Approach to Approach to

A case of meningitisA case of meningitis

Presented by

DR MOHAMED ABDELAZIZ march 2012

MENINGES

MENINGES

MENINGITISMENINGITIS

Meningitis is an inflammatory Meningitis is an inflammatory response to infections of the response to infections of the meninges and CSF,meninges and CSF,caused by bacteria, viruses, fungi, and other organisms such as protozoa and rickettsia.

Types of MeningitisTypes of Meningitis

Pyogenic Bacterial meningitisPyogenic Bacterial meningitis

Aseptic (viral) meningitisAseptic (viral) meningitis

Tubercular meningitisTubercular meningitis

Case studyCase study an infant, a 9 month old girl,presents to casuality an infant, a 9 month old girl,presents to casuality with history of fever,vomiting and loose stool over with history of fever,vomiting and loose stool over the last 3 days. She had a brief convulsion just the last 3 days. She had a brief convulsion just before arrival at the hospital in the form of a before arrival at the hospital in the form of a generalized colonic siezure with uprolling of the generalized colonic siezure with uprolling of the eyes, which settled spontanously. Mum fells that eyes, which settled spontanously. Mum fells that the child has not been herself for the last few days the child has not been herself for the last few days and seems irritable most of the time.and seems irritable most of the time.

On examination the infant is febrile at 39C, drowzy On examination the infant is febrile at 39C, drowzy and irritable but had apprpriate reactions on and irritable but had apprpriate reactions on being handled,is midly dehydrated and has cool being handled,is midly dehydrated and has cool peripheries. Her throat is slightly inflamed.peripheries. Her throat is slightly inflamed.

This infant appear s acutly unwell with This infant appear s acutly unwell with fever but no obvious source of fever but no obvious source of infection is discribed.infection is discribed.

You must concern about bacterial You must concern about bacterial infection causing septic shock and infection causing septic shock and meningitis.meningitis.

What are the most important differntial What are the most important differntial diagnosis?diagnosis?

MENINGITIS-DIFFERENTIAL DIAGNOSISMENINGITIS-DIFFERENTIAL DIAGNOSIS

Brain abscessBrain abscess

EncephalitisEncephalitis

Epidural abscessEpidural abscess

Bacterial endocarditis with septic Bacterial endocarditis with septic embolismembolism

Subarachnoid hemorrhageSubarachnoid hemorrhage

TumorTumor

NeonatesE. ColiProteusGroup B Streptococci Listeria monocytogenesEnterococcus, Enterobacter, Klebsiella, Salmonella,

What are the most common causing pathogen?

Pre School ChildrenPre School Children

– Hemophilus influenzaeHemophilus influenzae– Neisseria meningitidisNeisseria meningitidis– Streptococcus pneumoniaeStreptococcus pneumoniae– Mycobacterium tuberculosisMycobacterium tuberculosis

Older Children and AdultsOlder Children and Adults

– Neisseria meningitidis (Meningococcus)Neisseria meningitidis (Meningococcus)– Streptococcus pneumoniae Streptococcus pneumoniae – Mycobacterium tuberculosisMycobacterium tuberculosis– Listeria monocytogenesListeria monocytogenes– Hemophilus influenzaeHemophilus influenzae– Staphylococcus aureusStaphylococcus aureus

What examination findings and What examination findings and observations would you like to establish observations would you like to establish

immediately?immediately?Look for focusLook for focus

Ears:otitis media,mastoiditis.Ears:otitis media,mastoiditis.

Throat:tonsilitis,epiglottitis,glandular Throat:tonsilitis,epiglottitis,glandular fever,quinzy.fever,quinzy.

Skin:imptigo,cellulitis,abscess.Skin:imptigo,cellulitis,abscess.

Chest:bronchiolitis,upper respiratory tract Chest:bronchiolitis,upper respiratory tract infection,pneumonia.infection,pneumonia.

Abdomen:appendicitis,perforations,abscesAbdomen:appendicitis,perforations,abscess.s.

Bone and joint:osteomylitis,septic arthritis.Bone and joint:osteomylitis,septic arthritis.

Look for focusLook for focus

blood:septecaemia,toxic shock,acute blood:septecaemia,toxic shock,acute viraemia.viraemia.

renal:urinary tract renal:urinary tract infection,pyelonephritis.infection,pyelonephritis.

gastrointestinal tract:viral or bacterial gastrointestinal tract:viral or bacterial GE.GE.

CNS:encephalitis or brain abscessCNS:encephalitis or brain abscess

What are the clinical picture?What are the clinical picture?

Bacterial meningitis usually presents Bacterial meningitis usually presents in two patternsin two patterns– Acute - common with S. Acute - common with S.

pneumoniae and N. meningitidespneumoniae and N. meningitides– Subacute - preceding URI like Subacute - preceding URI like

symptoms, more common with H. symptoms, more common with H. influenza and other pathogensinfluenza and other pathogens

HeadacheHeadache Fever Fever DrowsinessDrowsinessNeck stiffnessNeck stiffnessNausea and vomitingNausea and vomitingIrritabilityIrritabilityAversion to lightAversion to lightRestlessnessRestlessnessAltered mental status (Stupor,Coma)Altered mental status (Stupor,Coma)SeizureSeizureMenngococcal meningits - Purpural rashes(70%)Menngococcal meningits - Purpural rashes(70%)

Most common

CLINICAL PRESENTATIONCLINICAL PRESENTATION

Skin rashesSkin rashes

Is due to small skin bleedIs due to small skin bleed

All parts of the body are affecedAll parts of the body are affeced

The rashes do not fade under pressureThe rashes do not fade under pressure

Pathogenesis:Pathogenesis:

a. Septicemiaa. Septicemia

b. wide spread endothelial damage b. wide spread endothelial damage

c. activation of coagulationc. activation of coagulation

d. thrombosis and platelets aggregationd. thrombosis and platelets aggregation

e. reduction of platelets e. reduction of platelets

What are the signs and findings in physical What are the signs and findings in physical examinations?examinations?

Bulging fontanelBulging fontanel

Focal neurological signsFocal neurological signs

Neck rigidity Neck rigidity

Ptosis, papilloedema,Ptosis, papilloedema,

Cushing’s triad (Bradycardia, Cushing’s triad (Bradycardia, Hypertension, Altered respirations) Hypertension, Altered respirations)

Positive Kernig’s and Brudzinski’s signPositive Kernig’s and Brudzinski’s sign

KERNIG’S SIGNKERNIG’S SIGN

Patient placed supine with hips Patient placed supine with hips flexed 90 degrees. Examiner flexed 90 degrees. Examiner attempts to extend the leg at the attempts to extend the leg at the kneeknee

Positive test elicited when there is Positive test elicited when there is resistance to knee extension, or pain resistance to knee extension, or pain in the lower back or thigh with knee in the lower back or thigh with knee extension due to meningeal irritationextension due to meningeal irritation

BRUDZINSKI’S SIGNBRUDZINSKI’S SIGN

Patient placed in supine position and Patient placed in supine position and neck is passively flexed towards the neck is passively flexed towards the chestchest

Positive test is elicited when flexion Positive test is elicited when flexion of neck causes flexion at knees of neck causes flexion at knees and/or hips of the patientand/or hips of the patient

What are the investigations requied for What are the investigations requied for this infantthis infant

CT or MRI are indicated if there are CT or MRI are indicated if there are focal neurological signs,raised ICP or focal neurological signs,raised ICP or prolonged fever. These are helpful in prolonged fever. These are helpful in detection of CNS complication of detection of CNS complication of bacterial infections such as bacterial infections such as hydrocephalus,cereberal infract,brain hydrocephalus,cereberal infract,brain abscess and venous sinus thrombosis.abscess and venous sinus thrombosis.

Lumber puncture :Lumber puncture :

MENINGITIS-DIAGNOSISMENINGITIS-DIAGNOSIS

ConditionCondition AppearanceAppearance WBC/mmWBC/mm3 3

Predominant Predominant typetype

GlucoseGlucose Total Total ProteinProtein

NormalNormal ClearClear 0-5 0-5

lymphocyteslymphocytes

50-7550-75

>60% of >60% of

Blood Blood glucoseglucose

15-4015-40

BacterialBacterial TurbidTurbid 100-10,000100-10,000

PMNPMN

<45<45 100-1000100-1000

ViralViral ClearClear 10- 200010- 2000

lymphocyteslymphocytes

NormalNormal 50-10050-100

FungalFungal CloudyCloudy <300<300

lymphocyteslymphocytes

<45<45 40-30040-300

TBTB CloudyCloudy <500<500

lymphocyteslymphocytes

<45<45 100-1000100-1000

CSF Patterns in Meningitis

OTHER INVESTIGATIONSOTHER INVESTIGATIONS

CBCCBC– Normal WBC does not rule out Normal WBC does not rule out

meningitismeningitisBlood culturesBlood culturesElectrolytesElectrolytesRenal functionRenal functionSerum glucoseSerum glucose - Useful to compare with CSF glucose- Useful to compare with CSF glucoseOther relevant investigationsOther relevant investigations

Quick initiation of antibiotics is a mustQuick initiation of antibiotics is a must

Typical Meningococcal rashTypical Meningococcal rash

Benzyle Penicillin 2.4 G IV 6Benzyle Penicillin 2.4 G IV 6thth hrly hrly

Adults without Typical Meningococcal rashAdults without Typical Meningococcal rash

Cefotaxime 2 G IV 6Cefotaxime 2 G IV 6thth hrly or hrly or

Ceftriaxone 2 G IV 12Ceftriaxone 2 G IV 12thth hrly hrly

Pinicillin Resistant pnuemococciPinicillin Resistant pnuemococci

Cefotaxime or Ceftriaxone Cefotaxime or Ceftriaxone

+ Vancomycin 1gm IV 12+ Vancomycin 1gm IV 12thth hrly hrly

Alter antibiotic choices once CSF gram stain results are Alter antibiotic choices once CSF gram stain results are

available .available .

What is the treat ment of this case?What is the treat ment of this case?

Bacterial MeningitisBacterial Meningitis

N . meningitidisN . meningitidis

Inj Benzyle Penicillin 2.4 G IV 6Inj Benzyle Penicillin 2.4 G IV 6thth hrly * 5-7 days hrly * 5-7 days

Strep. pneumoniaeStrep. pneumoniae / / H. influenaeH. influenae

InjInj Cefotaxime 2 G IV 6Cefotaxime 2 G IV 6thth hrly or hrly or

Inj Ceftriaxone 2 G IV 12Inj Ceftriaxone 2 G IV 12thth hrly * 10-14 days hrly * 10-14 days

Pinicillin Resistant pnuemococciPinicillin Resistant pnuemococci

InjInj Cefotaxime or Ceftriaxone Cefotaxime or Ceftriaxone

+ Inj Vancomycin 1gm IV 12+ Inj Vancomycin 1gm IV 12thth hrly hrly

Listeria monocytogenesListeria monocytogenes

Inj Ampicillin 2G iv 6 hrlyInj Ampicillin 2G iv 6 hrly

+ Inj Gentamycin 5g/kg iv * 8- 10 days+ Inj Gentamycin 5g/kg iv * 8- 10 days

Supportive CareSupportive Care

SteroidsSteroids

– Steroids thought to blunt effects of host Steroids thought to blunt effects of host inflammatory responseinflammatory response

– Theoretical concern of steroids reducing Theoretical concern of steroids reducing permeability of blood brain barrier to antibioticspermeability of blood brain barrier to antibiotics

Consider repeat LP 24-36 hours after initiating Consider repeat LP 24-36 hours after initiating treatment to assure sterilization of CSF if resistant treatment to assure sterilization of CSF if resistant organism or poor response to treatmentorganism or poor response to treatment

Features of Septicaemia – ICU CareFeatures of Septicaemia – ICU Care

Why do we use steroids?Why do we use steroids?

Decreases inflammation which can lead to decreased Decreases inflammation which can lead to decreased

intracranial pressure.intracranial pressure.

May interrupt the cytokine mediated neurotoxic effects May interrupt the cytokine mediated neurotoxic effects

of bacteriolysis, which are at a maximum during the of bacteriolysis, which are at a maximum during the

first few days of antibiotic therapy.first few days of antibiotic therapy.

Proven reduction in morbidity, such as severe hearing Proven reduction in morbidity, such as severe hearing

loss, in children with HiB meningitis and Strep. Pneumo loss, in children with HiB meningitis and Strep. Pneumo

meningitis.meningitis.

Proven reduction in mortality in adults and children Proven reduction in mortality in adults and children

with tuberculous meningitis(particularly due to a with tuberculous meningitis(particularly due to a

reduction in hepatitis secondary to treatment of TB.)reduction in hepatitis secondary to treatment of TB.)

When Do We Use Steroids?When Do We Use Steroids?

Therapy should be initiated shortly Therapy should be initiated shortly before or at the same time as the first before or at the same time as the first dose of antibiotics, (likelihood of dose of antibiotics, (likelihood of unfavorable outcome was much higher unfavorable outcome was much higher in patients in whom dexamethasone in patients in whom dexamethasone was given after antibiotics).was given after antibiotics).Dexamethasone should not be given Dexamethasone should not be given to adults who have already received to adults who have already received antibiotics, because it has not been antibiotics, because it has not been shown to improve patient outcomes.shown to improve patient outcomes.

What is the prognosis of this caseWhat is the prognosis of this case

Even with appropriate antibiotics, Even with appropriate antibiotics, mortality rate is significantmortality rate is significant– 8% H.influenza, 8% H.influenza, – 15% Neisseria meningitidis, 15% Neisseria meningitidis, – 25% Pneumococcal25% Pneumococcal

Up to 35% of survivors have sequelae Up to 35% of survivors have sequelae including deafness, seizures, including deafness, seizures, blindness, paresis, ataxia, blindness, paresis, ataxia, hydrocephalushydrocephalus

thank youthank you

VIRUSES

   Enteroviruses (coxsackievirus, echovirus, poliovirus, enterovirus)   Arboviruses: Eastern equine, Western equine, Venezuelan equine, St. Louis

encephalitis, Powassan and California encephalitis, West Nile virus, Colorado tick fever

   Herpes simplex (types 1,2)   Human herpesvirus type 6   Varicella-zoster virus   Epstein-Barr virus   Parvovirus B19   Cytomegalovirus   Adenovirus   Variola (smallpox)   Measles   Mumps   Rubella   Influenza A and B   Parainfluenza   Rhinovirus   Rabies   Lymphocytic choriomeningitis   Rotaviruses   Coronaviruses   Human immunodeficiency virus type 1

BACTERIA

   Mycobacterium tuberculosis   Leptospira species (leptospirosis)   Treponema pallidum (syphilis)

   Borrelia species (relapsing fever)

   Borrelia burgdorferi (Lyme disease)   Nocardia species (nocardiosis)

   Brucella species

   Bartonella species (cat-scratch disease)

   Rickettsia rickettsiae (Rocky Mountain spotted fever)

   Rickettsia prowazekii (typhus)   Ehrlichia canis

   Coxiella burnetii

   Mycoplasma pneumoniae

   Mycoplasma hominis

   Chlamydia trachomatis

   Chlamydia psittaci

   Chlamydia pneumoniae

   Partially treated bacterial meningitis

BACTERIAL PARAMENINGEAL FOCUS

   Sinusitis   Mastoiditis   Brain abscess   Subdural-epidural empyema   Cranial osteomyelitisFUNGI

   Coccidioides immitis (coccidioidomycosis)   Blastomyces dermatitidis (blastomycosis)

   Cryptococcus neoformans (cryptococcosis)

   Histoplasma capsulatum (histoplasmosis)

   Candida species

PARASITES (EOSINOPHILIC)

   Angiostrongylus cantonensis

   Gnathostoma spinigerum   Baylisascaris procyonis   Strongyloides stercoralis   Trichinella spiralis   Toxocara canis   Taenia solium (cysticercosis)

   Paragonimus westermani   Schistosoma species   Fasciola species

PARASITES (NONEOSINOPHILIC)

   Toxoplasma gondii (toxoplasmosis)   Acanthamoeba species   Naegleria fowleri   Malaria

POSTINFECTIOUS

   Vaccines:rabies, influenza, measles, poliovirus   Demyelinating or allergic encephalitis

SYSTEMIC OR IMMUNOLOGICALLY MEDIATED

   Bacterial endocarditis   Kawasaki disease   Systemic lupus erythematosus

   Vasculitis, including polyarteritis nodosa

   Sjögren syndrome   Mixed connective tissue disease   Rheumatoid arthritis   Behçet syndrome   Wegener granulomatosis   Lymphomatoid granulomatosis   Granulomatous arteritis   Sarcoidosis   Familial Mediterranean fever   Vogt-Koyanagi-Harada syndrome

MALIGNANCY

   Leukemia

   Lymphoma

   Metastatic carcinoma

   Central nervous system tumor (e.g., craniopharyngioma, glioma, ependymoma, astrocytoma, medulloblastoma, teratoma)

DRUGS

   Intrathecal infections (contrast media, serum, antibiotics, antineoplastic agents)

   Nonsteroidal anti-inflammatory agents

   OKT3 monoclonal antibodies

   Carbamazepine

   Azathioprine

   Intravenous immune globulins

   Antibiotics (trimethoprim-sulfamethoxazole, sulfasalazine, ciprofloxacin, isoniazid)

MISCELLANEOUS

   Heavy metal poisoning (lead, arsenic)

   Foreign bodies (shunt, reservoir)

   Subarachnoid hemorrhage

   Postictal state

   Postmigraine state

   Mollaret syndrome (recurrent)

   Intraventricular hemorrhage (neonate)

   Familial hemophagocytic syndrome

   Post neurosurgery

   Dermoid-epidermoid cyst