meningitis-case study

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Approach to A case of meningitis
Presented by
DR MOHAMED ABDELAZIZ march 2012
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MENINGES
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MENINGES
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MENINGITIS

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

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Types of Meningitis

• Pyogenic Bacterial meningitis
• Aseptic (viral) meningitis
• Tubercular meningitis

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Case study

• an infant, a 9 month old girl,presents to
  casuality with history of fever,vomiting and
  loose stool over the last 3 days. She had a brief
  convulsion just before arrival at the hospital in
  the form of a generalized colonic siezure with
  uprolling of the eyes, which settled
  spontanously. Mum fells that the child has not
  been herself for the last few days and seems
  irritable most of the time.
• On examination the infant is febrile at 39C,
  drowzy and irritable but had apprpriate
  reactions on being handled,is midly dehydrated
  and has cool peripheries. Her throat is slightly
  inflamed.

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What are the most important differntial diagnosis?

• This infant appear s acutly unwell with fever but
  no obvious source of infection is discribed.
• You must concern about bacterial infection
  causing septic shock and meningitis.

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MENINGITIS-DIFFERENTIAL DIAGNOSIS

• Brain abscess
• Encephalitis
• Epidural abscess
• Bacterial endocarditis with septic embolism
• Subarachnoid hemorrhage
• Tumor

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What are the most common causing pathogen?
Neonates E. Coli Proteus Group B Streptococci
Listeria monocytogenes Enterococcus,
Enterobacter, Klebsiella, Salmonella,
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• Pre School Children
• Hemophilus influenzae
• Neisseria meningitidis
• Streptococcus pneumoniae
• Mycobacterium tuberculosis

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• Older Children and Adults
• Neisseria meningitidis (Meningococcus)
• Streptococcus pneumoniae
• Mycobacterium tuberculosis
• Listeria monocytogenes
• Hemophilus influenzae
• Staphylococcus aureus

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

• Look for focus
• Earsotitis media,mastoiditis.
• Throattonsilitis,epiglottitis,glandular
  fever,quinzy.
• Skinimptigo,cellulitis,abscess.
• Chestbronchiolitis,upper respiratory tract
  infection,pneumonia.
• Abdomenappendicitis,perforations,abscess.
• Bone and jointosteomylitis,septic arthritis.

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• Look for focus
• bloodseptecaemia,toxic shock,acute viraemia.
• renalurinary tract infection,pyelonephritis.
• gastrointestinal tractviral or bacterial GE.
• CNSencephalitis or brain abscess

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What are the clinical picture?

• Bacterial meningitis usually presents in two
  patterns
• Acute - common with S. pneumoniae and N.
  meningitides
• Subacute - preceding URI like symptoms, more
  common with H. influenza and other pathogens

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CLINICAL PRESENTATION

• Headache
• Fever
• Drowsiness
• Neck stiffness
• Nausea and vomiting
• Irritability
• Aversion to light
• Restlessness
• Altered mental status (Stupor,Coma)
• Seizure
• Menngococcal meningits - Purpural rashes(70)

Most common
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Skin rashes

• Is due to small skin bleed
• All parts of the body are affeced
• 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

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What are the signs and findings in physical
examinations?

• Bulging fontanel
• Focal neurological signs
• Neck rigidity
• Ptosis, papilloedema,
• Cushings triad (Bradycardia, Hypertension,
  Altered respirations)
• Positive Kernigs and Brudzinskis sign

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KERNIGS SIGN

• Patient placed supine with hips flexed 90
  degrees. Examiner attempts to extend the leg at
  the knee
• Positive test elicited when there is resistance
  to knee extension, or pain in the lower back or
  thigh with knee extension due to meningeal
  irritation

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BRUDZINSKIS SIGN

• Patient placed in supine position and neck is
  passively flexed towards the chest
• Positive test is elicited when flexion of neck
  causes flexion at knees and/or hips of the patient

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What are the investigations requied for this
infant

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

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MENINGITIS-DIAGNOSIS
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CSF Patterns in Meningitis
Condition Appearance WBC/mm3 Predominant type Glucose Total Protein
Normal Clear 0-5 lymphocytes 50-75 gt60 of Blood glucose 15-40
Bacterial Turbid 100-10,000 PMN lt45 100-1000
Viral Clear 10- 2000 lymphocytes Normal 50-100
Fungal Cloudy lt300 lymphocytes lt45 40-300
TB Cloudy lt500 lymphocytes lt45 100-1000
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OTHER INVESTIGATIONS

• CBC
• Normal WBC does not rule out meningitis
• Blood cultures
• Electrolytes
• Renal function
• Serum glucose
• - Useful to compare with CSF glucose
• Other relevant investigations

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What is the treat ment of this case?
Bacterial Meningitis

• Quick initiation of antibiotics is a must
• Typical Meningococcal rash
• Benzyle Penicillin 2.4 G IV 6th hrly
• Adults without Typical Meningococcal rash
• Cefotaxime 2 G IV 6th hrly or
• Ceftriaxone 2 G IV 12th hrly
• Pinicillin Resistant pnuemococci
• Cefotaxime or Ceftriaxone
• Vancomycin 1gm IV 12th hrly
• Alter antibiotic choices once CSF gram stain
  results are available .

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• N . meningitidis
• Inj Benzyle Penicillin 2.4 G IV 6th hrly 5-7
  days
• Strep. pneumoniae / H. influenae
• Inj Cefotaxime 2 G IV 6th hrly or
• Inj Ceftriaxone 2 G IV 12th hrly
  10-14 days
• Pinicillin Resistant pnuemococci
• Inj Cefotaxime or Ceftriaxone
• Inj Vancomycin 1gm IV 12th hrly
• Listeria monocytogenes
• Inj Ampicillin 2G iv 6 hrly
• Inj Gentamycin 5g/kg iv 8- 10 days

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• Supportive Care
• Steroids
• Steroids thought to blunt effects of host
  inflammatory response
• Theoretical concern of steroids reducing
  permeability of blood brain barrier to
  antibiotics
• Consider repeat LP 24-36 hours after initiating
  treatment to assure sterilization of CSF if
  resistant organism or poor response to treatment
• Features of Septicaemia ICU Care

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Why do we use steroids?

• Decreases inflammation which can lead to
  decreased intracranial pressure.
• May interrupt the cytokine mediated neurotoxic
  effects of bacteriolysis, which are at a maximum
  during the first few days of antibiotic therapy.
• Proven reduction in morbidity, such as severe
  hearing loss, in children with HiB meningitis and
  Strep. Pneumo meningitis.
• Proven reduction in mortality in adults and
  children with tuberculous meningitis(particularly
  due to a reduction in hepatitis secondary to
  treatment of TB.)

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When Do We Use Steroids?

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

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What is the prognosis of this case

• Even with appropriate antibiotics, mortality rate
  is significant
• 8 H.influenza,
• 15 Neisseria meningitidis,
• 25 Pneumococcal
• Up to 35 of survivors have sequelae including
  deafness, seizures, blindness, paresis, ataxia,
  hydrocephalus

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thank you
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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
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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
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BACTERIAL PARAMENINGEAL FOCUS

   Sinusitis
   Mastoiditis
   Brain abscess
   Subdural-epidural empyema
   Cranial osteomyelitis
FUNGI

   Coccidioides immitis (coccidioidomycosis)
   Blastomyces dermatitidis (blastomycosis)
   Cryptococcus neoformans (cryptococcosis)
   Histoplasma capsulatum (histoplasmosis)
   Candida species
BACTERIAL PARAMENINGEAL FOCUS

   Sinusitis
   Mastoiditis
   Brain abscess
   Subdural-epidural empyema
FUNGI FUNGI

      Coccidioides immitis (coccidioidomycosis)
      Blastomyces dermatitidis (blastomycosis)
      Cryptococcus neoformans (cryptococcosis)
      Histoplasma capsulatum (histoplasmosis)
      Candida species
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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
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POSTINFECTIOUS

   Vaccinesrabies, 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
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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)
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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