meningitis case-study


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meningitis case-study summary for apprach to case of meningitis by DR/mohamed abdelaziz ali -egypt

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  • Headache, nausea, and vomiting are the most specific symptoms
  • meningitis case-study

    1. 1. Approach to A case of meningitis Presented byDR MOHAMED ABDELAZIZ march 2012
    2. 2. MENINGES
    3. 3. MENINGES
    4. 4. MENINGITISMeningitis is an inflammatory responseto infections of the meninges andCSF,caused by bacteria, viruses, fungi,CSF,and other organisms such as protozoaand rickettsia.
    5. 5. Types of MeningitisPyogenic Bacterial meningitisAseptic (viral) meningitisTubercular meningitis
    6. 6. Case study an infant, a 9 month old girl,presents to casualitywith history of fever,vomiting and loose stool over thelast 3 days. She had a brief convulsion j before ustarrival at the hospital in the form of a generalizedcolonic siezure with uprolling of the eyes, whichsettled spontanously. Mum fells that the child has notbeen herself for the last few days and seems irritablemost of the time.O n examination the infant is febrile at 39C, drowzyand irritable but had apprpriate reactions on beinghandled,is midly dehydrated and has coolperipheries. H er throat is slightly inflamed.
    7. 7. What are the most important differntial diagnosis?This infant appear s acutly unwell with fever but no obvious source of infection is d iscribed .You m ust concern about bacterial infection causing septic shock and m eningitis.
    8. 8. M EN IN GITIS-D IFFEREN TIAL D IAGN O SISBrain abscessEncephalitisEpid ural abscessBacterial end ocard itis with septic em bolismSubarachnoid hem orrhageTum or
    9. 9. What are the most commoncausing pathogen?N eonates E. C oli Proteus Group B Streptococci L isteria m onocytogenes Enterococcus, Enterobacter, K lebsiella, Salm onella,
    10. 10. Pre School C hild ren– H em ophilus influenzae– N eisseria m eningitid is– Streptococcus pneum oniae– M ycobacterium tuberculosis
    11. 11. O ld er C hild ren and Ad ults– N eisseria m eningitid is (M eningococcus)– Streptococcus pneum oniae– M ycobacterium tuberculosis– L isteria m onocytogenes– H em ophilus influenzae– Staphylococcus aureus
    12. 12. What exam ination find ings and observations would you like to establish im m ed iately?L ook for focus Ears:otitis m ed ia,m astoid itis. Throat:tonsilitis,epiglottitis,gland ular fever,quinzy. Skin:im ptigo,cellulitis,abscess. C hest:bronchiolitis,upper respiratory tract infection,pneum onia. Abd om en:append icitis,perforations,abscess. Bone and joint:osteom ylitis,septic arthritis.
    13. 13. L ook for focus blood :septecaem ia,toxic shock,acute viraem ia. renal:urinary tract infection,pyelonephritis. gastrointestinal tract:viral or bacterial GE. C N S:encephalitis or brain abscess
    14. 14. What are the clinical picture?Bacterial m eningitis usually presents in twopatterns – Acute - com m on with S. pneum oniae and N . m eningitid es – Subacute - preced ing U RI like sym ptom s, m ore com m on with H . influenza and other pathogens
    15. 15. C L IN IC AL PRESEN TATIO NH ead ache FeverD rowsiness Most commonN eck stiffnessN ausea and vom itingIrritabilityAversion to lightRestlessnessAltered m ental status (Stupor,C om a)SeizureM enngococcal m eningits - Purpural rashes(70% )
    16. 16. Skin rashesIs d ue to sm all skin bleedAll parts of the bod y are affecedThe rashes d o not fad e und er pressurePathogenesis:a. Septicem iab. wid e spread end othelial d am agec. activation of coagulationd . throm bosis and platelets aggregatione. red uction of platelets
    17. 17. What are the signs and find ings in physical exam inations?Bulging fontanelFocal neurological signsN eck rigid ityPtosis, papilloed em a,C ushing’s triad (Brad ycard ia, H ypertension,Altered respirations)Positive K ernig’s and Brud zinski’s sign
    18. 18. KERNIG’S SIGNPatient placed supine with hips flexed 90d egrees. Exam iner attem pts to extend the legat the kneePositive test elicited when there is resistance toknee extension, or pain in the lower back orthigh with knee extension d ue to m eningealirritation
    19. 19. BRU D ZIN SK I’S SIGNPatient placed in supine position and neck ispassively flexed toward s the chestPositive test is elicited when flexion of neckcauses flexion at knees and / hips of the orpatient
    20. 20. What are the investigations requied for this infantC T or M RI are ind icated if there are focalneurological signs,raised IC P or prolongedfever. These are helpful in d etection of C N Scom plication of bacterial infections such ashyd rocephalus,cereberal infract,brain abscessand venous sinus throm bosis.L um ber puncture :
    22. 22. CSF Patterns in MeningitisCondition Appearance WBC/mm3 Glucose Total Predominant Protein type Normal Clear 0-5 50-75 15-40 lymphocytes >60% of BloodBacterial Turbid 100-10,000 glucose <45 100-1000 PMN Viral Clear 10- 2000 Normal 50-100 lymphocytes Fungal Cloudy <300 <45 40-300 lymphocytes TB Cloudy <500 <45 100-1000 lymphocytes
    23. 23. O TH ER IN VESTIGATIO N S C BC – N orm al WBC d oes not rule out m eningitis Blood cultures Electrolytes Renal function Serum glucose - U seful to com pare with C SF glucose O ther relevant investigations
    24. 24. What is the treat m ent of this case?Bacterial M eningitis Quick initiation of antibiotics is a must Typical Meningococcal rash Benzyle Penicillin 2.4 G IV 6th hrly A dults without Typical Meningococcal rash C efotaxim e 2 G IV 6th hrly or C eftriaxone 2 G IV 1 2th hrly Pinicillin Resistant pnuemococci C efotaxim e or C eftriaxone + Vancom ycin 1 gm IV 1 2th hrly A lter antibiotic choices once C SF gram stain results are available .
    25. 25. N . meningitidisInj Benzyle Penicillin 2.4 G IV 6th hrly * 5-7 d aysStrep. pneumoniae / H. influenaeInj C efotaxim e 2 G IV 6th hrly orInj C eftriaxone 2 G IV 1 2th hrly * 1 0-1 4 d aysPinicillin Resistant pnuemococciInj C efotaxim e or C eftriaxone+ Inj Vancom ycin 1 gm IV 1 2th hrlyL isteria monocytogenesInj Am picillin 2G iv 6 hrly+ Inj Gentam ycin 5g/ iv kg * 8- 1 0 d ays
    26. 26. Supportive C areSteroid s – Steroid s thought to blunt effects of host inflam m atory response – Theoretical concern of steroid s red ucing perm eability of blood brain barrier to antibioticsC onsid er repeat L P 24-36 hours after initiating treatm ent toassure sterilization of C SF if resistant organism or poorresponse to treatm entFeatures of Septicaem ia – IC U C are
    27. 27. Why d o we use steroid s?D ecreases inflam m ation which can lead to d ecreasedintracranial pressure.M ay interrupt the cytokine m ed iated neurotoxic effects ofbacteriolysis, which are at a m axim um d uring the first fewd ays of antibiotic therapy.Proven red uction in m orbid ity, such as severe hearing loss, inchild ren with H iB m eningitis and Strep. Pneum o m eningitis.Proven red uction in m ortality in ad ults and child ren withtuberculous m eningitis(particularly d ue to a red uction inhepatitis second ary to treatm ent of TB.)
    28. 28. When D o We U se Steroid s?Therapy should be initiated shortly before or atthe sam e tim e as the first d ose of antibiotics,(likelihood of unfavorable outcom e was m uchhigher in patients in whom d exam ethasonewas given after antibiotics).D exam ethasone should not be given to ad ultswho have alread y received antibiotics, becauseit has not been shown to im prove patientoutcom es.
    29. 29. What is the prognosis of this caseEven with appropriate antibiotics, m ortalityrate is significant – 8% H .influenza, – 1 5% N eisseria m eningitid is, – 25% Pneum ococcalU p to 35% of survivors have sequelaeinclud ing d eafness, seizures, blind ness,paresis, ataxia, hyd rocephalus
    30. 30. thank you
    31. 31. VIRUSE S Enteroviruses (coxsackievirus, echovirus, poliovirus, enterovirus) Arboviruses: Eastern equine, Western equine, Venezuelan equine, St. L ouis encephalitis, Powassan and C alifornia encephalitis, West N ile virus, C olorad o tick fever H erpes sim plex (types 1 ,2) H um an herpesvirus type 6 Varicella-zoster virus Epstein-Barr virus Parvovirus B1 9 C ytom egalovirus Ad enovirus Variola (sm allpox) M easles M um ps Rubella Influenza A and B Parainfluenza Rhinovirus Rabies L ym phocytic choriom eningitis Rotaviruses C oronaviruses H um an im m unod eficiency virus type 1
    32. 32. BA C TE RIA Mycobacterium tuberculosis Leptospira species (leptospirosis) Treponema pallidum (syphilis) Borrelia species (relapsing fever) Borrelia burgdorferi (L ym e d isease) Nocardia species (nocard iosis) Brucella species Bartonella species (cat-scratch disease) Rickettsia rickettsiae (Rocky M ountain spotted fever) Rickettsia prowazekii (typhus) E hrlichia canis Coxiella burnetii Mycoplasma pneumoniae Mycoplasma hominis Chlamydia trachomatis Chlamydia psittaci Chlamydia pneumoniae Partially treated bacterial m eningitis
    33. 33. BA C TE RIA LPA RA ME NING EA L FOC US Sinusitis M astoid itis Brain abscess Subd ural-epid ural em pyem a C ranial osteom yelitisFUNG I Coccidioides immitis (coccid ioid om ycosis) Blastomyces dermatitidis (blastom ycosis) Cryptococcus neoformans (cryptococcosis) H istoplasma capsulatum (histoplasm osis) Candida species
    34. 34. PA RA SITE S(E OSINOPHIL IC ) Angiostrongylus cantonensis G nathostoma spinigerum Baylisascaris procyonis Strongyloides stercoralis Trichinella spiralis Toxocara canis Taenia solium (cysticercosis) Paragonimus westermani Schistosoma species F asciola speciesPA RA SITE S(NONE OSINOPHIL IC) Toxoplasma gondii (toxoplasm osis) Acanthamoeba species Naegleria fowleri M alaria
    35. 35. POSTINFE C TIOUS Vaccines:rabies, influenza, m easles, poliovirus D em yelinating or allergic encephalitisSYSTE MIC ORIMMUNOL OGIC A L L YME DIA TE D Bacterial end ocard itis K awasaki d isease System ic lupus erythem atosus Vasculitis, includ ing polyarteritis nod osa Sjögren synd rom e M ixed connective tissue d isease Rheum atoid arthritis Beh çet synd rom e Wegener granulom atosis L ym phom atoid granulom atosis Granulom atous arteritis Sarcoid osis Fam ilial M ed iterranean fever Vogt-K oyanagi-H arad a synd rom e
    36. 36. MA L IG NA NC Y L eukem ia L ym phom a M etastatic carcinom a C entral nervous system tum or (e.g., craniopharyngiom a, gliom a, epend ym om a, astrocytom a, m ed ulloblastom a, teratom a)DRUG S Intrathecal infections (contrast m ed ia, serum , antibiotics, antineoplastic agents) N onsteroid al anti-inflam m atory agents O K T3 m onoclonal antibod ies C arbam azepine Azathioprine Intravenous im m une globulins Antibiotics (trim ethoprim -sulfam ethoxazole, sulfasalazine, ciprofloxacin, isoniazid )
    37. 37. MISC E L L A NE OUS H eavy m etal poisoning (lead , arsenic) Foreign bod ies (shunt, reservoir) Subarachnoid hem orrhage Postictal state Postm igraine state M ollaret synd rom e (recurrent) Intraventricular hem orrhage (neonate) Fam ilial hem ophagocytic synd rom e Post neurosurgery D erm oid -epid erm oid cyst