Meningitis: The Basics

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MeningitisThe Basics

• Steven M. Snodgrass M.D.

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What is meningitis ?

• Inflammation of the meninges/leptomeninges the
  pia, arachnoid, and dura mater.
• Can have various causes bacteria, viruses,
  fungus.

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How it happens

• NP colonization of susceptible individual and
  invasion of respiratory tract
• Invasion of bloodstream (Bacteremia)
• Choroid plexitis
• Spread to meninges
• Ventriculitis and increased intracranial pressure
• Recruitment of inflammatory mediators

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How it happens

• Damage to blood-brain barrier leads to cerebral
  edema
• Endothelial cell damage, thrombosis
• Increase in CSF protein, decrease in glucose from
  hypoxia, decreased aerobic metabolism
• Infarction, Seizures, Abscess formation

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Typical presentations

• You are seeing a 14 day old infant in the
  emergency room with a 2 day history of
  congestion. Parents note infant to be
  increasingly irritable and lethargic, sleeping
  through feeds, multiple episodes of vomiting,
  difficult to console. Fever of 103 rectal.
  Infant looks pale and feels cool with HR of 225.
  A spinal tap shows 5000 white blood cells and a
  gram stain reveals gram negative rods.

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Typical presentations

• You are seeing a 15 yo high school student in
  your office with a 24 hour history of lethargy,
  repeated vomiting, and fever to 102. On exam he
  is unable to touch his chin to his chest and
  resists full extension of his knee while lying
  flat.

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Pathogens of Bacterial Meningitis

• Neonates (lt1mo)
• Group B streptococcus, E. coli, Listeria
• Infants (1-24 mos)
• Haemophilus influenzae type B, Streptococcus
  pneumoniae, Neisseria meningitidis
• Children (gt2yo)
• Neisseria (meningococcus), Strep pneumo
  (pneumococcus), H. flu

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Meningococcemia
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Gram negative diplococci
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Diagnosis

• Must maintain a high index of suspicion in many
  cases
• Gold standard is positive culture in CSF, may
  have CSF positive gram stain
• Lumbar puncture and CSF also show pleocytosis,
  increased protein, and hypoglycorrhea

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CSF findings
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How much does it happen1

• Pittsburgh similar to US in general
• For 5-17 yo in 2006
• Neisseria 0.4-0.5 cases per 100,000 with 50
  meningitis and 8 mortality
• Pneumococcus 3.3 cases per 100,000 with 6
  meningitis and 2.5 mortality
• 237 total cases of pneumococcal meningitis
• 68 total cases of meningococcal meningitis

1. http//www.cdc.gov/ncidod/dbmd/abcs/survreports
.htm
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Were lucky

• 1.1 cases per 100,000 in US in 2004 as compared
  to
• Cases per 100,000
• Pakistan 4.4
• Haiti 6.1
• Iraq 5.9
• China 7.7
• India 53.5

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Treatment

• Antibiotics Penicillins, Vancomycin,
  Cephalosporins
• ? Steroids - Dexamethasone
• Treat underlying hemodynamic compromise (shock)
  and other complications
• Monitor for and treat sequelae

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Complications and Sequelae

• Complications
• Shock/Sepsis
• Cerebral edema
• Subdural empyema
• Subdural effusion
• Ventriculitis
• Abscess
• Seizures

• Sequelae
• Deafness
• Developmental delay, cognitive impairments
• Chronic seizure disorder
• Hydrocephalus

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Vaccines

• Menactra
• Protects against four most common serogroups of
  Neisseria A, C, Y and W-135
• Most cases in infants due to serogroup B
• Adolescents and adults aged 11-55 yo
• Give at entry to H.S., college dorm residents,
  other at risk groups
• Conjugate vaccine as compared to MPSV

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Prophylaxis

• Most often for meningococcal meningitis and
  Haemophilus influenzae
• Close contacts
• Rifampin or Ciprofloxacin

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• Steve Snodgrass
• Childrens Hospital of Pittsburgh of UPMC
• Steven.Snodgrass_at_chp.edu
• Please e-mail with questions or comments