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Meningitis-By Dr Opiro Keneth
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    Meningitis-By Dr Opiro Keneth Meningitis-By Dr Opiro Keneth Presentation Transcript

    • MENINGITIS Dr. Opiro Keneth
    • • Definition: - Inflammation of the leptomeninges • Importance: - Significant cause of morbidity and mortality among children. 426,000 children are affected annually, with 85,000 deaths. Overall mortality rate is 5 – 10%: 15 – 20% in neonates, 3 -10% in older children. Mortality rate from S.pneumoniae is 26.3 – 30%, H. influenza type B is 7.7 – 10.3, N. meningitidis is 3.5 – 10.3%
    • - High frequency of neurologic sequelae: up to 30%, highest with S pneumonia. - Classical symptoms and signs may not be present in neonates and infants - The most important causes are preventable through immunisation (S. pneumonia, Hib, N. meningitidis, Mtb, and some viral causes e.g Measles, Rubella)
    • Aetiology • Bacterial: a) 0 - 2 months - Escherichia coli - Group B streptococci - Listeria monocytogenes - Others: Klebsiella, Salmonella b) 2 months – 2 years - Streptococcus pneumoniae - Haemophilus influenza type b - Neisseria meningitidis
    • c) 3 years and above - S. pneumonia - N. meningitis - Hib - Mycobacterium tuberculosis d) Unusual bacteria - Staphylococcus aureus - Pasteurella multocida - Mycoplasma
    • • Viruses: - Enterovirus - Paramyxoviruses - Herpes simplex - Cytomegalovirus - Influenza - Rubella - Adenovirus - Polio • Fungal - Cryptococcus neoformans - Candida albicans • Drugs and Chemicals - NSAIDs - IVIG - Antibiotics
    • Predisposing/ Risk factors • Age: prematures, neonates • Intrauterine infection • Maternal infection and pyrexia at delivery • Open head trauma (with skull fracture or CSF leakage) • Contiguous focus of infection e.g. sinusitis, otitis media, mastoiditis, osteomyelitis of skull, periorbital and facial cellulitis, septic arthritis, • Open neural tube defects • Neurosurgical procedures and patients with ventriculoperitoneal shunts • Immune deficiency (primary or secondary) • Sickle cell anaemia or asplenia • Overcrowding • Immunisation status
    • Pathogenesis • Acquisition: Aerosol or droplet, nasopharyngeal colonisation, replication and invasion • Spread: - Haematogenous: from nasopharynx, skin, or following pneumonia, infective endocarditis; bacteremia then meningeal seeding - Direct: Otitis media, mastoiditis, sinusitis, open head injury
    • • Local immune response • Endothelial cells, macrophages, neutrophils • Inflammation, increased blood brain barrier permeability, cerebral edema, increased ICP • Local thrombosis, infarction
    • Clinical features • History: Brief & fulminant Vs slow gradual a) Bacterial meningitis: Neonate: - Maternal infection or pyrexia at delivery - Non specific symptoms: change in feeding or sleeping habits, irritability, lethargy, vomiting, high pitched cry, seizures, paradoxical irritability (quiet at rest, cries when moved or comforted) Infants: - Fever, lethargy, irritability, change in
    • After 2 - 3 years: - Headache, irritability, nausea, vomiting, anorexia, nuchal rigidity, photophobia, confusion, back pain, seizures, coma b) Viral: - Onset variable; fever, general malaise, anorexia, vomiting - features of pharyngitis, conjunctivitis, myositis - seizures and evidence of encephalitis
    • c) Tuberculous meningitis - occurs 3 – 6 months following primary infection - sudden or insiduous presentation - 3 stages: - First stage: 1 -2 weeks of fever, headache, malaise, irritability - Second stage: typical meningeal signs - Third stage: worsening neurological condition, coma and death d) Fungal meningitis: - Immunesuppressed patients, variable presentation
    • Physical Examination • Young infant: - Irritable, unconscious - Febrile, hypothermic - Bulging fontanelle - Diastasis of the sutures - +/- Nuchal rigidity • Older child: - Meningeal signs: Neck stiffness, +ve Kernig and Brudzinski signs,
    • - Bulging fontanelle - Ptosis, Sixth nerve palsy, diplopia - Bradycardia, hypertension and apnea = Cushing’s triad – brain herniation - Focal neurological signs in 15% of patients - Seizures in up to 30% patients - Altered consciousness and coma 15 – 20%
    • Signs and Symptoms of Bacterial MeningitisSigns and Symptoms of Bacterial Meningitis Hemi paresis, ptosis, deafness, facial nerve palsy, optic neuritis Hemiparesis, ptosis, facial nerve palsy FocalFocal neurologicneurologic signssigns Headache, bulging fontanel, diastasis of sutures in infants, papilledema, mental confusion, altered state of consciousness Bulging fontanel, diastasis of sutures, convulsions, opisthotonus IncreasedIncreased intracranialintracranial pressurepressure Neck rigidity, Kernig and Brudzinski sign Neck rigidity,MeningealMeningeal inflammationinflammation Fever, anorexia, confusion, irritability, photophobia, nausea, vomiting, headache, seizure Fever or hypothermia, abnormally sleepy or lethargic, disinterest in feeding, poor feeding, cyanosis, grunting, apneic episodes, vomiting NonspecificNonspecific Older infants and childrenOlder infants and childrenNeonatesNeonatesSigns andSigns and symptomssymptoms
    • Investigations • Blood: - Complete blood count - Blood cultures - Blood glucose - Serum electrolytes - Bacterial antigen studies - Coagulation studies - Sickle cell screening test
    • • CSF examination: - Most important - Lumbar puncture: anatomical markings, opening and closing pressures - Analysis: - Cell counts; total and differential, - Gram stain ( - ZN stain - Indian ink stain - Glucose - Protein - Antigen tests - Culture and sensitivity (even with ‘normal csf’)
    • - Latex agglutination tests • Contraindications to LP: - Infection at LP site - Signs of increased ICP (other than a bulging fontanelle) - Suspicion of a mass lesion - Extreme patient instability CSF findings in various conditions are attached; Interpretation of CSF from a traumatic LP
    • • Imaging studies: - Rarely required - May be needed to rule out other pathology before LP, or when focal nerological signs are present - Helpful in abscesses, subdural effusions, empyema, hydrocephalus - CT Scan, MRI: Normal findings do not rule out increased ICP - Cranial Ultrasound Scan
    • DDx: Bacterial Meningitis • Tuberculous meningitis • Fungal meningitis • Brain abscess • Intracranial or spinal epidural abscesses • Encephalitis • Bacterial endocarditis with embolism • Subdural empyema • Subarachnoid hemorrhage • Brain tumors
    • Management • Airway, Breathing, Circulation • Management of seizures • Empiric and specific antibiotic therapy • Supportive treatment - ABC - Fluid: 2/3 of maintenance - Feeding - Antipyretics - Physiotherapy, occupational therapy - Counseling and support to attendants
    • Empiric Therapy for BacterialEmpiric Therapy for Bacterial MeningitisMeningitis Bacterial meningitis is a medical emergency, delay in treatment may lead to increased sequelae or death Drug of choice must be bactericidal for pathogen involved Must achieve adequate levels in the CSF Initial regimen should cover most likely pathogens for specific age groups, and reach bactericidal levels in the CSF Knowledge of local susceptibility patterns is essential
    • Empiric Therapy for Bacterial MeningitisEmpiric Therapy for Bacterial Meningitis Cefotaxime or Chloramphenicol Benzyl penicillin & Ceftriaxone H. influenzae S. pneumoniae N. meningitidis 2mos – 5 yrs Chloramphenicol Or Ceftriaxone Penicillin GS. pneumoniae N. meningitidis >5 yrs Ampicillin + Cefotaxime or Ceftriaxone Ampicillin or Penicillin + Aminoglycoside E. coli Gram (-) bacilli S. pneumoniae 0-2 mos AlternativePrimary Antimicrobial choiceLikely etiologyPatient group
    • Duration of Therapy of Bacterial Meningitis* Pathogen Suggested duration of therapy (days) H. influenzae 10-14 S. pneumoniae 10 -14 N. meningitidis 10 - 14 Grp. B. streptococci 14-21 G(-) bacilli 21 *Quagliarello, et al, NEJM 1997, 336(10):708-716
    • Supportive management IV Fluids and hydration maintain normal blood pressure, watch out for SIADH Control of increased intracranial pressure Nutritional support Prevention- chemoprophylaxis, immunizations, infection control
    • Complications • Fits/ Epilepsy • Hydrocephalus • Cranial nerve palsies: CN 3 – 6 • Subdural effusions ( common with Hib) • Brain abscess • Encephalitis/ Cerebritis • Hearing loss • Blindness • Cognitive dysfunction • SIADH secretion • Ventriculitis • Cerebral edema • Learning disabilities • Cerebral palsy • Paresis, ataxia
    • Persistent fever • Inadequate drug doses • Organism not sensitive to drug • Drug fever • Complications: cerebral abscess, ventriculitis, subdural effusion • Another focus of infection • Hib infection • Pericardial or joint effusions
    • Poor prognosis • Young age: Prematures, neonates • Long duration of illness prior to effective antibiotic therapy • Late onset seizures • Coma and other coplications at presentation • Shock • Low or absent CSF WBC count in the presence of visible bacteria on CSF Gram stain • Immunocompromised status • Positive CSF culture • Organism: Strep pneumoniae
    • Look out for: • Role of immunisation in the prevention and control of meningitis • Role of steroids in the management of meningitis • TB and fungal meningitis
    • and