Meningitis and Encephalitis
Meningitis <ul><li>Inflammation of the membranes of the brain or spinal cord </li></ul>
Encephalitis <ul><li>Inflammation of the brain  parenchyma, presents as diffuse and/or focal neuropsychological dysfunctio...
Epidemiology <ul><li>Bacterial meningitis is a common disease worldwide. </li></ul><ul><li>5-10 per 100,000 people per yea...
Etiology
<ul><li>Meningeal infection associated with a dural leak secondary to neurosurgery or neurotrauma –  S.pneumoniae, Staphyl...
Viral Etiologies
Causes in Thailand  <ul><li>Virus </li></ul><ul><ul><li>Arbovirus :  JEV & Dengue virus </li></ul></ul><ul><ul><li>Herpes ...
Etiology-encephalitis <ul><li>Arboviruses and herpes simplex virus, HHV are the most common causes of endemic and sporadic...
Viruses and Severity of Disease
Seasonal Distribution
Noninfectious meningitides
Pathophysiology <ul><li>Bacterial Meningitis </li></ul><ul><li>Nasopharyngeal colonization  and mucosal invasion  </li></u...
Bacterial Meningitis <ul><li>Mechanism of invasion is not completely understood. </li></ul><ul><li>Host defense mechanism ...
 
Viral Meningitis and Encephalitis
Herpes Simplex Virus
Viral Meningitis and Encephalitis <ul><li>Viral replication </li></ul><ul><li>Hematogenous spread to CNS </li></ul><ul><li...
Eastern Encephalitis Virus
Equine Death from Viral Encephalitis
Regions Reporting Japanese Encephalitis
 
Encephalitis morbidity and mortality, Thailand 1976-2005
อัตราป่วยของโรค  Encephalitis unspecified   ( ต่อ แสนประชากร )  จำแนกตามกลุ่มอายุ ปี พ . ศ .  2545 - 2549
อัตราป่วยของโรค  Japanese Encephalitis B  ( ต่อ แสนประชากร )  จำแนกตามกลุ่มอายุ ปี พ . ศ .  2545 - 2549
Japanese B Encephalitis morbidity and mortality, Thailand 1976-2005
History of Japanese Encephalitis <ul><li>1800s – recognized in Japan </li></ul><ul><li>1924 – Japan epidemic.  6125 cases,...
Japanese Encephalitis <ul><li>Most important cause of arboviral encephalitis worldwide, with over 45,000 cases reported an...
Encephalitis and Japanese Encephalitis situation by Province 2006
Rice Fields
Japanese Encephalitis Virus
คำแนะนำในการวินิจฉัยผู้ป่วยสมองอักเสบ  <ul><li>1. ประเมินสภาวะผู้ป่วย  ( comorbid status  และ  underlying disease)  ผู้ป่ว...
คำแนะนำในการวินิจฉัยผู้ป่วยสมองอักเสบ  <ul><li>-  บ้านที่อยู่อาศัย ที่ทำงาน และประวัติการเดินทางที่ผ่านมาในช่วง  3  สัปดาห...
คำแนะนำในการวินิจฉัยผู้ป่วยสมองอักเสบ  <ul><li>3. ตรวจร่างกาย  </li></ul><ul><li>3.1  ตรวจความผิดปกติทั่วไป เช่น ผื่น จุดห...
Clinical Features <ul><li>Symptoms and Signs </li></ul><ul><li>Classical  CNS infection  -  Fever, Headache, photophobia, ...
Clinical Features <ul><li>The physical finding </li></ul><ul><li>Vary </li></ul><ul><li>Depending on the host, causative o...
Clinical Features <ul><li>The systemic finding </li></ul><ul><li>Sinusitis, otitis media, mastoiditis, pneumonia, UTI, end...
Clinical Features <ul><li>Focal neuro deficit and seizure : more commonly with encephalitis than meningitis. </li></ul><ul...
Complication of Bacterial meningitis
Complication of Bacterial meningitis
Bacterial Meningitis <ul><li>Fatality rate for pneumococcal meningitis  ~ 20-25%. </li></ul><ul><li>Higher fatality rate -...
Viral meningitis <ul><li>Various complication related to the systemic effect  -  orchitis, parotitis, pancreatitis  </li><...
Viral Encephalitis <ul><li>The outcome dependent on in infecting agent. </li></ul><ul><li>HSV encephalitis  -> 60-70% mort...
TB meningitis <ul><li>Death in adult age 10-50% ( pt.age, duration of symptom before presentation) </li></ul><ul><li>Focal...
Fungal meningitis <ul><li>Abscess, papilledema, neuro deficit, seizure, bone invasion, fluid collection direct invasion of...
Diagnostic Strategies
Lumbar Puncture <ul><li>Contraindication  </li></ul><ul><li>Present of infection in the skin, soft tissue at the puncture ...
Indication for CT scan before LP in suspected Bacterial meningitis <ul><li>Immunocompromised state </li></ul><ul><li>Histo...
CSF Analysis
Opening pressure -  50-200 mmH 2 O - Lateral recumbent position and    sitting position  may increase    several fold. - E...
Collection of Fluid <ul><li>At least   3 specimens   (1.0-1.5 cc./spec) </li></ul><ul><li>Immediated analysis of turbidity...
Turbidity  <ul><li>Completely clear, colorless. </li></ul><ul><li>Leukocytosis is the most common cause of CSF turbidity (...
Cell count and diff. <ul><li>< 5 WBC /mm 3 </li></ul><ul><li>< 1 PMN /mm 3 </li></ul><ul><li>< 1 Eosinophil  /mm 3 </li></...
Cell count and diff. <ul><li>Early in viral infection < 48 hr.  -> PMN pleocytosis. </li></ul><ul><li>Normal cell count&di...
Traumatic LP <ul><li>Presense of a clot </li></ul><ul><li>Decrease RBC count from tube 1 to 3  </li></ul><ul><li>True CSF ...
Gram’s stain <ul><li>Diminished 20-30%  ใน   prior treatment with ATB </li></ul>Pathogen Typical characteristics Staphyloc...
Xanthrochromia <ul><li>Lysis of RBC and release of breakdown pigments, oxyhemoglobin, bilirubin and methemoglobin into the...
Glucose <ul><li>50-80 mg/dl </li></ul><ul><li>CSF glucose: serum glucose =  0.6:1 </li></ul><ul><li>Abnormal CSF to serum ...
Glucose <ul><li>Mild decrease CSF glucose level  </li></ul><ul><li>--> viral, parameningeal process. </li></ul><ul><li>Bac...
Protein <ul><li>15-45 mg/dl </li></ul><ul><li>Traumatic LP  </li></ul><ul><li>corrected  1 mg/dl of prot./1000 RBC </li></...
India Ink Preparation <ul><li>Cryptococcal disease  พบ   1/3 of cases </li></ul><ul><li>More definitive diagnostic test  i...
Lactic Acid <ul><li>Nonspecific </li></ul><ul><li>>35 mg/dl  -> bacterial meningitis </li></ul><ul><li><35 mg/dl  -> norma...
Antigen Detection <ul><li>CIE ( counterimmunoelectrophoresis) </li></ul><ul><li>latex agglutination </li></ul><ul><li>Coag...
Antigen Detection <ul><li>Bacteriologic culture  </li></ul><ul><li>->  N.meningitis  37-55% </li></ul><ul><li>->  H.influe...
Antigen Detection <ul><li>PCR  -> TB  sensitivity 80-85% specificity 97-100% </li></ul><ul><li>Sensitivities of detection ...
Neuroimaging Technique <ul><li>Possibility of an intracranial abscess, ICH, mass lesion </li></ul><ul><li>CT scan should n...
TB or Crypto meningeal involvement
MRI  in  HSV
Sporadic Herpes Simplex Encephalitis Fulminant hemorrhagic and necrotizing meningoencephalitis
Additional Investigation <ul><li>CBC  may show leukopenia in elderly, immunosuppressed person. </li></ul><ul><li>Blood cul...
Differential Consideration <ul><li>Three clinical symptom </li></ul><ul><li>Acute  , subacute, chronic meningitis </li></u...
Differential Consideration <ul><li>Subacute meningitis </li></ul><ul><li>1-7 day </li></ul><ul><li>viral meningitis, most ...
Differential Consideration <ul><li>Chronic meningitis </li></ul><ul><li>TB meningitis </li></ul><ul><li>Fungal CNS infecti...
Management Differential Consideration <ul><li>Chronic meningitis </li></ul><ul><li>TB meningitis </li></ul><ul><li>Fungal ...
Prehospital care <ul><li>Field stabilization + transport </li></ul><ul><li>Vital sign, Oxygen, alter mental status, seizur...
Assessment and stabilization <ul><li>Aggresssive management in septic shock, hypoxemia, seizure, cerebral edema, hypotensi...
Definitive Therapy Assessment and stabilization <ul><li>Aggresssive management in septic shock, hypoxemia, seizure, cerebr...
Bacterial meningitis
Empirical ATB for Bacterial meningitis
ATB for bacterial meningitis from Gram’s stain or Culture
ระยะเวลาในการให้ยาปฏิชีวนะใน  Bacterial meningitis
Bacterial meningitis <ul><li>Corticosteroid  -> additionally recommend in acute bacterial meningitis. </li></ul><ul><li>In...
Viral meningitis <ul><li>Short, benign, self-limited course </li></ul><ul><li>Complete recovery </li></ul><ul><li>Repeated...
Viral encephalitis  <ul><li>IV acyclovir 10 mg/kg every 8 hr. </li></ul><ul><li>Ganciclovir, foscarnet, ciclofovir  -> eff...
TB meningitis <ul><li>Corticosteroid  decrease secondary complication </li></ul>
Fungal meningitis <ul><li>4 agents are commonly used </li></ul><ul><li>Amphotericin B </li></ul><ul><li>Fluconazole  </li>...
Chemoprophylaxis <ul><li>Incidence of transmission </li></ul><ul><li>of meningococcus is  ~ 5% </li></ul><ul><li>Household...
Chemoprophylaxis <ul><li>Directed contact ( mouth to mouth, ET tube, nasotrachial suction)  </li></ul><ul><li>Ciprofloxaci...
Immunoprophylaxis <ul><li>Vaccination is also available to confer immune protection against JE virus </li></ul><ul><li>H.i...
Important ! <ul><li>Rule out non-viral causes that require specific treatment </li></ul><ul><li>Do not miss herpes simplex...
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Meningitis

  1. 1. Meningitis and Encephalitis
  2. 2. Meningitis <ul><li>Inflammation of the membranes of the brain or spinal cord </li></ul>
  3. 3. Encephalitis <ul><li>Inflammation of the brain parenchyma, presents as diffuse and/or focal neuropsychological dysfunction </li></ul><ul><li>Most commonly a viral infection with parenchymal damage varying from mild to profound </li></ul>
  4. 4. Epidemiology <ul><li>Bacterial meningitis is a common disease worldwide. </li></ul><ul><li>5-10 per 100,000 people per year in USA. </li></ul><ul><li>Men are affected more than women. </li></ul><ul><li>Meningococcal meningitis is endemic in parts of Africa. </li></ul><ul><li>The incidence of viral meningitis ~ 11-27 per 100,000 people </li></ul>
  5. 5. Etiology
  6. 6. <ul><li>Meningeal infection associated with a dural leak secondary to neurosurgery or neurotrauma – S.pneumoniae, Staphylococcus aureus, P.aeruginosa , coliform bacteria. </li></ul><ul><li>Viral meningitis- Enteroviruses are statistically most commonly -Causes of “nonparalytic polio” </li></ul><ul><li>Fungal and parasitic meningitides – immunocompromised. </li></ul>Etiology-meningitis
  7. 7. Viral Etiologies
  8. 8. Causes in Thailand <ul><li>Virus </li></ul><ul><ul><li>Arbovirus : JEV & Dengue virus </li></ul></ul><ul><ul><li>Herpes virus (simplex , zoster) </li></ul></ul><ul><ul><li>Enteroviruses including coxsackie virus, poliovirus, and echovirus </li></ul></ul><ul><ul><li>Other causes include varicella (chickenpox), measles, mumps, rubella, adenovirus, rabies </li></ul></ul>
  9. 9. Etiology-encephalitis <ul><li>Arboviruses and herpes simplex virus, HHV are the most common causes of endemic and sporadic cases of encephalitis, respectively. </li></ul><ul><li>Varicella, herpes zoster, HHV 6 and 7, and Epstein-Barr virus - cause of encephalitis in immunocompetent hosts. </li></ul><ul><li>Severe and Fatal Encephalitis-Arthropod-borne viruses and Herpes simplex viruses </li></ul>
  10. 10. Viruses and Severity of Disease
  11. 11. Seasonal Distribution
  12. 12. Noninfectious meningitides
  13. 13. Pathophysiology <ul><li>Bacterial Meningitis </li></ul><ul><li>Nasopharyngeal colonization and mucosal invasion </li></ul><ul><li>Evasion of the complement pathway </li></ul><ul><li>Bacterial cross the BBB to CSF </li></ul>
  14. 14. Bacterial Meningitis <ul><li>Mechanism of invasion is not completely understood. </li></ul><ul><li>Host defense mechanism within the CSF are often ineffective. </li></ul><ul><li>Bacterial proliferation stimulate a convergence of leukocyte into the CSF. </li></ul><ul><li>Meningeal and subarachnoid space inflammation release of cytokines into the CSF ( TNF, interleukin 1,6 ) </li></ul>
  15. 16. Viral Meningitis and Encephalitis
  16. 17. Herpes Simplex Virus
  17. 18. Viral Meningitis and Encephalitis <ul><li>Viral replication </li></ul><ul><li>Hematogenous spread to CNS </li></ul><ul><li>Retrograde transmission along neuronal axon </li></ul><ul><li>Direct invasion of the subarachnoid space หลังจาก infection ของ olfactory submucosa </li></ul>
  18. 19. Eastern Encephalitis Virus
  19. 20. Equine Death from Viral Encephalitis
  20. 21. Regions Reporting Japanese Encephalitis
  21. 23. Encephalitis morbidity and mortality, Thailand 1976-2005
  22. 24. อัตราป่วยของโรค Encephalitis unspecified ( ต่อ แสนประชากร ) จำแนกตามกลุ่มอายุ ปี พ . ศ . 2545 - 2549
  23. 25. อัตราป่วยของโรค Japanese Encephalitis B ( ต่อ แสนประชากร ) จำแนกตามกลุ่มอายุ ปี พ . ศ . 2545 - 2549
  24. 26. Japanese B Encephalitis morbidity and mortality, Thailand 1976-2005
  25. 27. History of Japanese Encephalitis <ul><li>1800s – recognized in Japan </li></ul><ul><li>1924 – Japan epidemic. 6125 cases, 3797 deaths </li></ul><ul><li>1935 – virus isolated in brain of Japanese patient who died of encephalitis </li></ul><ul><li>1938 – virus isolated from Culex mosquitoes in Japan </li></ul><ul><li>1948 – Japan outbreak </li></ul><ul><li>1949 – Korea outbreak </li></ul><ul><li>1966 – China outbreak </li></ul><ul><li>Today – extremely prevalent in South East Asia 30,000-50,000 cases reported each year </li></ul>
  26. 28. Japanese Encephalitis <ul><li>Most important cause of arboviral encephalitis worldwide, with over 45,000 cases reported annually </li></ul><ul><li>Transmitted by culex mosquito, which breeds in rice fields </li></ul><ul><ul><li>Mosquitoes become infected by feeding on domestic pigs and wild birds infected with Japanese encephalitis virus </li></ul></ul><ul><ul><li>Infected mosquitoes transmit virus to humans and animals during the feeding process </li></ul></ul>
  27. 29. Encephalitis and Japanese Encephalitis situation by Province 2006
  28. 30. Rice Fields
  29. 31. Japanese Encephalitis Virus
  30. 32. คำแนะนำในการวินิจฉัยผู้ป่วยสมองอักเสบ <ul><li>1. ประเมินสภาวะผู้ป่วย ( comorbid status และ underlying disease) ผู้ป่วยสุขภาพแข็งแรงดีหรือมีโรคประจำตัว ซึ่งมีความเสี่ยงต่อการติดเชื้อ เช่น เบาหวาน ติดสุรา HIV positive ( ซึ่งต้องทราบ CD4 count) neutropenia ( เช่นได้รับยาต้านมะเร็ง ) และภาวะอื่นๆที่มี ภูมิคุ้มกันบกพร่อง </li></ul><ul><li>2. รวบรวมข้อมูลที่อาจบ่งชี้ถึงต้นเหตุในช่วงระยะเวลาที่ผ่านมา </li></ul><ul><li>- ประวัติสัมผัสสัตว์เลี้ยง สัตว์ป่า </li></ul><ul><li>- ประวัติสัมผัส คลุกคลีกับผู้ป่วยไม่ว่าจะมีอาการทางระบบใดก็ตาม เช่น ทางระบบ หายใจ ทางเดินอาหาร </li></ul><ul><li>- อยู่ในสภาพที่แออัดยัดเยียด เช่น อยู่ในโรงเรียน กรมทหาร ในที่ประชุม </li></ul>
  31. 33. คำแนะนำในการวินิจฉัยผู้ป่วยสมองอักเสบ <ul><li>- บ้านที่อยู่อาศัย ที่ทำงาน และประวัติการเดินทางที่ผ่านมาในช่วง 3 สัปดาห์ รวมถึงฤดูกาลขณะที่เกิดโรคขึ้น </li></ul><ul><li>ประวัติอาการนำก่อนหน้าอาการทางระบบประสาท ( prodrome) เช่น ต่อมน้ำลาย parotid อักเสบใน mumps, อาการท้องเสีย ในกลุ่ม enterovirus และ อาการปวดเมื่อยกล้ามเนื้อ ซึ่งอาจจะมี URI symptoms หรือไม่ก็ตามใน influenza virus ส่วนการที่พบผื่น herpes simplex ที่ผิวหนัง ไม่จำเป็นว่าจะต้องเป็น HSV-1 encephalitis </li></ul>
  32. 34. คำแนะนำในการวินิจฉัยผู้ป่วยสมองอักเสบ <ul><li>3. ตรวจร่างกาย </li></ul><ul><li>3.1 ตรวจความผิดปกติทั่วไป เช่น ผื่น จุดหรือปื้นเลือดออก อาการทางระบบทางเดิน หายใจ ระบบทางเดินอาหาร ตับ ม้าม ต่อมน้ำเหลืองโต เป็นต้น </li></ul><ul><li>3.2 ระบุตำแหน่งของความผิดปกติในระบบประสาท </li></ul><ul><li>- CSF space ( เยื่อหุ้มสมอง - meningitis) ไม่มีความผิดปกติในการทำงานของเนื้อ สมอง มีเพียงไข้ ปวดหัว คอแข็ง </li></ul><ul><li>brain และ / หรือ spinal cord และ / หรือ spinal nerve root และ peripheral nerve (radiculoneuropathy) </li></ul><ul><li>3.3 ตรวจร่างกายทางระบบประสาท </li></ul><ul><li>4. ประเมินความเสี่ยงของการเจาะน้ำไขสันหลัง </li></ul>
  33. 35. Clinical Features <ul><li>Symptoms and Signs </li></ul><ul><li>Classical CNS infection - Fever, Headache, photophobia, nuchal rigidity, lethargy, malaise, altered sensorium, seizure, vomiting, chill </li></ul><ul><li>Immunosuppressed and geriatric pt. -> diagnostic challenge </li></ul><ul><li>Often, the only presenting sign of meningitis in the elderly pt. is an alteration of mental status </li></ul><ul><li>Some degree of fever is present in most pt. </li></ul>
  34. 36. Clinical Features <ul><li>The physical finding </li></ul><ul><li>Vary </li></ul><ul><li>Depending on the host, causative organism, severity of the illness </li></ul><ul><li>Kernig’s and Brudzinski’s signs are present ~ 50 % of adults. </li></ul><ul><li>DTR may be ↑. </li></ul><ul><li>Ophthalmoplegia may be present -> lateral rectus muscle </li></ul>
  35. 37. Clinical Features <ul><li>The systemic finding </li></ul><ul><li>Sinusitis, otitis media, mastoiditis, pneumonia, UTI, endocarditis, arthritis </li></ul><ul><li>Petechiae, cutaneous hemorrhage </li></ul>
  36. 38. Clinical Features <ul><li>Focal neuro deficit and seizure : more commonly with encephalitis than meningitis. </li></ul><ul><li>HSV encephalitis -> Dysphasia, seizure. </li></ul><ul><li>WNV -> produce myelitis -> flaccid paralysis, clear sensorium เหมือนกับ Guillian-Barre’ Syndrome และ polio. </li></ul>
  37. 39. Complication of Bacterial meningitis
  38. 40. Complication of Bacterial meningitis
  39. 41. Bacterial Meningitis <ul><li>Fatality rate for pneumococcal meningitis ~ 20-25%. </li></ul><ul><li>Higher fatality rate -> serious underlying, concomitant disease, advance age </li></ul><ul><li>Prognosis -> related to degree of neuro impairment on presentation </li></ul><ul><li>20-30% of pneumococcal meningitis -> residual neuro deficit. </li></ul><ul><li>40% fatality rate for Listeria meningitis. </li></ul><ul><li>ATB -> ↓mortality from meningococcal meningitis ได้เหลือ < 20% </li></ul><ul><li>Mortality rate in community-acquired G-ve meningitis < 20% เมื่อเริ่มให้ 3 rd gen cephalosporin. </li></ul>
  40. 42. Viral meningitis <ul><li>Various complication related to the systemic effect - orchitis, parotitis, pancreatitis </li></ul><ul><li>Usually all of these complication resolve without sequelae. </li></ul>
  41. 43. Viral Encephalitis <ul><li>The outcome dependent on in infecting agent. </li></ul><ul><li>HSV encephalitis -> 60-70% mortality </li></ul><ul><li>( before use acyclovir Tx ) </li></ul><ul><li> -> 30% ( Acyclovir Tx ) </li></ul><ul><li>Common sequelae -> seizure, motor deficit, change in mentation. </li></ul>
  42. 44. TB meningitis <ul><li>Death in adult age 10-50% ( pt.age, duration of symptom before presentation) </li></ul><ul><li>Focal ischemic stroke -> result from cerebral vasculitis. </li></ul><ul><li>25% of pt. -> required neurosurgical procedure ( VP shunt or drainage). </li></ul>
  43. 45. Fungal meningitis <ul><li>Abscess, papilledema, neuro deficit, seizure, bone invasion, fluid collection direct invasion of the optic n. -> ocular abn. 40% in cryptococcal meningitis. </li></ul>
  44. 46. Diagnostic Strategies
  45. 47. Lumbar Puncture <ul><li>Contraindication </li></ul><ul><li>Present of infection in the skin, soft tissue at the puncture site. </li></ul><ul><li>Likelihood of brain herniation. </li></ul>Diagnostic Strategies
  46. 48. Indication for CT scan before LP in suspected Bacterial meningitis <ul><li>Immunocompromised state </li></ul><ul><li>History of </li></ul><ul><li>Stroke </li></ul><ul><li>Mass lesion </li></ul><ul><li>Focal infection </li></ul><ul><li>Head trauma </li></ul><ul><li>Seizure within last 7 days </li></ul><ul><li>Contraindication </li></ul><ul><li>Present of infection in the skin, soft tissue at the puncture site. </li></ul><ul><li>Likelihood of brain herniation. </li></ul>Lumbar Puncture <ul><li>Abnormal level of consciousness </li></ul><ul><li>Inability to answer question or follow command appropiately </li></ul><ul><li>Abnormal visual fields or paresis of gaze </li></ul><ul><li>Focal weakness </li></ul><ul><li>Abnormal speech </li></ul>
  47. 49. CSF Analysis
  48. 50. Opening pressure - 50-200 mmH 2 O - Lateral recumbent position and sitting position may increase several fold. - Elevated in bacterial, TB, fungal. - Falsely elevated in tense, obese, marked muscle contraction .
  49. 51. Collection of Fluid <ul><li>At least 3 specimens (1.0-1.5 cc./spec) </li></ul><ul><li>Immediated analysis of turbidity, xanthochromia, glucose, protein, cell count & diff., Gram’s stain, bacterial culture, india ink, AFB, VDRL </li></ul><ul><li>ถ้าได้ CSF เล็กน้อย ส่ง cell count & diff., Gram’s stain, bacterial culture. </li></ul>
  50. 52. Turbidity <ul><li>Completely clear, colorless. </li></ul><ul><li>Leukocytosis is the most common cause of CSF turbidity ( > 200 cell/mm 3 ) </li></ul>
  51. 53. Cell count and diff. <ul><li>< 5 WBC /mm 3 </li></ul><ul><li>< 1 PMN /mm 3 </li></ul><ul><li>< 1 Eosinophil /mm 3 </li></ul><ul><li>Pretreatment with few doses of ATB -> diminishing the yield of Gram’s stain, bacterial culture, not affect CSF cell count. </li></ul><ul><li>Initial CSF analysis -> lymphocytosis 6-13% in bacterial meningitis </li></ul><ul><li>Viral meningitis and encephalitis -> usually less than 500 cell/mm 3 (nearly 100% mononuclear) </li></ul>
  52. 54. Cell count and diff. <ul><li>Early in viral infection < 48 hr. -> PMN pleocytosis. </li></ul><ul><li>Normal cell count&diff. -> reassure, do not absolutely exclude bacterial meningitis. </li></ul><ul><li>น้ำไขสันหลัง อาจไม่พบ cell เลยใน rabies, dengue, West Nile virus, herpes simplex virus, Nipah virus หรือ ในกรณีตั้งน้ำไขสันหลังทิ้งไว้นานเกินกว่า 2 ชม . เนื่องจาก 50% ของเม็ดเลือดขาว neutrophils จะสลายไปที่ระยะเวลานี้ </li></ul>
  53. 55. Traumatic LP <ul><li>Presense of a clot </li></ul><ul><li>Decrease RBC count from tube 1 to 3 </li></ul><ul><li>True CSF WBC = measure CSF WBC </li></ul><ul><li>CSF RBC x Blood WBC </li></ul><ul><li>Blood RBC </li></ul><ul><li>CSF from traumatic LP -> 1 WBC / 700 RBC </li></ul>
  54. 56. Gram’s stain <ul><li>Diminished 20-30% ใน prior treatment with ATB </li></ul>Pathogen Typical characteristics Staphylococcus G + cocci: single,double,tetrad,cluster Streptococcus pneumoniae G + cocci; paired diplococci Listeria monocytogenes G + rods: single or chain Neisseria meningitidis G – cocci: paired diplococci;kidney or coffee bean Haemophilus influenzae G – coccobacilli;pleomorphic Enterobacteriaceae G – rods Pseudomonas aeruginosa G – rods
  55. 57. Xanthrochromia <ul><li>Lysis of RBC and release of breakdown pigments, oxyhemoglobin, bilirubin and methemoglobin into the CSF. </li></ul><ul><li>Begin within 2 hr. -> persist up to 30 days. </li></ul><ul><li>Traumatic tap -> ↑ CSF protein 150mg/dl or more </li></ul><ul><li>Subarachnoid hemorrhage. </li></ul>
  56. 58. Glucose <ul><li>50-80 mg/dl </li></ul><ul><li>CSF glucose: serum glucose = 0.6:1 </li></ul><ul><li>Abnormal CSF to serum glucose ratio </li></ul><ul><li>< 0.5 in normoglycemic or </li></ul><ul><li> 0.3 in hyperglycemic </li></ul><ul><li>impaired glucose transport mechanism </li></ul><ul><li>increase CNS glucose use </li></ul><ul><li>( pyogenic meningitis ) </li></ul>
  57. 59. Glucose <ul><li>Mild decrease CSF glucose level </li></ul><ul><li>--> viral, parameningeal process. </li></ul><ul><li>Bacterial or fungal meningitis -> “hypoglycorrhachia” </li></ul><ul><li>ถ้าระดับ serum glucose เพิ่มขึ้นอย่างรวดเร็ว เช่น การให้ 50% glucose อาจจะใช้เวลา 4 ชั่วโมงในการปรับสมดุลใน CSF </li></ul>
  58. 60. Protein <ul><li>15-45 mg/dl </li></ul><ul><li>Traumatic LP </li></ul><ul><li>corrected 1 mg/dl of prot./1000 RBC </li></ul><ul><li>Elevated CSF protein </li></ul><ul><li>-> usually higher than 150mg/dl </li></ul><ul><ul><li>Meningitis CNS vasculitis </li></ul></ul><ul><ul><li>SAH Viral encephalitis </li></ul></ul><ul><ul><li>Syphilis Demyelination symdrome </li></ul></ul><ul><ul><li>Neoplasm </li></ul></ul><ul><ul><li>>1000 mg/dl -> suggest fungal disease </li></ul></ul>
  59. 61. India Ink Preparation <ul><li>Cryptococcal disease พบ 1/3 of cases </li></ul><ul><li>More definitive diagnostic test is cryptococcal Antigen. </li></ul>
  60. 62. Lactic Acid <ul><li>Nonspecific </li></ul><ul><li>>35 mg/dl -> bacterial meningitis </li></ul><ul><li><35 mg/dl -> normal, viral meningitis </li></ul>
  61. 63. Antigen Detection <ul><li>CIE ( counterimmunoelectrophoresis) </li></ul><ul><li>latex agglutination </li></ul><ul><li>Coagglutination </li></ul><ul><li>Useful in receiving ATB before CSF sampling </li></ul><ul><li>Result - vary </li></ul><ul><li>Presense only an antigen, not viable organism </li></ul><ul><li>PCR -> HSV sensitivity 95-100% specificity 100% </li></ul><ul><li>ระยะเวลาที่เหมาะสมในการส่งตรวจน้ำไขสันหลังสำหรับไวรัส HSV คือ ภายในวันที่ 3- 10 หลังจากที่เริ่มมีอาการแสดงทางระบบประสาท </li></ul><ul><li>ถ้าผู้ป่วยได้รับยาต้านไวรัส เช่น acyclovir เป็นเวลานานมากกว่า 5-7 วัน อาจทำให้ กรวดน้ำไขสันหลังไม่พบเชื้อได้ </li></ul>
  62. 64. Antigen Detection <ul><li>Bacteriologic culture </li></ul><ul><li>-> N.meningitis 37-55% </li></ul><ul><li>-> H.influenzae 50% </li></ul><ul><li>PCR -> at least as sensitive as culture technique in detect cryptococcal meningitis. </li></ul><ul><li>PCR -> resumed for less clear presentation , pretreat with ATB, care in which concern exists for TB, cryptococcal, treatable viral CNS infection. </li></ul>
  63. 65. Antigen Detection <ul><li>PCR -> TB sensitivity 80-85% specificity 97-100% </li></ul><ul><li>Sensitivities of detection in CSF by PCR for N.meningitidis 88%, H.influenzae 100%, S.pneumoniae 92% (nearly 100% specificity) </li></ul>
  64. 66. Neuroimaging Technique <ul><li>Possibility of an intracranial abscess, ICH, mass lesion </li></ul><ul><li>CT scan should not unnecessarily delay LP or ATB </li></ul><ul><li>Hypodensity CT scan in the temporal lobes -> HSV encephilitis </li></ul>
  65. 67. TB or Crypto meningeal involvement
  66. 68. MRI in HSV
  67. 69. Sporadic Herpes Simplex Encephalitis Fulminant hemorrhagic and necrotizing meningoencephalitis
  68. 70. Additional Investigation <ul><li>CBC may show leukopenia in elderly, immunosuppressed person. </li></ul><ul><li>Blood culture -> identify causative organism more often when the meningitis is caused by pneumococcus than meningococcus </li></ul><ul><li>50% of pt. with pneumococcal meningitis -> evidence of pneumonia on an initial CxR. </li></ul><ul><li>EEG -> focal or lateralized EEG abn. -> associated with HSV type 1 encephalitis </li></ul><ul><li>( strong evidence) </li></ul>
  69. 71. Differential Consideration <ul><li>Three clinical symptom </li></ul><ul><li>Acute , subacute, chronic meningitis </li></ul><ul><li>Acute meningitis </li></ul><ul><li>< 24 hr., rapidly deteriorate </li></ul><ul><li>most likely pathogen </li></ul><ul><li> S.pneumoniae </li></ul><ul><li> N.meningitidis </li></ul><ul><li> H.influenzae </li></ul>
  70. 72. Differential Consideration <ul><li>Subacute meningitis </li></ul><ul><li>1-7 day </li></ul><ul><li>viral meningitis, most of bact.& some of fungal </li></ul><ul><li>fever + mental status change หา disease อื่น นอก CNS เช่น pneumonia, UTI </li></ul>
  71. 73. Differential Consideration <ul><li>Chronic meningitis </li></ul><ul><li>TB meningitis </li></ul><ul><li>Fungal CNS infection </li></ul><ul><li>Tertiary syphilis </li></ul><ul><li>CNS neoplasm </li></ul><ul><li>Lupus cerebritis </li></ul><ul><li>Sarcoidosis </li></ul><ul><li>Rheumatoid arthritis </li></ul><ul><li>Granulomatous angiitis </li></ul><ul><li>Various encephalitides </li></ul><ul><li>Toxic encephalopathies </li></ul><ul><li>Metabolic encephalopathies </li></ul><ul><li>Multiple sclerosis </li></ul><ul><li>Chronic subdural hematoma </li></ul>
  72. 74. Management Differential Consideration <ul><li>Chronic meningitis </li></ul><ul><li>TB meningitis </li></ul><ul><li>Fungal CNS infection </li></ul><ul><li>Tertiary syphilis </li></ul><ul><li>CNS neoplasm </li></ul><ul><li>Lupus cerebritis </li></ul><ul><li>Sarcoidosis </li></ul><ul><li>Rheumatoid arthritis </li></ul><ul><li>Granulomatous angiitis </li></ul><ul><li>Various encephalitides </li></ul><ul><li>Toxic encephalopathies </li></ul><ul><li>Metabolic encephalopathies </li></ul><ul><li>Multiple sclerosis </li></ul><ul><li>Chronic subdural hematoma </li></ul>
  73. 75. Prehospital care <ul><li>Field stabilization + transport </li></ul><ul><li>Vital sign, Oxygen, alter mental status, seizure </li></ul>
  74. 76. Assessment and stabilization <ul><li>Aggresssive management in septic shock, hypoxemia, seizure, cerebral edema, hypotension from dehydration </li></ul><ul><li>Preexisting condition may complicated the pt. dz. - Recent neurosurgery, trauma, leukopenia, immunocompromised, DM. </li></ul><ul><li>Acute cerebral edema or increase ICP -> immediate intubation and adequate ventilation +- osmotic agent (mannitol, diuretic) </li></ul>
  75. 77. Definitive Therapy Assessment and stabilization <ul><li>Aggresssive management in septic shock, hypoxemia, seizure, cerebral edema, hypotension from dehydration </li></ul><ul><li>Preexisting condition may complicated the pt. dz. - Recent neurosurgery, trauma, leukopenia, immunocompromised, DM. </li></ul><ul><li>Acute cerebral edema or increase ICP -> immediate intubation and adequate ventilation +- osmotic agent (mannitol,diuretic) </li></ul>
  76. 78. Bacterial meningitis
  77. 79. Empirical ATB for Bacterial meningitis
  78. 80. ATB for bacterial meningitis from Gram’s stain or Culture
  79. 81. ระยะเวลาในการให้ยาปฏิชีวนะใน Bacterial meningitis
  80. 82. Bacterial meningitis <ul><li>Corticosteroid -> additionally recommend in acute bacterial meningitis. </li></ul><ul><li>In animal study – pneumococcal meningitis -> ลด brain edema, CSF pressure, CSF lactate level </li></ul><ul><li>Dexamethasone + Cefuroxime or ceftriaxone </li></ul><ul><li>-> ↓ long term hearing loss in infants & children. </li></ul><ul><li>Absolute risk reduction of 10% in adult -> Dexamethasone is given either 15 min before or concomitantly with ATB and continued for 4 days at 6 hr intervals. (greatest in S.pneumoniae .) </li></ul><ul><li>No benefit in N.meningitidis </li></ul>
  81. 83. Viral meningitis <ul><li>Short, benign, self-limited course </li></ul><ul><li>Complete recovery </li></ul><ul><li>Repeated LP in 8-12 hr. </li></ul>
  82. 84. Viral encephalitis <ul><li>IV acyclovir 10 mg/kg every 8 hr. </li></ul><ul><li>Ganciclovir, foscarnet, ciclofovir -> effective in HHV infection </li></ul><ul><li>Pleonaril -> effective in enteroviral dz. </li></ul>
  83. 85. TB meningitis <ul><li>Corticosteroid decrease secondary complication </li></ul>
  84. 86. Fungal meningitis <ul><li>4 agents are commonly used </li></ul><ul><li>Amphotericin B </li></ul><ul><li>Fluconazole </li></ul><ul><li>Miconazole </li></ul><ul><li>Flucytosine </li></ul>
  85. 87. Chemoprophylaxis <ul><li>Incidence of transmission </li></ul><ul><li>of meningococcus is ~ 5% </li></ul><ul><li>Household contact </li></ul><ul><li>Rifampin adult 600 mg </li></ul><ul><li>child > 1 mo 10mg/kg </li></ul><ul><li>child < 1 mo 5mg/kg </li></ul><ul><li>oral q 12 hr. for a total of 4 doses. </li></ul><ul><li>Health care worker -> do not required prophylaxis </li></ul>
  86. 88. Chemoprophylaxis <ul><li>Directed contact ( mouth to mouth, ET tube, nasotrachial suction) </li></ul><ul><li>Ciprofloxacin 500 mg oral or Ceftriaxone 250 mg im. ( <15 yr. 125 mg im.) </li></ul><ul><li>No indication for chemoprophylaxis in pneumococcal meningitis </li></ul>
  87. 89. Immunoprophylaxis <ul><li>Vaccination is also available to confer immune protection against JE virus </li></ul><ul><li>H.influenzae type B vaccine use in pediatrics. </li></ul>
  88. 90. Important ! <ul><li>Rule out non-viral causes that require specific treatment </li></ul><ul><li>Do not miss herpes simplex encephalitis, which has highly effective treatment </li></ul>
  89. 91. END Have Any question ?
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