Slide 2:This lecture will outline the consequences of meningococcal disease, and meningitis from all causes, as they are known today. It will summarise the pathology behind the after-effects and then elaborate on the multidisciplinary approach that is required to give sufferers the help they need. Finally it will look at the kinds of support that are available in the UK and the ways in which they can be utilised.

Slide 3: The major after-effects of meningococcal disease and meningitis such as limb amputation, brain damage and hearing loss are well known and often multiple. The consequences are often severe, with many survivors being left with permanent disability. Meningococcal disease can present as meningitis, with or without septicaemia, but meningitis can be caused by other organisms, both bacterial and viral, which also cause after-effects of differing degrees of severity. After effects can range from mild through to moderate and severe.

Slide 4: The complications of septicaemia and shock can lead to areas, often large, of necrotic tissue and skin loss that requires skin grafting or cause areas of scarring. Skin grafts speed up the healing time of large areas of skin loss, thus protecting the underlying structures and reducing the chances of infection Amputation of limbs and digits is sometimes necessary if necrotic areas become gangrenous.

Slide 5: The major after effects of meningitis caused by meningococcal disease and other organisms include complications that arise from damage to various areas of the brain. The majority of these complications are well recognised.

Slide 6: The pathophysiology of these complications is however not so easily recognised. Damage in meningococcal septicaemia is due to the consequences of septic shock and coagulopathy. In septic shock circulatory failure, if untreated, will cause hypotension, inadequate tissue perfusion and oxygenation. As a result necrosis and gangrene can occur, this requires skin grafting and in some cases amputation of digits and limbs.

Slide 7: Neurological complications, including seizure disorders and cerebral palsy, are associated with damage to various parts of the brain as a consequence of inflammation in the subarachnoid space. This appears as exudate covering the surface of the brain. Many complications, for example, cranial nerve palsies, are due to cranial nerve damage.

Slide 8: Visual impairment results from raised intracranial pressure that may cause neuronal damage to the visual cortex and/or the posterior visual pathways. Visual impairment may be partial or total, resulting in cortical blindness

Slide 9: Postmeningitic hearing impairment is an important cause of acquired sensorineural deafness. The literature reports that around 10% of children surviving bacterial meningitis (this includes causative organisms other than the meningococcus) experience permanent sensorineural deafness. Hearing impairment may be mild to moderate, reversible as well as profound, and there is evidence that damage to the hair cells in the inner ear is a major pathological event.

Slide 10: As well as the numerous physical complications there are less well-documented effects. Organisations such as the Meningitis Trust and the Meningitis Research Foundation have much anecdotal evidence on their files that suggest subtle behavioural after effects as well as profound psychological and emotional disturbances in some patients. These effects may be age specific and can have a devastating effect on the lives of individuals and those around them. This is an area that requires exploration by researchers if we are to provide optimal care and support for patients and their families

Slide 11: Young infants may show their bewilderment by temper tantrums, reversion behaviour, attention seeking behaviour and changes in normal sleep patterns.

Slide 12: These effects may also be seen in older patients but now perhaps the cause can be articulated as headaches and tiredness.

Slide 13: However there are many psychological and emotional challenges and issues that may not have an organic cause. These issues include emotional distress, problems coping with everyday events and problems caused by loss of income. As a result anxiety and depression may occur and with it a reduction in quality of life. A full recovery may take weeks or sometimes months. During this time patients and their families require a great deal of patience and understanding both within themselves and from the professionals involved in their care.

Slide 14: Behaviour problems can include mood swings, aggression and occasionally violent temper tantrums. Many of the behavioural issues reported are non-specific and it remains to be seen, in children at least, whether these are a direct result of meningitis or meningococcal disease per se, or a result of the stay in hospital and the trauma suffered during any life threatening disease.

Slide 15: Learning difficulties however have been more widely researched and there is now evidence to suggest that they are variable, with a range of effects seen. Problems can range from subtle issues such as short term difficulties in concentrating and reading to mild to moderate reduction in IQ, resulting in additional support at mainstream school, and to severe long term learning difficulties requiring special educational placements.

Slide 16: It is recommended that all patients should have a hearing test, before or soon after discharge from hospital. In the case of children, this is the responsibility of the paediatrician in charge of the case. Patients with profound sensorineural deafness can benefit from cochlear implantation. For those patients with amputations after septicaemia, assessment and specialist advice on the type of prosthesis best suited to their needs is required. Regular outpatient follow up is required for these patients.

Slide 17: To meet the many complex needs of patients a multidisciplinary health care approach is needed in order to devise an appropriate management strategy and provide optimal care. It is imperative that there is effective communication between health professionals, caregivers, teachers and patients where possible, to ensure optimal care and provision for education. Furthermore, This approach enables frequent and detailed assessment and intervention of ongoing problems so that important deficits are not missed.

Slide 18 and 19: Patients and their families require a great deal of ongoing support. This can come from a number of different sources including: the multidisciplinary health care team, family and friends and voluntary organisations such as the Meningitis Trust. Voluntary organisations are to be found in the UK, and increasingly, global, offering a range of services.

Slide 20: Known effects are multifactorial and may be easily observable and treated, however, more subtle affects such as emotional and psychological consequences require an understanding approach from a variety of sources.

USEFUL REFERENCES Bedford, H., deLouvois, J., Halket, S., Peckham, C., Hurley, R. and Harvey, D. (2001) Meningitis in infancy in England and Wales: follow up at age five years. BMJ, Vol 323, 533-536. Fellick, J.M., Sills, J.A., Marzouk, O., Hartis, C.A., Cooke, R.W.I. and Thomson, A.P.J. (2001) Neurodevelopmental outome in meningococcal disease-a case control study. Archive of Disease in Childhood, Vol 85, 6-11. Fortnum, H.M. (1992) Hearing Impairment after bacterial meningitis: a review. Archives of Disease in Childhood, Vol 67, 1128-1133 Grimwood, K., Anderson, P., Anderson, V., Tan, L. and Nolan, T. (2000) Twelve year outcomes following bacterial meningitis:further evidence for persisting effects. Archives of disease in childhood, Vol 83, 111-116. Grimwood, K. (2001) Legacy of bacterial meningitis in infancy. BMJ, Vol 323, 523-524.