1. Neisseria meningitidis Case Study
Dr. Jennifer Coetzee

2. Clinical Scenario 19 year old engineering student
Presents to campus health in morning, c/o flu-like symptoms, feeling unwell
Sent home with paracetamol, vitamin C
Late afternoon found by roommate, delirious, feverish, severe headache, rash
Diagnosed at E.R. with suspected meningitis
Lab confirms diagnosis of meningococcal meningitis, septicemia

3. Microbiological Characteristics
Gram negative diplococci
Grows on chocolate agar
Oxidase positive, ferments glucose, maltose
Immunologic reactivity of capsular polysaccharides basis for serogrouping
At least 13 serogroups
A, B and C cause most cases of disease worldwide

4. The organisms are intracellular, gram-negative diplococci.
Neisseria meningitidis (Arrow) in Cerebrospinal Fluid (Gram's stain, x1000)
Figure 1. Neisseria meningitidis (Arrow) in Cerebrospinal Fluid (Gram's stain, x1000).
The organisms are intracellular, gram-negative diplococci.
Rosenstein N et al. N Engl J Med 2001;344:

5. Cross-Sectional View of the Meningococcal Cell Membrane
Figure 2. Cross-Sectional View of the Meningococcal Cell Membrane.
Rosenstein N et al. N Engl J Med 2001;344:

6. Conditions for Invasive Disease
4 conditions to be met for invasive disease to occur:
Exposure to a pathogenic strain
Colonisation of nasopharyngeal mucosa
Passage through that mucosa
Survival of the meningococcus in the bloodstream

7. Colonization of Neisseria meningitidis in the Nasopharynx and Entry into the Bloodstream and Cerebrospinal Fluid
Figure 3. Colonization of Neisseria meningitidis in the Nasopharynx and Entry into the Bloodstream and Cerebrospinal Fluid.
N. meningitidis enters the nasopharynx and attaches to nonciliated epithelial cells, probably through the binding of the pili to the CD46 receptor (a membrane cofactor protein) and the subsequent binding of opacity-associated proteins, Opa and Opc, to the CD66e (carcinoembryonic antigen) and heparan sulfate proteoglycan receptors, respectively. The attached organisms are engulfed by the cells, enter phagocytic vacuoles, and may then pass through the cells. IgA1 protease (an outer-membrane protein) cleaves lysosome-associated membrane protein and may promote the survival of N. meningitidis in epithelial cells. PorB (another outer-membrane protein) crosses the cell membrane and arrests the maturation of the phagosome. In the bloodstream, the organisms release endotoxin in the form of blebs (vesicular outer-membrane structures) that contain 50 percent lipooligosaccharide and 50 percent outer-membrane proteins, phospholipids, and capsular polysaccharide. The endotoxin and probably other components stimulate cytokine production and the alternative complement pathway. N. meningitidis crosses the blood-brain barrier endothelium by entering the subarachnoid space, possibly through the choroid plexus of the lateral ventricles.
Rosenstein N et al. N Engl J Med 2001;344:

8. Pathogenesis Humans only natural reservoir
Transmitted from nasopharynx by aerosol/ secretions
10% of population colonised at any time
Attaches via pili to nonciliated columnar epithelial cells
Small percentage will penetrate mucosa, enter blood stream, and cause disease
Carriage results in protective antibodies

9. Virulence Factors Polysaccharide capsule Endotoxin IgA protease
Protects against complement mediated lysis
Anti-phagocytic
Capsule switching
Endotoxin
Lipo-oligosaccharide
Releases outer-membrane vesicles with endotoxin, outer membrane proteins, phospholipids, capsular polysaccharides
IgA protease
Promotes attachment to mucosal surfaces

10. Pathogenesis
Upon invasion of blood stream, activation of 3 main pathways:
Complement system
Regulates degree of hypotension
Patients with complement deficiency have increased susceptibility to meningococcal disease, but disease is less severe
Inflammatory response
Coagulation and fibrinolytic pathway

11. Risk Factors 6 – 24 month old babies most susceptible
Role of maternal antibodies
Terminal complement deficiency – up to 6000x higher risk, also recurrent disease
Functional / anatomical asplenia
Household crowding, urban residence
Active or passive tobacco smoke
Concurrent viral infections of the upper respiratory tract

12. Management Diagnosis! Antibiotics ASAP Supportive measures
Cerebrospinal fluid or blood cultures
Culture or antigen detection
Antibiotics ASAP
Supportive measures

13. Prevention Notify Department of Health
Chemoprophylaxis to all household contacts
Also close contacts
? Healthcare personnel
Chemoprophylactic regimens (for reference only):
Rifampicin 600 mg po BD x 4 doses
Ciprofloxacin 500 mg po stat
Ceftriaxone 250 mg po stat

14. Vaccines
Quadrivalent polysaccharide vaccine against serogroups A, C, Y and W-135 available
Antibody responses are serogroup-specific and independent
Recommended for healthcare workers, also tertiary students
Recommended for the control of outbreaks due to serogroup C
Beware of capsular switch

15. References
Rosenstein N.E., Perkins B., et al. Meningococcal Disease. N Eng J Med 200; 344:
Emonts M., Hazelzet J.A., et al. Host genetic determinants of Neisseria meningitidis infections. Lancet Infect Dis. 2003; 3: