MENINGITIS

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MENINGITIS
Prof Mohammad Abduljabbar

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Definition

• Meningitis is defined as an infection of the tow
  layers of meninges ( Pia And Arachnoid )
  including the fluid in between namely
  cerebrospinal fluid (CSF)

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CAUSES

• 1-Bacterial.
• 2-Viral.
• 3-Fungal.

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N. meningitides G-ve diplococci

E.Coli G-ve bacilli
Streptococci-GBS Gve cocci
Strep. pneumoniae Gve diplococci
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Bacterial Meningitis - Organisms

•  Birth - 4 wks GBS, E.coli
• 4 - 12 wks GBS, E.coli, Pneumococcus
  Salmonella, Listeria, H. Influenza.
• 3 months - 3 yrs Pneumococcus, Meningococcus
• H. Influenza.
• 3 yrs adult Pneumococcus, Meningococcus

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Bacterial Meningitis - Pathogenesis

• Infection of upper respiratory tract
• Invasion of blood stream (bacteraemia)
• Seeding inflammation of meninges

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Clinical PresentationTriad of Meningitis

• Headache
• Fever
• Neck pain

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Meningitis Clinical features

• Newborn Infants non-specific symptoms
  including
• Fever
• Irritability
• Lethargy
• Poor feeding
• High pitched cry, bulging AF
• Convulsions, opisthotonus

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Meningitis older children
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Kernigs sign
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Brudzinskis sign
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Acute Meningococcaemia

• Neisseria meningitidis serotype Grp B commonest
• Endotoxin causes vascular damage vasodilatation,
  third spacing, severe shock
• Severe complication
• Waterhouse-Friderichsen syndrome massive
  haemorrhage of adrenal glands secondary to
  sepsis adrenal crisis-low B.P, shock, DIC,
  purpura, adreno-cortical insufficiency

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Purpura fulminans
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Clinical features
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Clinical features
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Clinical features

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DIAGNOSIS

• History and physical examination
• Investigations
• CBC
• Renal profile
• CRP
• Coagulation
• Blood gas
• Glucose

• Blood C/S
• Skin scrapings
• PCR
• CXR
• Skin test

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Diagnosis
LP
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CSF FINDINGS

         Bacterial Viral
TB
        Cells 10-100,000
lt2,000 250-500
        polys lymph
lymph
        Glucose low
normal very low
        Protein N or Inc Normal
High
        G-Stain
gen ve -ve
ve Zn
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Bacterial Meningitis Management

•   Medical emergency
•   Early diagnosis essential
• Immediate optimum treatment
• Intensive supportive therapy
• Rehabilitation
• Prophylaxis to family
• Notification to GP Public Health

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Bacterial Meningitis/Meningococcaemia Management

• ABC
• ICU admission
• Fluid management aggressive resuscitation
• Dexamethasone only in Pneumococcal and H I
  bacteria, given before antibiotics
• Inotropes to maintain good blood pressure.

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Antibiotics

• Less than 2 months of age
• Ampicillin Cefotaxime/- Gentamicin
• Treat for 3 weeks (neonate)
• Over 2 months
• Cefotaxime
• Treat for 7-10 days

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Prophylaxis

• Rifampicin
• Children 5mg/kg bd x 2/7
• Adults 600 mg bd x 2/7
• Pregnant contact
• Cefuroxime IM x 1 dose
• OR
• Just do T/S and await result

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Meningitis - Complications

• Septic shock - DIC
• Cerebral oedema
• Seizures
• Arteritis/venous thrombosis
• Subdural effusions
• Hydrocephalus . Abscess . Brain damage
• Deafness

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Meningococcaemia - poor prognosis

• Onset of Petechiae within 12 hrs
• Absence of meningitis signs
• Shock (BP 70 or less)
• Normal or low WBC
•  Normal or low ESR

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Subdural Effusion

• Failure of temperature to show progressive
  reduction after 72 hours
• Persistent positive spinal cultures after 72
  hours
• Occurrence of focal/ persistent convulsions
• Persistence/recurrence of vomiting
• Development of focal neurological signs
• Clinical deterioration after 72 hours especially
  ICP

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Partially treated meningitis

• 50 cases prior antibiotic - alters the findings
  in bacterial meningitis -
• Accurate history is vital
• CSF mainly lymphocytic not usual polys
• Can have normal glucose
• Positive cultures reduced by 30
• Gram stain reduced by 20

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Viral meningitis

• Most common infection of CNS especially in lt1yr
• Causes enterovirus (commonest, meningitis
  occurring in 50 of children lt3mth ) herpes,
  influenza, rubella, echo, coxsackie, EBV,
  adenovirus
• Mononuclear lymphocytes in CSF
• Symptomatic treatment. Complications associated
  with encephalitis and ICP

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TB Meningitis

• Usually insidious difficult to diagnose in early
  stages (fever 30, URTI 20)
• Rare in children in developed countries
• If untreated is usually fatal
• Meningitis usually occurs 3-6mths after primary
  infection
• 1 stage-lasts 1-2wk, fever malaise, headache
• 2 stage-/- suddenly, meningeal signs
• 3 stage-worsening neurological condition, death

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Mortality/Morbidity

• Bacterial meningitis Overall mortality 5-10
• Neonatal meningitis 15-20
• Older children 3-10
• Strep. pneumonia 26-30
• H. influenza type B 7-10
• N. meningitidis 3.5-10
• 30 neurological complications
• 4 Profound bilateral hearing loss (sensory
  neural) in all bacterial meningitis

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Mortality/Morbidity

• Viral meningoencephalitis Enteroviral fewer
  complications
• Tuberculous meningitis related to stage of
  disease
• Stage I-30 morbidity
• Stage II- 56
• Stage III-94

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THANK YOU