Medicine 5th year, 5th lecture/part one (Dr. Mohammed Tahir)

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The lecture has been given on May 21st, 2011 by Dr. Mohammed Tahir.

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Medicine 5th year, 5th lecture/part one (Dr. Mohammed Tahir)

  1. 1. NERVOUS SYSTEM INFECTIONS MENINGITIS Acute infection of the meninges presents with the characteristic combination: pyrexia Headache Meningism
  2. 2. CAUSES OF MENINGITIS <ul><li>Infective </li></ul><ul><li>Bacteria Viruses: Enteroviruse,Mumps, </li></ul><ul><li>Influenza Herpes simplex </li></ul><ul><li>Protozoa & parasites:Toxoplasma </li></ul><ul><li>Amoeba </li></ul><ul><li>Fungi:Cryptococcus neoformans, candida </li></ul>
  3. 3. Fever,Headache,Nuchal rigidity <ul><li>Altered mental status </li></ul><ul><li>Yes No </li></ul><ul><li>Encephalitis,ADEM,Abscess Meningitis </li></ul><ul><li>Imaging,CT or MRI. CSF </li></ul>Brain imaging CSF
  4. 4. Bacterial causes of meningitis <ul><li>Less common </li></ul><ul><li>Common </li></ul><ul><li>Age of onset </li></ul><ul><li>L –m,T.B,Crypto </li></ul><ul><li>N-Meningitidis </li></ul><ul><li>St-pneumonia </li></ul><ul><li>Older child </li></ul><ul><li>And adult </li></ul><ul><li>Mycobacterium </li></ul><ul><li>tuberculosis </li></ul><ul><li>H-influenzae </li></ul><ul><li>N-meningitidis </li></ul><ul><li>St-pneumonia </li></ul><ul><li>Pre-school child </li></ul><ul><li>Listeria monocytogenes </li></ul><ul><li>G-negative bacillia,Group B </li></ul><ul><li>streptococci </li></ul><ul><li>Neonate </li></ul>
  5. 5. Neonate G-negative bacilli Group B streptococci
  6. 6. Pre-school child Haemophillus ifluenza Neisseria meningitidis Streptococcus pneumonia
  7. 7. Older child & adult Neisseria meningitidis Streptococcus pneumoniae Listeria monocytogenes
  8. 8. CSF INDICES IN MENINGITIS often Increase Low 50-5000 L/P,M TB + N/ Increase Low 1000 5000 Poly Bacterial - normal normal 10-2000 Lymp Viral - Normal >60% B-G 0-4 Lymp Normal G- stain protein Glucose CELL Count CELl Type Condition
  9. 9. CHEMOTHERAPY OF BACTERIAL MENINGGITIS <ul><li>N-meningitidis Benzylpenicillin </li></ul><ul><li>Strep.pneumoniae Cefotaxime </li></ul><ul><li>Sensitive to B-lactams Ceftriaxone </li></ul><ul><li>Resistant +Vancomycin </li></ul><ul><li>H.Influenzae Cefotaxime </li></ul><ul><li>Ceftriaxone </li></ul><ul><li>Listeria monoctogenes Ampicillin $ </li></ul><ul><li>gentamicine </li></ul>
  10. 10. Treatment of pyogenicmeningitis of unknown cause <ul><li>1-patients with a typical meningococcal rash </li></ul><ul><li>Benzylpenicillin 2.4 gIV.6-hourly </li></ul><ul><li>2-Adult aged 18-50 years without meningococcal rash </li></ul><ul><li>Cefotaxime 2 g IV.6-hourly </li></ul><ul><li>Ceftriaxone 2g IV.12-hourly </li></ul><ul><li>3-Patient in whome pencillin-resistant pneumococcal infection is suspected </li></ul><ul><li>As 2 but add-Vancomycin 1g Iv,12-hourly or Rifampicin 600 mg </li></ul><ul><li>IV.12-hourly </li></ul><ul><li>4-Adult aged over 50 years and those in whome Listeria monocytogees infection is suspected </li></ul><ul><li>As for 2 but add Ampicillin 2g IV.4-jourly or Co-trimoxazole </li></ul><ul><li>5-Patients with a clear history of anaphylaxis to B-lactams </li></ul><ul><li>Chloramphenicol 25 mg/kg IV.6-hourly plus Vancomycin 1g IV.12-hourly </li></ul>
  11. 11. Recommendations for Empirical antimicrobial therapy in adult with community-acquired meningitis <ul><li>Predisposing factor pathogen Drugs </li></ul><ul><li>16-50 yr N-St-pn Vancomycin + </li></ul><ul><li>3 rd cephalosporin </li></ul><ul><li>>50 yr ٍ St-pn, N, List Van+3 rd Ceph+ </li></ul><ul><li>Ampicillin </li></ul><ul><li>Presence of a risk St-pn, list, Van+3 rd ceph+ </li></ul><ul><li>H-infuenzae Ampicillin </li></ul><ul><li>www.NEJM.ORG ,N ENGL ,Jan-2006 </li></ul>
  12. 12. Chemoprophylaxis for meningococcal infection <ul><li>Dose it reduce the incidence of clinical disease among contact? </li></ul><ul><li>Observational data suggest that antibiotic reduce the risk of disease </li></ul><ul><li>In adults a single dose of 500 mg ciprofloxacin or oral rifampicin 600mg(12-hourly) for 2 days. </li></ul><ul><li>Vaccines for groups A&C but not B menigococci. </li></ul>
  13. 13. COMPLICATIONS OF MININGOCOCCAL SEPTICEMIA <ul><li>Menigitis </li></ul><ul><li>Rash </li></ul><ul><li>Shock </li></ul><ul><li>Intravascular coagulation </li></ul><ul><li>Renal failure </li></ul><ul><li>Gangrene </li></ul><ul><li>Arthritis </li></ul><ul><li>Pericarditis </li></ul>
  14. 14. Major intracranial complications in Bacterial meningitis in adult ----------------------------------------- 1-Transtentorial herniation 2-Hydrocephalus 3-Infarction 4-Seizures
  15. 15. CLINICAL FEATURES OF TB MENINGITIS <ul><li>Vomiting </li></ul><ul><li>Low-grade fever </li></ul><ul><li>lassitude </li></ul><ul><li>Depression </li></ul><ul><li>Confusion </li></ul><ul><li>Behavior changes </li></ul>
  16. 16. Signs <ul><li>Meningism (may be absent) </li></ul><ul><li>Ocular palsies </li></ul><ul><li>Papilloedema </li></ul><ul><li>Depression of conscious level </li></ul><ul><li>Focal hemispher signs </li></ul>
  17. 17. Viruses causing acute encephalitis <ul><li>Common </li></ul><ul><li>Arboviruses </li></ul><ul><li>Enterovirsuses </li></ul><ul><li>HSV </li></ul><ul><li>Less common </li></ul><ul><li>CMV </li></ul><ul><li>EBV </li></ul><ul><li>HIV </li></ul><ul><li>Mumps </li></ul>
  18. 18. Viruses causing acute meningitis <ul><li>Enterviruses =75-90 </li></ul><ul><li>Echo 30% Coxsa-A 10% Coxsac-B 40% </li></ul><ul><li>Mumpsvirus 15% </li></ul>
  19. 19. Practical points <ul><li>The typical profile is lymphocytic pleocytosis(25-500 cells/uL.) </li></ul><ul><li>A normal or slightly elevated protein </li></ul><ul><li>A normal glucose concentration. </li></ul><ul><li>PMN pleocytosis should always promt an alternative diagnosis </li></ul><ul><li>In both enterovirus &HSV,PCR is the diagnostic procedure of choice </li></ul>
  20. 20. Differential diagnosis <ul><ul><li>Bacterial menigitis: Mycoplasma,lasteria,brucella </li></ul></ul><ul><ul><li>Parameningeal infection </li></ul></ul><ul><ul><li>Partially treated bacterial meningitis </li></ul></ul><ul><ul><li>Tb,fungal, parasitic, Syphilitic disease </li></ul></ul><ul><ul><li>Neoplastic meningitis </li></ul></ul><ul><ul><li>Sarcoid, Behcets disease </li></ul></ul>
  21. 21. Chronic & recurrent meningitis <ul><li>Characteristic neurological syndrome for>4weeks </li></ul><ul><li>& </li></ul><ul><li>Persistent inflammation in CSF (WBC>5/Ul) </li></ul><ul><li>Causes:1-Meningeal infection </li></ul><ul><li>2-Malignancy </li></ul><ul><li>3-Noninfectious inflammatory disorder </li></ul><ul><li>4-Chemical meningitis </li></ul><ul><li>5-Parameningeal infections </li></ul>
  22. 22. Symptoms & signs of chronic meningitis <ul><li>Symptom Sign </li></ul><ul><li>Chronic headache Sign of Meningeal irritation </li></ul><ul><li>Change in personality Altered mental status </li></ul><ul><li>Facial weakness Crainal nerve palsy </li></ul><ul><li>Double visions Papilledema,optic atrophy </li></ul><ul><li>Weakness Myelopathy,radiculopathy </li></ul><ul><li>Sensory symptoms Frontal lobe dysfunction </li></ul><ul><li>Sphincter dysfunction Ataxia </li></ul>

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