Project: Ghana Emergency Medicine Collaborative
Document Title: Meningitis and Other CNS Infections
Author(s): Frank Mador...
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Meningitis
and other CNS infections
Frank Madore, MD
Hennepin County Medical Center
Minneapolis, MN, USA
3
BACKGROUNDBACKGROUND
4
history

first described by Viesseux in 1805

Flexner developed antiserum in 1913

antibiotic use began in 1930s-40s

...
definitions

meningitis – inflammation of the
meninges

encephalitis – inflammation of brain
parenchymaa

myelitis – in...
epidemiology

meningitis endemic in parts of Africa

occurs in epidemics in US
– incidence is 5-10/100,000 per year,
win...
MENINGITISMENINGITIS
8
etiology
streptococcus pneumoniae

neisseria meningitidis (<45 yo)

listeria monocytogenes

aseptic
viral – HSV, enter...
pathophysiology

nasopharyngeal colonization → mucosal
invasion → enter blood stream → evade
immune destruction → cross b...
risk factors

age <5 or >60

male

african descent

crowding

sickle cell disease

malignancy

etoh, DM

recent EN...
clinical presentation

headache

fever

nausea/vomiting

seizures

altered mental status

nuchal rigidity

photopho...
clinical presentation

often have a primary source of infection
on exam (PNA, UTI, sinusitis, OM, etc.)

purpuric rash w...
complications

acute – coma, seizure, loss of airway
reflexes, respiratory arrest, cerebral
edema, DIC, dehydration, deat...
ENCEPHALITISENCEPHALITIS
15
etiology

usually viral – HSV, HHV, west nile virus,
arbovirus, VZV, EBV

occasionally idiopathic, post infectious, or
b...
pathophysiology

innoculation occurs via various
mechanisms depending on the virus

viremia, proliferation within neuron...
clinical presentation

symptoms similar to meningitis, except:

almost all have AMS

personality changes

focal neurol...
complications

dependent on etiologic agent

Japanese, Eastern equine, and St. Louis
encephalitis have high M&M

West N...
CNS ABSCESSCNS ABSCESS
20
etiology

usually invasion from more common ENT
infections (otitis media, sinusitis, dental
infections, etc.)

streptoco...
clinical presentation

similar to encephalitis, often difficult to
differentiate clinically

usually subacute (>2 weeks ...
complications

mortality >50% without aggressive care
– <20% with surgical aspiration + abx

80% develop seizure disorde...
DIAGNOSISDIAGNOSIS
24
CT before LP?
unnecessary in most patients with
suspected meningitis, except:
– focal neuro deficits
– altered mental sta...
lumbar puncture
collect at least 3 tubes of 1 mL each
opening pressure = 5-20 cm H2O
cell count <5 WBC/mm3
differentia...
adjuncts to LP

blood cultures
– often have higher yields for bacteria

CBC w/diff
– don't let it talk you out of an LP
...
MANAGEMENTMANAGEMENT
28
resuscitation

fulminant presentation
– septic shock
– seizures
– cerebral edema
– hypoxia
– loss of airway reflexes

st...
antibiotic regimen

vancomycin plus
– ceftriaxone or
– cefotaxime or
– meropenem or
– chloramphenicol

add ampicillin if...
other medications

acyclovir for suspected HSV

INH, rifampin, etc. for TB

amphotericin B for fungal (not in ED)

fla...
steroids in meningitis

dexamethasone has been shown to
reduce cerebral edema, ICP, CSF lactate

past studies with varia...
chemoprophylaxis

rifampin 600 mg x4 doses in household
contacts

ciprofloxacin 500 mg x1 dose in HCW with
direct contac...
disposition

admit

can consider d/c if symptoms are classic
for viral meningitis and follow up within
24 hours can be e...
SUMMARYSUMMARY
35
in conclusion...

suspicion of CNS infection mandates LP
unless contraindications to blind LP exist
– in which case, perf...
QUESTIONSQUESTIONS
37
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GEMC- Meningitis and Other CNS Infections- Resident Training

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This is a lecture by Frank Madore, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

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GEMC- Meningitis and Other CNS Infections- Resident Training

  1. 1. Project: Ghana Emergency Medicine Collaborative Document Title: Meningitis and Other CNS Infections Author(s): Frank Madore, MD License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1
  2. 2. Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2
  3. 3. Meningitis and other CNS infections Frank Madore, MD Hennepin County Medical Center Minneapolis, MN, USA 3
  4. 4. BACKGROUNDBACKGROUND 4
  5. 5. history  first described by Viesseux in 1805  Flexner developed antiserum in 1913  antibiotic use began in 1930s-40s  high morbidity and mortality to this day – 20-40% depending on organism – 30% with residual deficits  changing landscape of causative organisms based on vaccination patterns 5
  6. 6. definitions  meningitis – inflammation of the meninges  encephalitis – inflammation of brain parenchymaa  myelitis – inflammation of spinal cord 6
  7. 7. epidemiology  meningitis endemic in parts of Africa  occurs in epidemics in US – incidence is 5-10/100,000 per year, winter – 80% are Neisseria and Strep pneumo – viral meningitis twice as common, summer  encephalitis less common but incidence rising due to West Nile Virus  rare brain abscesses due to sinusitis, otitis media, immunocompromised 7
  8. 8. MENINGITISMENINGITIS 8
  9. 9. etiology streptococcus pneumoniae  neisseria meningitidis (<45 yo)  listeria monocytogenes  aseptic viral – HSV, enteroviruses, etc. – fungal – crypto, histo, blasto, coccidioides – parasites – toxo, neurocyster. trichinosis – rickettsiae – RMSF, typhus – non-infectious – post inf, drugs, systemic dz 9
  10. 10. pathophysiology  nasopharyngeal colonization → mucosal invasion → enter blood stream → evade immune destruction → cross blood brain barrier into CSF  meningeal inflammation → increased permeability of BBB, vasculitis, edema, increased ICP  decreased cerebral perfusion, decreased CSF glucose, increased CSF protein 10
  11. 11. risk factors  age <5 or >60  male  african descent  crowding  sickle cell disease  malignancy  etoh, DM  recent ENT surgery or head injury 11
  12. 12. clinical presentation  headache  fever  nausea/vomiting  seizures  altered mental status  nuchal rigidity  photophobia  many present atypically (old, young, immune compromised, aseptic) 12
  13. 13. clinical presentation  often have a primary source of infection on exam (PNA, UTI, sinusitis, OM, etc.)  purpuric rash with menincococcemia  Kernig Sign – can't extend knee to 180 while laying supine with hip in flexion  Brudzinski Sign – 5 described, 2 used now – contralateral – flexion of one hip causes flexion of the other hip – neck – flexion of neck causes hip flexion  jolt acceleration of headache 13
  14. 14. complications  acute – coma, seizure, loss of airway reflexes, respiratory arrest, cerebral edema, DIC, dehydration, death  delayed – seizures, paralysis, cognitive deficits, hydrocephalus, hearing loss, ataxia, blindness, death  complications from viral meningitis are rare 14
  15. 15. ENCEPHALITISENCEPHALITIS 15
  16. 16. etiology  usually viral – HSV, HHV, west nile virus, arbovirus, VZV, EBV  occasionally idiopathic, post infectious, or bacterial (mycoplasma pneumoniae) 16
  17. 17. pathophysiology  innoculation occurs via various mechanisms depending on the virus  viremia, proliferation within neurons, or invasion via nasal mucosa  CSF invasion similar to meningitis but less of an immune response if viral → fewer neurologic sequelae in most patients 17
  18. 18. clinical presentation  symptoms similar to meningitis, except:  almost all have AMS  personality changes  focal neurologic signs  higher incidence of seizure  hallucinations, bizarre behavior – may precede other signs → psych dx 18
  19. 19. complications  dependent on etiologic agent  Japanese, Eastern equine, and St. Louis encephalitis have high M&M  West Nile Virus infects few but has significant mortality  HSV mortality dropped from 70% to 30% with acyclovir – survivors: seizure, motor/cognitive deficits  TB M&M vary based on duration  fungal mortality high, morbidity low 19
  20. 20. CNS ABSCESSCNS ABSCESS 20
  21. 21. etiology  usually invasion from more common ENT infections (otitis media, sinusitis, dental infections, etc.)  streptococcus milleri most common  also bacterioides, staph aureus, propionbacterium, enterobacteriae 21
  22. 22. clinical presentation  similar to encephalitis, often difficult to differentiate clinically  usually subacute (>2 weeks onset) course of illness  often have papilledema  acute worsening can occur with rupture of abscess into ventricles or with uncal herniaton  can mimic intracranial hemorrhage 22
  23. 23. complications  mortality >50% without aggressive care – <20% with surgical aspiration + abx  80% develop seizure disorder  cognitive deficits, focal neuro deficits common  epidural abscess → paralysis, motor & sensory deficits, bowel/bladder dysfunction 23
  24. 24. DIAGNOSISDIAGNOSIS 24
  25. 25. CT before LP? unnecessary in most patients with suspected meningitis, except: – focal neuro deficits – altered mental status/coma – papilledema – seizures – trauma CT and LP should not delay treatment abx → CT if needed → LP 25
  26. 26. lumbar puncture collect at least 3 tubes of 1 mL each opening pressure = 5-20 cm H2O cell count <5 WBC/mm3 differential <1 PMN/mm3 protein = 15-45 mg/dL glucose = 60% blood glucose gram stain/AFB culture, specific antigen tests 26
  27. 27. adjuncts to LP  blood cultures – often have higher yields for bacteria  CBC w/diff – don't let it talk you out of an LP  chemistry panel – compare glucose to CSF, renal function  CXR – 50% w/strep pnuemo meningitis have PNA  EEG – encephalitis (HSV) 27
  28. 28. MANAGEMENTMANAGEMENT 28
  29. 29. resuscitation  fulminant presentation – septic shock – seizures – cerebral edema – hypoxia – loss of airway reflexes  standard supportive measures – mannitol for cerebral edema – empiric antibiotics as soon as possible 29
  30. 30. antibiotic regimen  vancomycin plus – ceftriaxone or – cefotaxime or – meropenem or – chloramphenicol  add ampicillin if >50 yrs  neonates: cefotaxime + ampicillin  special cases: penetrating trauma, post neurosurgery, VP shunt 30
  31. 31. other medications  acyclovir for suspected HSV  INH, rifampin, etc. for TB  amphotericin B for fungal (not in ED)  flagyl for CNS abscess – also early neurosurgical consultation 31
  32. 32. steroids in meningitis  dexamethasone has been shown to reduce cerebral edema, ICP, CSF lactate  past studies with variable results  randomized controlled study in sub- Saharan Africa showed no benefit in children  randomized controlled study in Vietnam showed reduction of long-term neurologic sequelae with dexamethasone >14 yo – dexamethasone for strep pneumoniae 32
  33. 33. chemoprophylaxis  rifampin 600 mg x4 doses in household contacts  ciprofloxacin 500 mg x1 dose in HCW with direct contact (intubation, suctioning) 33
  34. 34. disposition  admit  can consider d/c if symptoms are classic for viral meningitis and follow up within 24 hours can be ensured – often viral meningitis is admitted on abx until bacterial causes can be excluded 34
  35. 35. SUMMARYSUMMARY 35
  36. 36. in conclusion...  suspicion of CNS infection mandates LP unless contraindications to blind LP exist – in which case, perform HCT first  do not delay abx for HCT or LP  evaluation for CNS infection in a patient with the right symptoms should not stop if another infection is found – many have hematogenous spread from PNA or UTI 36
  37. 37. QUESTIONSQUESTIONS 37
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