Meningitis

MENINGITIS

Meningitis is an inflammatory process of the meninges and CSF

Demography of Meningococcal Meningitis

♦ Meningitis belt ♦ epidemic zones cases

♦ sporadic

Causes/Major Pathogens Type Bacterial Viral infection TB meningitis Protozoal Infection Fungal infection

Pathogen (most Common) Strep pneumoniae, E-coli, Neisseria meningitis Coxsackie Virus, Echovirus, Enterovirus, Arbovirus, HIV, HSV-2 M. Tuberculosis Toxoplasma Gondii (toxoplasmosis) Cryptococcus neoformans (cryptococcal meningitis)

Other:

Progressive multifocal leukoencephalopathy (PML) Primary CNS lymphoma, HIVassociated dementia (HAD), Painful sensory and motor peripheral neuropathies, Neurosyphilis

PATHO PHYSIOLOGY Direct to CSF

Microorganisms Via Blood Subarachnoid

Immune Response Space from Astrocytes+Micro glia, Cytokin Release

Inc. BBB permeabilty Fluid leakage from vessels Vasogenic edema

Inc. no. of WBC in CSF Inflammation of Meninges Interstitial edema (Inc. ECF)

Vasculitis of cerebral vessels Dec. cerebral blood flow Ischemia, cytotoxic edema

Cerebral Edema Dec. Cerebral blood flow, Ischemia, apoptosis (Brain Death)

MAJOR FORMS OF MENINGITIS Bacterial

Viral

More serious, less common Immunization available

Less serious, more common No immunization

for some

available

Treatable with antibiotics

Treatment includes waiting it out

More common in winter

More common in summer/ early fall

Classification • • • •

Acute pyogenic (bacterial) meningitis Acute aseptic (viral) meningitis Chronic bacterial infection (tuberculosis). Acute focal suppurative infection (brain abscess, subdural and extradural empyema)

1) Acute Pyogenic Bacterial Meningitis

2) Acute Aseptic (Viral ) Meningitis • Can follow any viral infection • Less danger • Viral meningitis is usually self-limiting and treated • Fever ± delirium, lethargy, disorientation, symptomatically. malaise, headache most common • Stiff neck, photophobia, cranial nerve deficits less common • No focal neurological deficits • Gastrointestinal symptoms: diarrhea, colitis, esophageal ulceration appear in 12-15% of

3) Chronic bacterial infection (tuberculosis/ TB Meningitis)

Complications • Antibiotic treatment------ full recovery • Delayed or untreated cases--- can be fatal • Healing by fibrosis cause obliteration of subarachenoid space--- HYDROCEPHALUS • Brain abscess • Septic shock and skin rashes, why ?

1) Brain abscess

• Causes : 1. complication of bacterial meningitis 2. bacterial endocarditis 3. pulmonary sepsis : pneumonia……etc 4. other sepsis

Brain abscess cause a space occupying lesion in the brain

2) Skin rashes Is due to small skin bleed

• • All parts of the body are affected • The rashes do not fade under pressure • Pathogenesis: a. Septicemia b. wide spread endothelial damage c. activation of coagulation d. thrombosis and platelets aggregation e. reduction of platelets (consumption ) f. BLEEDING 1.skin rashes 2.adrenal hemorrhage Adrenal hemorrhage is called WaterhouseFriderichsen Syndrome. It cause acute adrenal insufficiency and is usually fatal

Work up for Meningitis Physical Exam • Brudzinski’s & Kernig’s sign • Nuchal rigidity • Papilledema Lumbar puncture to obtain CSF Chemistry (glucose & protein) Cytology (WBC# & %PMN’s) Gram stain or rapid identification test (< 24hrs) • CIE (Counterimmunoelectrophoresis), coagglutination, or latex • •

•

agglutination Limulus lysate for gram negative endotoxin PCR (N.meningitidis, S. pneumoniae, H. influenzae, S. agalactiae, L. monocytogenes & enteroviruses) Lactate (>4.2 mmol/L considered positive for bacterial meningitis) Procalcitonin (> 5 micrograms/L suggestive of bacterial meningitis) C-reactive proteins (CRP) (Elevated in bacterial meningitis)

• • • Culture for pathogens (> 24hrs)

Blood, Urine, & Sputum Cultures

Kernig's sign The thigh is flexed on the abdomen, with the knee flexed; attempts to passively extend the knee elicit pain when meningeal irritation is present. Brudzinski's sign: passive flexion of the neck results in spontaneous flexion of the hips and knees. Nuchal rigidity: Inability to flex the neck forward passively due to increased neck muscle tone. It occurs in 70% of adult cases of bacterial meningitis

Jolt accentuation maneuver:

•The patient is told to rapidly rotate his or her head horizontally; if this does not make the headache worse, meningitis is unlikely. •It helps determine whether meningitis is present in patients reporting fever and headache. Kernig’s and Brudzinski’s signs have high specificity but low sensitivity(44%) for the diagnosis of meningitis. Jolt accentuation of headache was determined to have a 97% sensitivity and 60% specificity. It has been suggested that absence of the jolt sign essentially excludes meningitis.

CSF Detail Report Changes in CSF Appearance WBC

Normal

Viral

Crystal-clear

Clear/Turbid

< 5 mm3

25-500 mm3

Pyogenic (Bacterial) Turbid/purule nt > 1000 mm3

< 5 mm3

10-100 mm3

<50 mm3

Mononuclear cells Polymorph cells Protein

Nil

Nil

0.2- 0.4 g/L

0.4-0.8 g/L

200-300/ mm3 0.5-2.0 g/L

Glucose

40-80 mg/dl

30-70 mg/dl

<40 mg/dl

Harrison's Principles of Internal Medicine, 17`Edition, 2008

Tuberculosis Turbid/visco us < 500 mm3 100-300 mm3 0-200/ mm3 1-5g/L 20-40 mg/dl

Empirical Therapy For ABM Age

Common Pathogen

Anti microbial

<1 month

Streptococcus agalactiae, Escherichia coli, Listeria monocytogenes, Klebsiella species

Ampicillin plus cefotaxime or ampicillin plus an aminoglycoside Vancomycin plus a

1-23 month

Streptococcus pneumoniae, Neisseria meningitidis, S. agalactiae, Haemophilus influenzae, E. coli

2-50 yrs

N. meningitidis, S. pneumoniae

Vancomycin plus a third-generation cephalosporina,b

> 50 yrs

S. pneumoniae, N. meningitidis, L. monocytogenes, aerobic gram-negative bacilli

Vancomycin plus ampicillin plus a third-generation cephalosporina,b

third-generation cephalosporina,b

ftriaxone or cefotaxime me experts would add rifampin if dexamethasone is also given. •Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004 Nov 1;39(9):1267-84. [120 references] Pub Med

Recommendations for Appropriate use of Antimicrobials at Hospitals in Pakistan Departments of Infectious Disease and Infection Control

Total Daily Dose and Dosing Interval Antimicrobia Child (>1 month) l Agent

Adult

Ampicillin 200 (mg/kg)/d, 12 g/d, q4h q4h Cefotaxime 200 (mg/kg)/d, 12 g/d, q4h q6h Ceftriaxone 100 (mg/kg)/d, 4 g/d, q12h q12h Ceftazidime 150 (mg/kg)/d, 6 g/d, q8h q8h Gentamicin 7.5 (mg/kg)/d, 7.5 (mg/kg)/d, q8h b q8h Metronidazo 30 (mg/kg)/d, q6h 1500–2000 mg/d, le q6h Penicillin G 400,000 (U/kg)/d, 20–24 million U/d, q4h q4h Vancomycin 60 (mg/kg)/d, q6h 2 g/d, q12hb All antibiotics are administered intravenously; doses indicated assume normal renal and hepatic function. Doses should be adjusted based on serum peak and trough levels: gentamicin therapeutic level: peak: 5–8 g/mL; trough: <2 g/mL; vancomycin therapeutic level: peak: 25–40 g/mL; trough: 5–15 g/mL. a b

Harrison's Principles of Internal Medicine,

Duration OF Therapy For ABM Microorganism

Duration of therapy, days

Neisseria meningitidis

7

Haemophilus influenzae

7

Streptococcus pneumoniae

10-14

Streptococcus agalactiae

14-21

Aerobic gram-negative bacillia Listeria monocytogenes

21 >21

Duration of Antimicrobial Therapy for Bacterial Meningitis Based on Isolated Pathogen (A-III) a Duration in the neonate is 2 weeks beyond the first sterile CSF culture or >3 weeks, whichever is longer. •Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL, Scheld WM, Whitley RJ. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004 Nov 1;39(9):1267-84. [120 references] PubMed

Adjunct Steroid Therapy for Infants, Children and Adults • Dexamethasone should be initiated 10-20 min prior to, or at least concomitant with, the first antimicrobial dose, at 0.15 mg/kg every 6 h for 2-4 days. • Adjunctive dexamethasone should not be given to the patients who have already received antimicrobial therapy, because administration of dexamethasone in this circumstance is unlikely to improve patient outcome At present, there are insufficient data to make a recommendation on the use of adjunctive dexamethasone in neonates with bacterial meningitis •Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL, Scheld WM, Whitley RJ. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004 Nov 1;39(9):1267-84. [120 references] Pub Med

Management and Treatment Of TBM Daily administration of Rifampicin 600 mg (450 mg for weight <55 KG) Isoniazid 300 mg Pyrizinamide 1.5 g for <55 Kg & 2 gm for above 55 Kg. (Initial 2 Months) All in combination 30 min before breakfast. Treatment require For PTB is six months For bone TB is nine months & For TB meningitis is 1 year. The addition of a fourth drug STREPTOMYCIN is left to the choice of the local physicians and their experience, with little evidence to support the use of one over the other Tarakad S Ramachandran, MBBS, FRCP(C), FACP, Chief, Department of Neurology, Crouse Irving Memorial Hospital; Professor, Department of Neurology, State University of New York Upstate Medical University Contributor Information and Disclosures Updated: Mar 9, 2007 from E medicine web Md

Vaccines For Meningitis Routine immunization can go a long way toward preventing meningitis. The vaccines against Hib, measles, mumps, polio, meningococcus, and pneumococcus can protect against meningitis caused by these microorganisms. Bacteria H. influenzae S. Pneumoniae N. Meningitidis

Polysaccharide Conjugate Vaccine Vaccine PRP PRP-OMP (PedvaxHIB, Comvax) PPV23 PCV7 (Prevnar) Quadrivalent Quadrivalent A/C/Y/W135 A/C/Y/W135 (Menactra) (Menomune) Monovalent C (Meningitec) WHO Fact sheet N°141 Revised May 2003

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