8. Other Cases That Require Attention at the Scene of the Disaster

Objectives

  • Distinguish other clinical entities that can present at the scene of the disaster, such as tuberculosis.
  • Consider meningitis in emergency settings and assess the clinical findings.

Tuberculosis

Even though tuberculosis (TB) is the leading infectious cause of death in some parts of the developing world, TB treatment and control programs are not part of an emergency relief response. TB is a chronic infection and effective treatment is very resource-intensive. Treatment programs need to include resources to identify and monitor true cases by sputum smears exam, a stable population for at least 6 months (to complete shortcourse therapy), enough available drugs to treat all cases, and enough personnel to supervise all therapy in the first 2 to 3 months. Administration of anti-TB drugs to persons who will not adhere to or complete treatment is likely to contribute to drug resistance in the community.

Even though tuberculosis (TB) is the leading infectious cause of death in some parts of the developing world, TB treatment and control programs are not part of an emergency relief response.

Meningitis

Meningitis is the inflammation of the membranes (meninges) that surround the brain and spinal cord. Encephalitis is the inflammation of the cerebral Meningoencephalitis cortex. involves both the meninges and the cerebral cortex.

Meningitis may be due to viral, bacterial, or fungal infections. Approximately two thirds of diagnosed cases are viral and one third are bacterial. The most common viral infections are caused by enteroviruses and herpes simplex virus.

The most common bacterial pathogens that cause meningitis during the first 3 months of life include group B Streptococcus (GBS), Escherichia coli, Listeria monocytogenes, enterococci, Staphylococcus aureus, and gram-negative enteric organisms. The viral pathogens in this age group are herpes simplex virus, enterovirus, and cytomegalovirus.

Pathogens infecting infants older than 3 months of age and children are most often S. pneumoniae, Haemophilus influenzae type b (Hib) and Neisseria meningitidis. Other organisms such as M. tuberculosis, Salmonella, and Mycoplasma pneumoniae are rare.

The frequency of Haemophilus infection has dramatically decreased with immunization. However, in areas of the world where conjugate Hib vaccine is not administered, this organism remains a common cause of meningitis. Viral pathogens most prevalent in this arbo age group include enterovirus, virus, herpes simplex virus, herpes virus, influenza, and Epstein-Barr virus.

Clinical findings of meningitis

Look for changes in mental status and level of activity, including irritability, changes in feeding and sleeping patterns, unresponsiveness, and seizures.

Check for signs of meningeal irritation: nuchal rigidity, bulging fontanelle, paradoxical irritability, and Brudzinski and Kernig signs.

Evaluate hydration status and signs of shock, such as mottled skin, slow capillary refill, increased pulse, and decreased blood pressure. Perform a neurologic examination and document focal neurologic signs, paresis, or ataxia. Measure the head circumference and look for exanthem, purpura or petechiae, or soft-tissue, bone, or joint infections.

Signs associated central nervous system complications include focal neurologic findings, prolonged seizures, persistent changes in mental status, enlarging head circumferences, or ataxia. Complications include subdural effusion or empyema, cerebral edema, cerebral abscess, cerebral infarction, or hydrocephalus.

Treatment of meningitis

Suspected cases of severe sepsis or meningitis need to be treated promptly with the best available drugs. Report such cases to health authorities and make attempts to obtain appropriate samples for identification of the causative agent.

Identification of Neisseria meningitidis is particularly important because of its epidemic potential and the fact that a reasonably effective vaccine is available.

During confirmed N. meningitidis outbreaks, chemopr implement vaccination and ophylaxis of household contacts.

N. meningitidis remains susceptible to penicillin all over the world. A long-acting suspension of chloramphenicol in oil, called tifomycin, could be an alternative to penicillin. When other antibiotics are available, the initial antibiotic therapy depends on the age of the patient. Treat newborn infants with ampicillin and an aminoglycoside (gentamicin) or cefotaxime. Ampicillin is needed to cover Listeria and enterococci. Treat infants 1 to 3 months of age with ampicillin and ceftriaxone, or cefotaxime to cover enterococcus, Listeria, and H. influenzae. Treat older children with vancomycin and ceftriaxone if the rate of penicillin-resistant S. pneumoniae in the area is high.

When non susceptible organisms are identified, consider the recommended high doses of cefotaxime and ceftriaxone, and add rifampin when the minimum inhibitory concentration (MIC) of the nonsusceptible pneumococci is >2.0 µg/ mL. If possible, obtain serum creatinine levels before giving vancomycin and repeat weekly during treatment, because vancomycin excretion depends on glomerular filtration.

When non susceptible organisms are identified, consider the recommended high doses of cefotaxime and ceftriaxone, and add rifampin when the minimum inhibitory concentration (MIC) of the nonsusceptible pneumococci is >2.0 µg/ mL. If possible, obtain serum creatinine levels before giving vancomycin and repeat weekly during treatment, because vancomycin excretion depends on glomerular filtration.

When using aminoglycosides or chloramphenicol, monitor blood levels if possible (therapeutic levels for gentamicin or tobramycin are 4 to 8 µg/mL; for kanamycin or amikacin, 15 to 25 µg/mL). Adequate blood chloramphenicol levels can be achieved with oral administration. Whenever possible, avoid administering aminoglycosides in patients with renal disease and chloramphenicol in patients with hepatic dysfunction.