Tammy Infectious Disease
The problem “Tammy's Trouble” allowed us to further explore infectious disease. This problem was particularly special because as college aged girls, we could relate to a lot of the issues Tammy faced. Tammy Emaciato was a normal 18 year old facing the challenges of her first year at college. Going from being an active high school senior to an overwhelmed college student caused her to gain fifteen pounds during her first year away from home. The weight gain caused serious confidence problems and led to debilitating health-related issues. Tammy began to binge and purge. She also picked up smoking to curb her appetite. Soon enough, she began to abuse laxatives. She quickly dropped thirty pounds and her eating disorder was out of control. When she returned to school for her sophomore year, she was living in an overcrowded dorm room. She was going to crowded bars, drinking excessively, and not getting enough sleep. She was under high stress as her grades started to slip.
Towards the end of the fall semester, Tammy developed classic flu symptoms: headache, fever and sore throat. The symptoms progressed quickly into a stiff neck, joint and back pain, leg cramping, vomiting, and light sensitivity. She also developed a rash on her legs. Tammy's roommate had to take her to the emergency room in the middle of the night.
Before we diagnosed Tammy, we considered all of the factors that could have been causing her symptoms or weakening her immune system. These included smoking, drinking, weight fluctuations caused by bulimia nervosa and laxative abuse, general stress, lack of sleep, and overcrowded living and social conditions. Though it is unknown why, smoking is thought to suppress cells involved in the immune response such as leukocytes and antibodies (“Foundations”). There is research that there is a relationship between smoking and meningitis infection (“Talk”). Excessive drinking interferes and or inhibits the functions of neutrophils, monocytes and macrophages. Drinking also alters the production of cytokines and adversely affects the function of T and B cells. All of theses factors increase a person's susceptibility to bacterial infections (Szabo). Tammy's purging and laxative abuse habits are considered binge and purge episodes. People who intake abnormal amounts of food and proceed to evacuate through vomiting, obsessive exercise, or overuse of laxatives are especially at risk for immune disorders. Some of the dangers associated with all eating disorders include poor circulation causing irregular heartbeat, liver failure, depression, menstrual complications, kidney infection and failure, low platelet count and thrombocytopenia (“Physical”). Thrombocytopenia is a condition associated with abnormal bleeding due to poor clotting (Cutler). General stress and lack of sleep ultimately cause fatigue to biological systems. Stress causes the activation of the fight or flight response. Unresolved stress constantly activates the body's nervous and endocrine systems, wearing the body out. Lack of sleep raises Cortisol causing stress and anxiety. It also reduces the release of interleukin-1, decreasing immunity (Grohol). Finally, overcrowding leads to an increased susceptibility to diseases that others might have and increased stress.
After arriving at the emergency room, Tammy was immediately administered two grams of ceftiaxone intravenously, two million units of penicillin intravenously, and two grams of nafcillin intravenously. Treatments for bacterial meningitis include all three of these antibiotics (“Acute”). It is important that treatment is given as soon as possible to stop the infection. This can be dangerous though before the proper diagnostic tests are completed. This is mostly because a doctor may be treating the wrong disease, allowing the actual disease causing pathogen to continue infecting. At this point, we could not be absolutely positive that Tammy was suffering from bacterial meningitis.
To accurately diagnose Tammy's disease, a number of tests were ordered. The complete blood count test came back to say that she had an extremely low platelet count. The prothrombin time study came back with a very elevated time, above 100 seconds. These two results indicated that Tammy had rapidly evolving disseminated intravascular coagulation (DIC). DIC is caused by endotoxin produced by gram-negative organisms. The endotoxin causes generation of tissue factor activity in phagocytic, endothelial, and tissue cells (“Disseminated”). A cerebral spinal fluid study determined that there was intracellular gram-negative diplococci, a protein level above normal, a glucose level below normal, and increased level of polymorphonuclear cells. High levels of protein and low glucose levels are both characteristic of bacterial meningitis (“Cerebral"). The brain depends on glucose as a source of energy. There is not a lot of glucose stored in the brain under normal conditions so it is important that blood supply is not obstructed. Low glucose level is a sign of decreased blood flow. Neurons deprived of oxygen and nutrients will die (Widmaier 205). An exchange of substance between blood and cerebral spinal fluid is important to avoid buildup of molecules that might inhibit brain function. When the blood brain barrier is compromised, proteins and immune system cells cannot get in or out (Widmaier205). Polymorphonuclear leukocytes are the predominant cell type in the cerebral spinal fluid of people infected with bacterial meningitis (“Cerebral Spinal”). The CT scan indicated cerebral edema, which is also characteristic of meningitis (Incesu).
Now that we were pretty certain that Tammy was suffering from bacterial meningitis, we looked for gram-negative, diplococci that can cause meningitis. One of the most common causes of meningitis in the United States is Neisseria meningitidis. N. meningitidis is a gram-negative encapsulated, diplococci, consistent with the bacteria found in her cerebral spinal fluid microscopic study (Pommerville 280). Humans are the natural reservoir for Neisseria species. Specifically, Neisseria inhabits the nose, mouth, and orthopharynx (Prescott 700). In general, normal Microbiota of the nose includes coagulase-negative staphylococci, Viridans streptococci, Staphylococcus aureus, Neisseria species, Haemophilus species, and Streptococcus pneumonia (Prescott 700). 5-15% of the human population carries the nonpathogenic form of N. meningitidis. Only some carriers develop meningitis. What makes one person more susceptible than another is unknown. The bacteria are carried in blood from the site of colonization to the meninges. There is uncertainty about why some bacteria travel to the cerebral spinal fluid while some does not. It has something to do with encapsulation and pili binding. Bacteria get into the cerebral spinal fluid by binding to the choroid plexus, which is the source of cerebral spinal fluid production. It can enter through direct extension from nearby infections. Also, entrance can be achieved through open spaces that are normally closed. Surface proteins, complement and inflammatory cytokines associated with the bacteria attract neutrophils to the cerebral spinal fluid. The neutrophils release metabolites which damage the surrounding blood vessels. This causes brain edema. The blood brain barrier is also compromised which allows for more swelling (“Acute”).
From her initial symptoms, headache, neck and back pain, and rash, we were confident that she was suffering from meningitis. Through later research, we found that she was a victim of a particularly dangerous form known as meningococcal meningitis caused by N. meningitidis (Pommerville 280). This form of meningitis is a form of acute bacterial meningitis.
Meningococcemia can occur with this particular infection. When the body is overwhelmed with bacterial toxins, meningococcemia occurs. Meningococcemia is sepsis that causes septicemia and or inflammation of the meninges (Pommerville 280). The diffuse petechiae indicated that she had septicemia. Septicemia is a serious form of blood poisoning. The toxins released by the bacteria into the blood stream break down blood vessel walls. Blood leaks out under the skin causing the rash. Septicemia also causes muscle and joint pain. The rash does not fade with pressure (“Meningitis”).
The bacterium causing Tammy's meningitis is particularly hard for the immune system to fight. The bacteria compromise the phagocytic pathway. Phagocytosis requires direct contact between the phagocyte and the invasive bacterium. N. meningitidis produce a slippery mucoid capsule that prevents effective contact (Prescott 801). Because of the lack of contact, the white blood cells are ineffective at stopping this disease.
Bacteria, fungal or viral invasions in addition to non-infectious causes, can cause meningitis. Bacterial meningitis, also known as acute meningitis, is the most common. Onset is very rapid. Some examples include cryptococcal meningitis, haemonphilus meningitis, listeric meningitis, and meningococcal meningitis. Acute meningitis must be treated with an antibiotic. There is also aseptic meningitis where there is no apparent cause of infection after a cerebral spinal fluid culture. This subset of meningitis includes some bacteria including those that cause tuberculosis, lyme disease and syphilis however it is most commonly caused by enteroviruses. There are also some noninfectious causes including brain tumors, stroke, vaccine response, and reactions to some drugs. Symptoms include fever, headache, and meningeal signs. Symptoms are usually treated. Sub acute or chronic meningitis is characterized by meningial inflammation lasting more than two weeks or more than one month respectively. Fungi, most commonly Cryptococcus neoformans, in addition to viral infections like those causing aseptic meningitis, cause sub acute and chronic meningitis. There are also non-infectious causes like cancer (“Meningococcal”).
Up until 1986, Haemophilus meningitis caused about 18,000 meningitis cases annually. It was considered the most common cause of meningitis. It occurred primarily in children aged six months to two years or as a complication to a previous disease. Symptoms are similar to those of meningococcal meningitis, but the mortality rate is lower. A vaccine was found by 1986. It is a conjugated vaccine consisting of polysaccharides from the bacteria's capsule joined to a bacterial protein. By 1994, all 50 states were administering the vaccine to infants and children. In 2001, there were only 1,597 cases. The cases in children declined rapidly. The number of cases in patients over age five has remained stable. The occurrence of Haemophilus meningitis in the second group has always been extremely rare. The reason the number of cases is still stable is probably because people in that age group have never received the vaccine (Prescott 282).
Fortunately Tammy survived the disease. She was discharged to a rehabilitation center 25 days after being admitted to the hospital. Unfortunately, Tammy suffered from gangrene and cellulitis. As a result, all of her toes had to be amputated. Gangrene is the tissue death due to insufficient blood flow to the extremities. This is common with meningococcemia. Since the capillaries are leaking, characterized by petechiae, there is not enough blood flow to the extremities (Perez). Cellulitis is inflammation of the skin caused by bacterial infection. Cellulitis has tremendous complications if the infected area is not treated or removed. It can cause meningitis, sepsis and cell death. The infection can be superficial or under the skin (Halachami). Tammy was also left deaf after her recovery. Hearing loss is the result of the spread of infection to the inner ear. This can cause damage to the cochlea. Also, if the auditory nerve becomes inflamed, sound signals cannot be carried to the brain (“Meningitis Booklet”).
Meningitis epidemics tend to occur within closed groups of people like the military and dorm room residents. Transmission is through respiratory droplets, which reach people easiest when they are in close quarters. It is important that anybody that was in close contact with Tammy be prescribed preventative antibiotics such as ciprofloxacin or rifampin (“Health”). Antibiotics can also be prescribed to carriers before they show signs of meningitis.
There were some measures Tammy could have taken to prevent contraction of meningitis. Some forms of bacterial meningitis are preventable through the use of vaccines. There are two meningococcal vaccines available in the US, Meningococcal polysaccharide vaccine (MPSV4) and meningococcal conjugate vaccine (MCV4). MPSV4 and MCV4 both protect against Neisseria meningitides among other causes of meningococcal meningitis. MCV4 is believed to have several advantages over MPSV. MCV4 reduces bacterial carriage in the nose and throat, longer duration of immunity, and better immunologic memory with no need for booster doses. MCV4 is only licensed for people between the ages of 11 and 55 years and MPSV4 is licensed for children aged two and up. Both vaccines have the antigens for serogroups A, C, Y and W-135. Serogroups C and Y are the cause of two of the three most common causes of meningococcal meningitis in the United States. Unforturnately there has not been a vaccine discovered for serogroup B, the third most common cause. Serogroups A and W-135 are uncommon in this country (“Meningococcal”). It is mandatory for most college students to receive one of the two forms of meningococcal vaccination.
There are other immunizations for different bacteria causing meningitis besides meningococcal meningitis. Haemophilus influenza type b vaccine has been available since 1986. It is responsible for the decline in childhood Haemophilus meningitis, as it is administered as a routine immunization for infants. Pneumococcal conjugative vaccine is also part of the routine infant immunization. Pneumococcal polysaccharide vaccine is administered to people with weakened immune systems, especially the elderly and cancer patients (“Meningitis”).
This problem helped us realize how serious meningococcal meningitis can be. It is important for students to understand the devastation associated with meningitis along with what could happen if you neglect your health and body. This problem reaffirmed the significance of modern vaccines. All of the cases we have studied have been very informative and important, but this one was especially important because of its relevance to our age group.
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