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Viral meningitis
Acute aseptic meningitis syndrome Any meningitis
(infectious or noninfectious), usually with a
lymphocytic pleocytosis, with negative routine
stains and cultures of CSF. Viruses are the major
cause of acute aseptic meningitis
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Etiology of Viral meningitis Enteroviruses

• 85-95 of all identified pathogens
• Echovirus coxsackievirus (many serotypes)
• Summer/fall seasonality
• Fecal-oral transmission also recovered from
  houseflies, wastewater, and sewage
• Mostly Infants and young children

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Etiology of Bacterial meningitis

• The most common pathogens (gt80 of cases)
• Streptococcus pneumoniae
• Neisseria meningitidis
• Haemophilus influenzae

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Etiology of Bacterial meningitis

• Vaccine-related decline in H. influenzae type B
  meningitis from 2.9/100,000 population in 1986
  to 0.2/100,000 population in 1995
• Bacterial meningitis is now a disease
  predominantly of adults rather than infants and
  children.

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• Bacterial meningitis is now a disease
  predominantly of adults rather than infants and
  children.

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The inflammation (WBC) in the sub-arachnoid spcae
extends along the vasculature
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Induction of Subarachnoid Space Inflammation
Bacterial factors (after bacteriolysis) Cell wall
components, teichoic acid and peptidoglycan, (not
capsular polysaccharides)
Host factors Prostaglandins (PGE2,
prostacyclin) Interleukins (IL-1b, IL-6, IL-8,
IL-12) Interferon-gamma
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The blood-brain barrier (BBB)

• Separates the brain from the intravascular
  compartment
• The permeability of the BBB increases in
  meningitis at the level of the choroid plexus
  epithelium and the cerebral microvascular
  endothelium.

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Increased BBB permeability

• Separation of intercellular tight junctions
• Direct effect of bacterial component
• Through inflammatory cytokines (e.g. IL-1, TNF)

The resulting increased extravasation of serum
components, including antibiotics leads to
higher concentrations in the CSF during
meningitis, with an approximately fivefold
increase over the uninfected state for most
antibiotics
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Electron micrograph A rat model of meningitis.
Gold-albumin complexes exiting through an open
intercellular junction (arrowheads). Lvessel
lumen, evenular endothelium, NWBC nucleus.
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Nasopharyngeal colonization
Bloodstream invasion
Bacteremia
Meningeal invasion
Bacterial replication and lysis
Subarachnoid space inflammation

• BBB permeability

CSF outflow obstruction
Brain edema
Hydrocephalus
Vasculitis
Vascular spasm thrombosis
Increased intracranial pressure
Cerebral ischemia necrosis
Decreased cerebral blood flow loss of
cerebrovascular autoregulation
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Bacterial meningitis
Exudate covering the cerebral hemispheres. Close
up view inflammatory vasculitis and thrombosis
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Acute meningococcemia with DIC intraventricular
hemorrhage
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Acute bacterial meningitis Strep. Pneumoniae
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?? ???? ??? ????, ????? ????, ??? 38.6, ???? ??
????, ?????? ????, ????? ??????? ????? ?? ????
?????.
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?? 16, ???"? ????, ??????, ??? 39.0, ??? ???,
???? ?????, ????? ??? ??? ??????. ?????? ????
?????? ?????, ???????? ??????. ??? 39.0, ??????
???? ????.
Kernings sign
Brudzinskis sign
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??? ???? ??????? ????????.

• Purpura fulminans
• Meningococcemia with or without meningitis
• Splenectomized patients with rapidly
  overwhelming sepsis caused by S. pneumoniae or H.
  influenzae type B.

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Meningococcal meningitis
Early rash
Hemorrhagic rash
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Purpura fulminans meningococcal meningitis
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Purpura fulminans and peripheral gangrene
meningococcal meningitis
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Adrenal hemorrhage in fulminant meningococcemia
Waterhouse-Friderich
sen syndrome
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Purpura fulminans overwhelming sepsis, with or
without meningitis
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Rhinorrhea or otorrhea

• Basilar skull fracture CSF leak
• Meningitis may be recurrent and is most commonly
  caused by S. pneumoniae

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Turbid (purulent)CSF
Gram-negative diplococci
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Suspicion of bacterial meningitis
Yes
Papilledema/focal neurologic sign
No
Blood Cultures
Blood Cultures
Lumbar Puncture ASAP!!!!
Antibiotics
CSF suggesting bact. meningitis
Head CT
Mass lesion
No Mass lesion or high ICP
Antibiotics
????! ???? ???? ???? LP ??? 30 ??' ?? ????? ?????
??? ??? ??????????? ???? LP
Alternative diagnosis?
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Bacterial meningitis treatment-1

• Empirical antimicrobial therapy is based on the
  patient's age and underlying diseases
• Early antimicrobial therapy before advancing to a
  high level of clinical severity improves clinical
  outcome.
• Intravenous administration
• Maximal doses

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Add ampicillin to immunocompromised patients
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Bacterial meningitis corticosteroid therapy-1
?????? ?? ????????? ?"? H. influenzae ?????? ?-
dexamethasone ??? ???? ?????? ????? ????????
??????????.
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Bacterial meningitis corticosteroid therapy-2
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???? ????? ????? ???? (7 ????? 15) ????? ????
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????? 25) ??????? ?????? ??????? ??? ?????????.
??????? ??? ?????? ?????? ?????? ?? ????????? ???
??????????? (????? ?? 14 ?????? ????????? ?????
34 ?????? ??????? 26 ?????? ???? ?????? ??????
????????? ????? 52 ?????? ???????) N Engl J Med
20023471549-56, Editorial 1613-4
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• Prophylactic antibiotics after close contact with
  a patient with meningitis
• N. meningitidis rifampin, ciprofloxacin,
  ceftriaxone, azithromycin)
• H. influenzae rifampin

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?? 60, ???? ?????????? ???? 6 ????. ????? ???????
?????????. ??? 6 ?????? ??? ???? (?? 37.9), ???
??? ??????? ?? ?????? ?????. ??? ??? ????? ?????.
???? ?????? ??????? ??? ???????. ???? ????
??????? ?????? ?????? ?????.
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????????? ??????-2
?????? ?? ????? ????? ???? ?? CSF ????? 90, WBC
285, ???? ??????????. ?????? 29. ????? ???
??????. ????? ????????? ??????.
????? ???-????? (acid fast)?????? ???? PPD ?????
20 ?"?
????? (????) ?????? ???? 4 ??' 5 ?????? ?? MTB
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Causes of chronic meningitis
Tuberculosis (Mycobacterium tuberculosis) Syphilis
(Treponema Pallidum) Lyme Disease (Borrelia
burgdorferi) Brucellosis Fungal (Cryptococcosis,
Coccidioidomycosis..) Parasite Angiostrongylus
cantonensis infection Protozoa Acanthamoeba
infection Non-infectious Neoplasm, Sarcoidosis,
Behcet Dis.
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Brain abscess
A Rt. hemisphere brain abscess. The diencephalon
and the midbrain are pushed to the left.
MRI
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A 43-year-old male, with ASD presented with
seizures after dental workup. Note the
ring-enhancing lesion with edema and mass effect
Brain abscess