Title: meningitis-case study
1Approach to A case of meningitis
Presented by
DR MOHAMED ABDELAZIZ march 2012
2MENINGES
3MENINGES
4MENINGITIS
- 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.
5Types of Meningitis
- Pyogenic Bacterial meningitis
- Aseptic (viral) meningitis
- Tubercular meningitis
6Case 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.
7What 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.
8MENINGITIS-DIFFERENTIAL DIAGNOSIS
- Brain abscess
- Encephalitis
- Epidural abscess
- Bacterial endocarditis with septic embolism
- Subarachnoid hemorrhage
- Tumor
9What are the most common causing pathogen?
Neonates E. Coli Proteus Group B Streptococci
Listeria monocytogenes Enterococcus,
Enterobacter, Klebsiella, Salmonella,
10- Pre School Children
- Hemophilus influenzae
- Neisseria meningitidis
- Streptococcus pneumoniae
- Mycobacterium tuberculosis
11- Older Children and Adults
- Neisseria meningitidis (Meningococcus)
- Streptococcus pneumoniae
- Mycobacterium tuberculosis
- Listeria monocytogenes
- Hemophilus influenzae
- Staphylococcus aureus
12What 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.
13- Look for focus
- bloodseptecaemia,toxic shock,acute viraemia.
- renalurinary tract infection,pyelonephritis.
- gastrointestinal tractviral or bacterial GE.
- CNSencephalitis or brain abscess
14What 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
15CLINICAL 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
16Skin 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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18What 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
-
19KERNIGS 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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21BRUDZINSKIS 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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23What 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
24MENINGITIS-DIAGNOSIS
25CSF 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
26OTHER 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
27What 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 . -
28- 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
-
29- 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
30Why 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.)
31When 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.
32What 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
33 thank you
34VIRUSES
  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
35BACTERIA
  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
36BACTERIAL 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
37PARASITES (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
38POSTINFECTIOUS
  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
39MALIGNANCY
  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)
40MISCELLANEOUS
  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