The following describes your patient’s clinical presentation: A 19-year-old Cauc

Question

The following describes your patient’s clinical presentation:

A 19-year-old Caucasian female in her first year at University presented in A&E with confusion, irritability, marked neck stiffness, petechial rash and a body temperature of 38.5oC. In the preceding 24h, the patient had experienced a severe occipital headache with vomiting. A CSF sample was then obtained by lumbar puncture and analysed and the results obtained are shown in Table A:

Table A: Results of the analysis of the patient’s CSF sample

Parameter measured

Result

Reference range

Appearance

Cloudy & turbid

Clear & colourless

Protein

5.2 g/L

0.2 – 0.4 g/L

Glucose mmol/L

0.18 mmol/L

3.3 – 4.4 mmol/L

White cells

4800 x 106/L

97% neutrophils

0 – 5 x 106/L

All lymphocytes

No neutrophils

Red Cells

6.2 x 106/L

0 – 10 x 106/L

Microbiology

Positive for Neisseria meningitides

N/A

The patient was treated with intravenous cefotaxime and made a full recovery. The patient then reported a previous N. meningitides infection at aged 13 years with N. meningitides serogroup Y so, following recovery, further investigations were undertaken to evaluate her immune function. The results obtained are presented in Table B:

Table B: Results of immune screen

Parameter

Result

Reference Range

Serum IgG

12.1 g/L

6.0 – 16.0 g/L

Serum IgA

2.8 g/L

0.8 – 4.0 g/L

Serum IgM

1.2 g/L

0.5 – 2.0 g/L

AH50

0 units

80 – 200 units/mL

CH50

0.6

100- 500 units/mL

Based on the above and in light of the results you have obtained, what possible underlying cause(s) have led to the patient’s reduced resistance to N. meningitides? Explain your rationale.

Parameter measured

Result

Reference range

Appearance

Cloudy & turbid

Clear & colourless

Protein

5.2 g/L

0.2 – 0.4 g/L

Glucose mmol/L

0.18 mmol/L

3.3 – 4.4 mmol/L

White cells

4800 x 106/L

97% neutrophils

0 – 5 x 106/L

All lymphocytes

No neutrophils

Red Cells

6.2 x 106/L

0 – 10 x 106/L

Microbiology

Positive for Neisseria meningitides

N/A

Explanation / Answer

Now a days, expanded-spectrum cephalosporins (ceftriaxone and cefotaxime) are widely accepted antimicrobials for the treatment of patients suspected of having meningococcal disease. Previously, penicillin was used for treatment of this disease (Sachdeva et al 2005). Results from various experiments indicate that cephalosporins including cefotaxime are highly active against N. meningitidis isolates that are fully susceptible and moderately resistant to penicillin (Blondeau and Yaschuk,1995). One common reason is that because these drugs have not been used before much against this disease, the bacteium has not yet been able to develop a resistance power against it.

Another reason which have led to the patient's reduced resistance to N.meningitidies could be due to the memory cells which have developed due to previous infection by N.meningitidis. B lymphocytes are the cells of the immune system that make antibodies to invading pathogens like viruses. They form memory cells that remember the same pathogen for faster antibody production in future infections. A polyclonal secondary antibody response is developed against the infection.

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