MENINGITIS

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• MENINGITIS
• OUTCOME ? VARIABLE
• Acute Benign Form of Viral
• TO
• Rapidly Fatal Bacterial Meningitis
• WITH
• Local Progressive mental
• deterioration and death

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• Meningitis inflammation of the meninges
• Encephalitis infection of the brain parenchyma
• Meningoencephalitis inflammation of brain
  meninges
• Aseptic meningitis inflammation of meninges
  with sterile CSF

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• Introduction
• Meningitis inflammation of the pia mater and the
  arachnoid mater, with suppuration of the
  cerebrospinal fluid

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Symptoms of meningitis

• Fever
• Altered consciousness, irritability, photophobia
• Vomiting, poor appetite
• Seizures 20 - 30
• Bulging fontanel 30
• Stiff neck or nuchal rigidity
• Meningismus (stiff neck Brudzinski Kernig
  signs)

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• Contraindications
• ? ICP reported to increase risk of herniation
• Cellulitis at area of tap
• Bleeding disorder

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• WHAT DETERMINE THE OUTCOME?
• 1. Etiological organism
• 2. Speed and appropriation of the therapy.
• MORTALITY
• Bacterial Meningitis 40

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CAUSES OF MENINGITIS
INFECTIOUS NON-INFECTIOUS
Viral Aseptic Meningitis
Bacteria Malignancy
Mycobacterial Sarcoid
Brucella behcet disease
Fungal SLE
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• Viral Meningitis
• Generally benign, rarely fatal
• Enterovirus around 80 of cases
• Other viruses mumps, Epstein-Barr virus,
• Rare but serious forms Herpes group viruses
• No specific preventive or curative treatment for
• most except Herpes viruses
• Clears up on its own with no treatment in 3
• to 8 days

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Bacterial meningitis - Organisms

• Neonates
• Most caused by Group B Streptococci
• E coli, enterococci, Klebsiella, Enterobacter,
  Samonella, Serratia, Listeria
• Older infants and children
• Neisseria meningitidis, S. pneumoniae,
  tuberculosis, H. influenzae

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Causes of bacterial meningitis

• Strep pneumonia.37
• Neisseria meningitides..13
• Listeria monocytogenes.10
• Other strept.species.7
• Gram negative.4
• Haemophillus influenza4
• No pathogens37
• Review of 493 cases of adult meningits
• (Durand NEJM 1993 )

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APPROACH TO PATIENTWITH POSSIBLE MENINGITIS

• I) Maintain diagnostic VIGILANCE
• a.) Suspect the diseases b.) Look for
  classical features
• 1) Headache
• 2) meningeal irritation.HOW?
• 3) Obtundation
• c.) Confirm or exclude the diagnosis

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• II) INITIATE RAPID TRATMENT
• a. I.V.
• b. Large and sufficient dose
• c. Effective choice

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INITIAL MANAGEMENT APPROACH

• Recognition of the meningitis syndrome.
• Rapid diagnostic evaluation.
• Emergent antimicrobial adjunctive therapy.

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III. CONSIDER CHANGING EPIDEMIOLOGY

• A.) Global emergence and Prevalence
  of Penicillin- Resistant Strain of Strep.
• pneumonia.
• B.) Dramatic Reduction in invasive H.
• influenza disease secondary to use of
  conjugate Haemophillus Type B-
  vaccine.
• C.) Group B Streptococci ? Neonate Now ? gt 50
  also.

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IV. COMPLEXITIES OF EMPIRIC MANAGEMENT

• I F Focal Sign
• Pappiledema OR Focal Neurological
• deficit (often gtVI N)
• ? Brain abscess
• Chr. Meningitis
• DONT Delay Administration
• of Antibiotics

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Bacterial Meningitis - TreatmentNeonatal (lt3 mo)

• Ampicillin (covers Listeria)
• Cefotaxime
• High CSF levels
• Less toxicity than aminoglycosides
• No drug levels to follow

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Management Algorithm for Adults
Suspicion of bacterial meningitis
YES
new onset seizure, papilledema, altered level of
consciousness, or focal neurological deficit or
delay in performance of diagnostic L.P
NO
YES
Blood c/s Lumbar puncture
B/C stat
Dexamethasone empirical Abx
Dexamethasone empirical Abx
-ve CT-scan of the head
CSF is abnormal
YES
Perform L.P
ve CSF gram stain
NO
YES
Dexamethasone empirical Abx
Dexamethasone targeted Abx
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• CASE I
• A 12 year old Nigerian boy who has arrived to
  Riyadh 2 days prior to presentation - C/O
  severe headache Photophobia?
• How do you approach manage him?
• Presence of fever neck stiffness.

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• Neurological deficit Fundus.
• Skin ? RASH
• CSF examination
• Opening pressure 260 mm H20
• cloudy
• WBC 1500/ ml. 96
• segmented
• Glucose 24mg / dl
• Protein 200 mg.

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• MOST LIKELY DIAGNOSIS
• 1. Neisseria m.
• 2. Strep. Pneumonia
• 3. H. influenza
• 4. Listeria monocytogen
• EPIDEMIOLOGICAL FEATURES
• OF MENINGOCOCCAL MENINGITIS
• 1. Affect children young adult
• 2 20 years

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• 2. Epidemic usually sero group A C
• 3. Nasopharyngeal Acquisition
• 4. Predisposing in those with
• Terminal Complement
• deficiencies ( Cs ----- C9 )
• 5. SKIN RASH ?

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• a. Fulminate meningococcemia with purpura
• b. Meningitis with RASH (Petechiae)
• c. Meningitis without RASH.
• 6. Mortality 3 - 10 .
• 7. D. O. Choice ? Penicillin I.V.

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• CASE 2
• A 26 YEAR OLD Saudi female who has been C /
  O unwell fever cough and headache for the
  last 3 days. Examination revealed ill looking
  women with sign of consolidation R Lung base.
• DIAGNOSIS
• Bacteria Pneumonia.
• Organism?

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• Six (6) hours after admission, her headache
  became worse and she became obstunded.
• DIAGNOSIS ? MENINGITIS
• CSF WBC 3000 99 DML
• Sugar Zero
• Protein 260 mg/dl.
• Gram Stain Gram
• DIAGNOSIS
• Bacterial..?

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Epidemiological Features ofPneumococcal
meningitis

• The most common. Cause
• The most killing. 20 - 30
• DEATH
• May be associated with other Focus
• a. Pneumonia 25

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• b.Otitis Media 30
• c. Sinusitis 15
• d. Head Trauma CSF Leak 10.
• E. splenectoy and SS disease..
• Global emergence of Penicillin Resistant.

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Case presentation

• 30 years old sudanese male who was to the ER in
  confusional state for few hours befor
  presentation ..history revealed presence of two
  attacks of seizures in the same day with high
  fever

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• EXAMINATION
• Looks unwell - Temp. 39C
• Neck Stiffness - absent
• Funds - Bilateral
• papilledema
• Possible diagnosis
• 1. Meningitis
• 2. Brain abscess
• 3. Subarachnoid. Hemorrhage

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MENINGITIS

• 1. Viral Meningitis
• 2. Bacterial Meningitis
• 3. Brucella Tuberculosis

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PREVENTION CHEMOPROPHYLAXIS

• Neiseria meningitidis
• Eradication of nasopharyngeal carriage..(post
  exposure ) for
• 1)house hold contact
• 2)Treating doctor who has examined patient very
  closely

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• What drugs are recommonded
• Rifampicin 600 X 2 d
  Ciprofloxacin 500X1
• Ceftriaxon 125mg I.M X1

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• VACCINE TO
• 1. Hib Type B vaccine ? 1.Protection
• 2. Eliminate
• 2. Meningococcal vaccine A, C, Y, W135
• - Up to 3 years adult - Does
  not affect N. ph. Carriage ? Does not provide
  herd immunity.

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Viral meningitis - Treatment

• Supportive
• No antibiotics
• Analgesia
• Fever control
• Often feel better after LP
• No isolation - Standard precautions

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Caes

• 56 years saudi women presented to the infectious
  disease clinic c/o low grade fever and night
  sweating for the last 6 wkson detailed inquires
  she admitted to have headache for 4 wks improving
  on analgesics..
• EXAMINATION
• T 38.2..Fully conscious
• Neck stiffnes..bilateral papillodema

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LABORATORY RESULTS..

• CSFxanthocromic
• wbc 340 L 85
• protein 1.5g sugar 25 mg
• WHAT IS YOUR ANYLASIS OF THIS
• CSF..

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• 1) Partially treated bacterial meningitis
• 2) Aseptic meningitis
• 3) Bruclla meningitis
• 4) Tubercoulus meningitis
• 5) OTHERS..

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• TREATMENT
• A. Principles of Therapy
• 1. Multiple drugs. ( INH Rif.)
• 2. Educate the patient ? Long
• therapy ? 6/12
• 3. Tell about Potential side effects
• ?
• a. Orange sweat tears with
• Rifampicin.
• b. Hepatitis with INH.

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• 4. Follow patient closely.
• B. Commonly Used Drugs
• 1. INH (Isonized)
• a. Bactericidal ? inhibit DNA
  synthesis
• b. Excellent tissue and CNS penetration.
• c. Acetylated with liver ? Renal.
• d. Toxicity Hepatitis / P.

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• Neuropathy.
• 2. Rifampicin
• a. Bactericidal ? inhibit RNA
  synthesis b. Excellent tissue CNS
• penetration
• c. Hepatic excretion
• d. Toxicity Hepatitis / RASH
• / Drugs interaction

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MalariaTravel Medicine
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MALARIA

• Febrile illness caused by
• Plasmodium.
• 200 300,000,000 cases.
• 700,000---2.7,000,000 death/year
• more in rural area..
• more during rainy season
• Human ---- -----? Another
• Mosquito

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Transmission

• BITE OF FEMALE ANOPHELES
• BETWEEN DUSK AND DAWN
• BLOOD TRANSFUSION
• CONTAMINATED NEEDLES
• CONGENITAL.

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• ETIOLOGY
• Four species.
  Death is mostly due to ..?
• SYPMTOMS
• ---? Non-specific
• Headache fatigue
• muscle pain
• Fever
• DX ? Viral infection..?

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• Clinical Features
• Symptoms
• 7 10 days ? Malaria Paroxysms.
• Cold ? Chills Rigor cold skin
• Hot ? Fever, warm skin
• 3-6
• hours
• deverevescence ? Marked sweating

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• Between Paroxyms ? Well DX ?
• SIGNS
• Spleen Enlargement
• Jaundice
• Fever
• Anemia

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• Clinical example
• An 18 years old Saudi pregnant young women
  originally from Jazan came C/O Fever and
  headache.
• Exam Pale, jaundiced,
• Temp. - 39C
• Spleen enlarged NEXT?
• CBC WBC - 8000
• Hb - 9.0

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• Platelets 90
• MCU 98
• CXR Normal
• DIAGNOSIS
• 1. Index of suspicion Travel hist.
• Incubation Period
• 2 WKS
• Prophylaxis -? Longer
• 2. ? Malaria
• 3. Blood smear Thin thick
• 4. Special Drug

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• COMPLICATION
• 1. Cerebral Malaria
• ? encephalopathy
• ? Seizure
• ? Death 20
• 2. Black. Water Fever
• ? non immune
• ? High degree
• of F.M.
• ? Hemolysis

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• Malaria Pregnancy
• 1. Risk of low birth abortion.
• 2. Risk of glucose , pulm. oedema
• TREATMENT
• 1. History
• 2. Smear
• 3. Species

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• 4. Severity CBC
• Hib
• Coagulation
• 5. Drugs

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• TREATMENT
• 1. Uncontrolled airway
• 2. I.V . infusion Blood
  glucose test,
• parasitemia, Hct.
• 4. Antimalaria.
• a. Chloroquine p.o.
• b. Mefloquine
• C . Quinine AND
  DOXYCYCLINE
• D.
  ARTEMISININS
• E .
  ATOVAQUONE PLUS PROGUANEL
• 5. Fluid balance
• ? P. Edema
• ? Dehydration Shock
• 6. Convulsion ? Diazepam
• 7. Blood C/ S8) LP

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DRUG TOXICITY

• MEFLOQUINE neuropsychiatric symptoms mood
  changes .encephalopathytransient
• QUININE Bitter taste , GIT upset , cinchonism
  ( nausea, vomiting , tinnitus , high tone
  deafness )
• Doxycycline ..GIT upset, vaginal candidiasis..(
  use antifungal )

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• PREVENTION
• Avoid mosquito
• Wear long sleeved clothing
• Sleep in well screened rooms
• Use mosquito netting
• Use insect repellents (e.g. DEET)
• Chemoprophylaxis..

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• 1) CHLOROQUINE
• ONE TABLET EVERY WK..
• DAILY WILL LEED TO RETINOPATHY
• Consider resistant plasmodium

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• Chloroquine-sensitive areas
• Drug of choice
• Chloroquine 500 mg (300 mg base) once/wk
• Atovaquone/ proguanil (Malarone) 1 tab/d
• ( 250 mg atovaquone /100 mg proguanil)
• Mefloquine 250 mg once/wk
• Doxycycline 100 mg daily
• Alternatives
• Primaquine 30 mg base daily
• Chloroquine plus proguanil 500 mg (300 mg base)
  once / wk 200 mg