
Source: https://commons.wikimedia.org/wiki/File%3AKoplik_spots%2C_measles_6111_lores.jpg
Koplik spots are a specific rash seen in the inner cheek. Koplik spots are visible from 1 – 2 days before the measles rash and disappears to 1 – 2 days later. They look like white spots with a blue center on the bright red background of the cheek. They can easily be missed because they are not present for long, but if seen are classic for measles.

What is the timeline of symptoms after exposure?

Measles is highly infectious. It is primarily transmitted by large respiratory droplets in the air, so handwashing doesn’t help prevent exposure.

An area remains at risk for up to 2 hours after a person with measles was there. This is why it is IMPERATIVE that you should not leave your house if you suspect you have measles until you have spoken with the health department or your physician. DO NOT go to a walk in clinic or your doctor’s office unannounced. You will need to make arrangements to meet someone outside and wear a mask into the building. You will be put in a special negative pressure room, which is not available in most clinics.

More than 90% of susceptible people develop measles when they’re exposed.

The average incubation period for measles is 11–12 days. It takes 7–21 days for the rash to show. It is due to this long time for the characteristic rash that susceptible people who were exposed are put in isolation for up to 21 days.

Most people are contagious from about 4 days before they show the rash until 4 days after the rash develops. If a person has measles and the rash resolves, they can leave isolation when cleared by their physician and/or the health department.

What is a measles outbreak?

Measles outbreaks are defined as 3 or more measles cases linked in time and space.

How do outbreaks start?

I know the big question on everyone’s mind during an outbreak is, “Where did it start?”

Often an unimmunized traveler brings the measles virus into the US. Countries in Europe, Africa, Asia, and the Pacific continue to have outbreaks. Travelers who visit those countries can return to the US and share the virus for a few days before symptoms are recognized. Anyone who was in the same area as an infected person for up to 2 hours after that person left the area could be exposed.

In case you’ve heard that vaccines can lead to outbreaks: that’s not the case. Measles shedding from the MMR does not cause disease.

What happens during an outbreak?

Measles Outbreaks: What can you do to protect your family?During an identified outbreak of any reportable infectious disease, the health department directs what to do. They attempt to identify and notify all people who are at risk.

Our current outbreak involves several infants from the same unnamed daycare in addition to people not associated with the daycare. I know many families are worried that their child was at that daycare. Families at that daycare will have been notified by the health department already. The health department will track all known contacts of those families.

Local health departments also will notify the public of known locations of potential contact with the virus. The above linked article lists the known locations that infected people visited during their contagious period.

Why are infants at risk?

Infants are at particular risk because they are not typically vaccinated against measles until 1 year of age.

When the virus is in a setting with infants, such as a daycare, it can easily spread.

Infants under 2 years of age who are infected also tend to have more complications from the disease than older children and adults. This is one of the biggest reasons to not wait until 2 years to start immunizations, as some anti-vaccine groups suggest.

If you think you were exposed to or have symptoms of measles

It is IMPERATIVE that you should not leave your house if you suspect you have measles until you have spoken with the health department or your physician.

DO NOT go to a walk in clinic or your doctor’s office unannounced.

You will need to make arrangements to meet someone outside and wear a mask into the building. You will be put in a special negative pressure room, which is not available in most clinics.

Do not go to the pharmacy to pick up medications. Don’t go to the grocery store for food.

Do not leave your home unless it is to a medical facility that knows you’re coming and is prepared.

(Yes, I know I repeated myself for much of this section, but it’s that important!)

The MMR vaccine can help stop the spread

The MMR vaccine is recommended routinely at 12-15 months and again at 4-6 years of age. Vaccines not only help the vaccinated, but provide herd immunity to those too young to be immunized and to those who are immunocompromised.

Please be sure your family is up to date on all their vaccines. All children over 1 year of age should have at least 1 MMR vaccine. All school aged children and adults should have 2 MMRs. By vaccinating your family, you not only protect them, but also those around you!

Why is a second dose given?

The second dose is used to provide immunity to the approximately 5% of people who did not develop immunity with the first dose. It is not a booster because it doesn’t boost the effect of the first dose.

The second MMR helps some people develop immunity if the first vaccine did not work effectively.

This second dose can be given as early as 28 days after the first.

Why don’t we start the vaccine series earlier?

Many parents worry that we don’t give live virus vaccines to infants because they’re less safe, but that’s not why at all.

Maternal antibodies (fighter cells from mom that got into baby during pregnancy) can inhibit the body from being able to build its own antibodies well against a vaccine.

Maternal antibodies are good because as long as they’re in the baby’s body, they fight off germs and protect the infant! They tend to hang around for the first 6-12 months of life.

If a disease has a low incidence, it is acceptable to let the maternal antibodies do their job for the first year.

By the first birthday most maternal antibodies have left the infant, so a vaccine can be used to build the baby’s immunity.

Sometimes we do vaccinate earlier

If there is a high risk of exposure it is recommended to give the vaccine as early as 6 months in case the maternal antibodies are already too low for infant protection.

Many parts of the world have high measles rates so fit into this recommendation. When infants between 6 and 12 months travel internationally, they should receive one dose of MMR vaccine prior to travel.

Sometimes during US outbreaks it is recommended to vaccinate infants 6-12 months. The local health department helps to determine which infants should be immunized in this situation.

If the maternal antibody levels are still high in the infant, the vaccine won’t work. In this situation the baby should still be protected against the disease from mom’s antibodies. That is why this early vaccine does not “count” toward the two needed after the first birthday.

At some point the maternal antibodies go away, we just don’t know when exactly, so the baby who gets the MMR early needs another dose after his first birthday to be sure he’s making his own antibodies once mom’s go away. This dose after the birthday is the first that “counts” toward the two MMRs that are needed.

The next dose of MMR can be anytime at least 28 days after the first counted dose, but we traditionally give it between 4-6 years with the kindergarten shots.

What if someone who hasn’t been vaccinated is exposed?

measles outbreaks, what can you do to protect your family
Source: http://www.immunize.org/photos/measles-photos.asp

The MMR vaccine may be effective if given within the first 3 days (72 hours) after exposure to measles. This is why the local health department is so aggressive in identifying cases during an outbreak.

Immune globulin (IGIM, a type of immunity that doesn’t require a person to make their own immunity) may be effective for as long as 6 days after exposure. IGIM should be given to all infants younger than 6-12 months who have been exposed to measles. The MMR vaccine can be given instead of IGIM to infants age 6 through 11 months, if it can be given within 72 hours of exposure.

Are boosters of the MMR needed?

are mmr boosters needed
From my practice Facebook page. Note: In this reply I was going off of my experience many years ago. At that time the advice was only 1 additional MMR, but my research for this blog shows otherwise!

Those of us who work in healthcare must have titers checked to verify immunity to many of the vaccine preventable diseases.

Healthcare workers come into contact with sick patients and patients with weak immune systems, so this is one way to help control disease spread.

From Immunize.org:
Adults with no evidence of immunity (defined as documented receipt of 1 dose [2 doses 4 weeks apart if high risk] of live measles virus-containing vaccine, laboratory evidence of immunity or laboratory confirmation of disease, or birth before 1957) should get 1 dose of MMR unless the adult is in a high-risk group. High-risk people need 2 doses and include healthcare personnel, international travelers, students at post-high school educational institutions, people exposed to measles in an outbreak setting, and those previously vaccinated with killed measles vaccine or with an unknown type of measles vaccine during 1963 through 1967.

Most people don’t know their immune status, and it’s not recommended at this time to check it for the general population.

During an outbreak exposed people might be asked to be tested to help identify risk factors and track disease patterns.

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