Infections of the CNS: Meningitis


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physical therapy in meningitis, neurological rehabilitation,

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Infections of the CNS: Meningitis

  2. 2.  There are four main causes of infections ofCNS Bacterial Viral Fungal ProtozoalDr.L.Surbala(MPTNeurology)
  3. 3.  Fungal infections Cryptococcal meningitis Brain abscess Spinal epidural infectionDr.L.Surbala(MPTNeurology)
  4. 4.  Protozoal infections Toxoplasmosis Malaria Primary amoebic meningoencephalitisDr.L.Surbala(MPTNeurology)
  5. 5.  Bacterial infections Tuberculosis Leprosy Neurosyphilis Bacterial meningitis Brain abscess NeuroborreliosisDr.L.Surbala(MPTNeurology)
  6. 6.  Viral infections Viral meningitis Eastern equine encephalitis St Louis encephalitis Japanese encephalitis West nile encephalitis Herpes simplex encephalitis Rabies California encephalitis virus Varicella-zoster encephalitis La crosse encephalitis Measles encephalitis Poliomyelitis Slow virus infections, whichinclude: Subacute sclerosingpanencephalitis Progressive multifocalleukoencephalopathy AIDSDr.L.Surbala(MPTNeurology)
  8. 8. INTRODUCTION It is an acute inflammation of meninges of brain& spinal cord present with characteristiccombination of pyrexia, headache & meningium(confusion or altered consciousness) The inflammation may be caused by infectionwith viruses, bacteria, or other microorganisms,and less commonly by certain drugs It can be life-threatening because ofinflammations proximity to brain & spinal cord;hence condition is classified as a medicalemergencyDr.L.Surbala(MPTNeurology)
  9. 9. CLINICAL FEATURES Acute onset of illness High grade of fever Severe headache Nuchal rigidity & pain Irritability & drowsiness Photophobia & phonophobiaDr.L.Surbala(MPTNeurology)
  10. 10.  Features of rapid ICP (normally between 6 and 18 cmwater) Projectile vomiting, blurring of vision, altered sensorium &convulsions, loss of pupillary light reflex, & abnormalposturing In infants up to 6 months of age, bulging of fontanelle Septic shock & septicimia Cranial nerve damage Acute renal failure Meningitis caused by meningococcal bacteria may beaccompanied by a characteristic rash consists of numerous small, irregular purple or red spots("petechiae") on trunk, LE, mucous membranes, conjuctiva, &(occasionally) palms or solesDr.L.Surbala(MPTNeurology)
  11. 11. COMPLICATIONS Meningitis can lead to serious long-termconsequences deafness epilepsy hydrocephalus cognitive deficits if not treated quicklyDr.L.Surbala(MPTNeurology)
  12. 12. TYPES Pyogenic / bacterial miningitis Tubercular miningitis Viral meningitisDr.L.Surbala(MPTNeurology)
  14. 14. PYOGENIC BACTERIAL MENINGITIS Causative organism Neonates – E-coli, proteus Children – Haemiphillus influenzae type B, Neisseriameningitidis (Meningococcus) Adolescent - N meningitidis Adult – streptococcus pneumoniaeDr.L.Surbala(MPTNeurology)
  15. 15.  Route of entry Direct contact of the CSF by Contaminated lumbarpuncture, Sinusitis, Trauma Ottitis media Through the blood stream Incubation period 4- 24 hoursDr.L.Surbala(MPTNeurology)
  16. 16. PATHOGENESIS The large-scale inflammation that during meningitislargely be attributed to response of immune system Immune cells of brain (astrocytes and microglia),respond by releasing large amounts of cytokines,hormone-like mediators that recruit other cells &stimulate other tissues to participate in an immuneresponse.Dr.L.Surbala(MPTNeurology)
  17. 17.  The blood-brain barrier becomes more permeable,leading to "vasogenic" cerebral edema (swelling ofbrain due to fluid leakage from blood vessels) Large numbers of WBC enter CSF, causinginflammation of meninges, & leading to "interstitial"edema (swelling due to fluid between cells). In addition, walls of blood vessels become inflamed(cerebral vasculitis), which leads to a decreasedblood flow and a third type of edema, "cytotoxic"edemaDr.L.Surbala(MPTNeurology)
  18. 18.  The three forms of cerebral edema all lead to anincreased ICP together with low BP oftenencountered in acute infection, Brain cells are deprived of oxygen & undergoapoptosis (automated cell death)Dr.L.Surbala(MPTNeurology)
  19. 19. SIGNS Positive kernig’s sign & Positive brudjinski’s Kernigs sign is assessed with patient lying supine, with hip& knee flexed to 90 degrees. Positive Kernigs sign - pain limits passive extension of knee Brudzinskis sign – if positive, flexion of neck causesinvoluntary flexion of knee & hip. Jolt accentuation maneuver helps determine whethermeningitis is present in patients reporting fever &headache The patient is asked to rapidly rotate his headhorizontally; if this does not make the headache worse,meningitis is unlikely Papillary oedemaDr.L.Surbala(MPTNeurology)
  20. 20. INVESTIGATIONS Blood analysis TC is increased DC- neutrophillia ESR- normal Hb- normal CSF analysis Glucose decreased Protiens increased (100-200mg/dl) Cells – neutophillia (>90%) CT or MRI scan is recommended prior to lumbarpuncture in suspects of riskDr.L.Surbala(MPTNeurology)
  21. 21.  Gram stain to identify the organism Culture & sensitivity test Postmortem The findings are widespread inflammation of piamater and arachnoid layers Cranial nerves & spinal cord, may be surrounded withpusDr.L.Surbala(MPTNeurology)
  22. 22. PREVENTION For some causes of meningitis, prophylaxis can beprovided in long term with vaccine against Haemophilus influenzae type B Meningococcus vaccines against Streptococcus pneumoniae with pneumococcalconjugate vaccine (PCV) Childhood vaccination with Bacillus Calmette-Guérin (BCG) Short-term antibiotic prophylaxis is also a method ofprevention, particularly of meningococcal meningitis rifampicin, ciprofloxacin or ceftriaxone can reduce theirrisk of infection , but does not protect against futureinfectionsDr.L.Surbala(MPTNeurology)
  23. 23. MANAGEMENT High dose intravenous antibiotic Penicillin, Cephalosporin Rifampicin, norfloxacin, erythromycin Mannitol to decrease the raised ICP Corticosteroids can also be used to preventcomplications from overactive inflammation IV fluids should be administered if hypotension orshock are present Mechanical ventilation may be needed if level ofconsciousness is low, or if evidence of respiratoryfailureDr.L.Surbala(MPTNeurology)
  24. 24.  Seizures are treated with anticonvulsants Hydrocephalus may require insertion of atemporary or long-term drainage device(cerebral shunt)Dr.L.Surbala(MPTNeurology)
  25. 25. TUBERCULAR MENINGITIS It can be seen as a part of primary TB inchildren & a part of secondary TB in adults The primary focus being in the lungDr.L.Surbala(MPTNeurology)
  26. 26. PATHOGENESIS TB bacilli reached all parts of body & remainsdormant in meninges When immunity is less the foci or bacilli willrupture in CSF Produce TB meningitis & lots of exudates Obstruction of CSF circulation Damage to lower cranial nervesDr.L.Surbala(MPTNeurology)
  27. 27. CLINICAL FEATURES Gradually progressive disease Gradual onset of fever associated withheadache, general weight loss & weakness Loss of appetite Raised ICP Feature of lower cranial nerve paralysis (IX, X,XI, XII) Difficulty in speaking, swallowing etcDr.L.Surbala(MPTNeurology)
  28. 28. INVESTIGATIONS Blood analysis TC nearly normal DC – lymphocytosis ESR elevated CSF analysis Turbid & cloudy High protien (500mg/ dl) Boderline increase in glucose Cell are increased (lymphocytosis) Gram stain: gram positive ZN stain: AF bacilli CT scan with contrast: exudates can be seenDr.L.Surbala(MPTNeurology)
  29. 29. TREATMENT Anti – tubercular drugs Corticosteroids MannitolDr.L.Surbala(MPTNeurology)
  30. 30. VIRAL MENINGITIS It is also known as aseptic meningitis Clinical presentation is similar to that of acutepyogenic meningitisDr.L.Surbala(MPTNeurology)
  31. 31. INVESTIGATION Microbiological findings shows no microorganisms CSF glucose is normal Boderline increase in CSF cells (lymphocytes) &protiens Gram stain is of no importance Polymerase chain reaction (PCR) amplify small tracesof DNA & detect presence of bacterial or viral DNAin CSF Assist in distinguishing various causes of viral meningitis(enterovirus, herpes simplex virus 2 and mumps in thosenot vaccinated for this) Serology (identification of antibodies to viruses) maybe useful in viral meningitisDr.L.Surbala(MPTNeurology)
  32. 32. TREATMENT Viral meningitis typically requires supportivetherapy only Most viruses responsible for causing meningitisare not amenable to specific treatment Herpes simplex virus & varicella zoster virus mayrespond to treatment with antiviral drugs suchas aciclovirDr.L.Surbala(MPTNeurology)
  33. 33.  Mild cases of viral meningitis can be treated athome with conservative measures such as fluid,bed-rest, & analgesics. Prognosis is good Gradually recovers without any treatmentDr.L.Surbala(MPTNeurology)
  34. 34. PT ASSESSMENT History of presenting illness: acute or gradual onset ofillness, high grade fever Past history Infectious history, trauma, spinal anaesthesia, lumbarpuncture, sinusitis, ottitis media Vital signs: temperature, BP, HR, RR Observation: abnormal posturing may be seen Abnormal respiration Attitude of limb Examination Level of conciousness, orientation, memory, speech Cranial nerve examination: signs of damage of lower cranialnervesDr.L.Surbala(MPTNeurology)
  35. 35.  Sensory screening: sensations may be intact Motor assessment ROM, tonicity, reflexes, muscle power Chest examination: important in TB meningitis Respiratory assessment Gustatory examination: swallowing Bladder & bowel involvement Functional assessment Special test: kernig, brudjinski Investigations: blood & CSF examination, CT or MRI,gram stain, serologyDr.L.Surbala(MPTNeurology)
  36. 36.  Problem listDr.L.Surbala(MPTNeurology)
  37. 37. PT MANAGEMENT (GOALS) Psychological support Positioning strategies & prevent bed sores Prevent chest complications Promote vital function Prevent DVT Promote integration of sensory input Postural correction General fitness exerciseDr.L.Surbala(MPTNeurology)
  38. 38. PSYCHOLOGICAL SUPPORT Maintain a non threatening positive attitude Good support Gain confidence of the patient Counseling of family members & patient Give information as necessary onlyDr.L.Surbala(MPTNeurology)
  39. 39. POSITIONING STRATEGIES & PREVENT BED SORES Proper positioning with pads & cushions Use of water bed or foam mattress Regular inspection of the skin Use cotton clothing to absorb sweat Avoid dragging during transfer Regular turning & changing positionDr.L.Surbala(MPTNeurology)
  40. 40. PREVENT CHEST COMPLICATIONS Breathing exercise, postural drainage &suctioning as required Cervical & thoraxic mobility exercise Thoraxic expansion exercise Strengthening of respiratory musclesDr.L.Surbala(MPTNeurology)
  41. 41. PROMOTE VITAL FUNCTION Improve respiratory capacity with positioning &tech s/a glossopharyngeal breathing exercise inrespiratory paralysis Keeping the neck in slight flexion improvesrespiratory capacity Specific positioning increase air entry in targetedlobesDr.L.Surbala(MPTNeurology)
  42. 42.  Massage & mechanical pressure provides reflexstimulus to improve peristalsis (kneading/stroking) Facilitate swallowing with positioning, rightselection of food texture, oromotor stimulation Maintaining cardio respiratory endurance withactive exercise of possible muscle workDr.L.Surbala(MPTNeurology)
  43. 43. PREVENT DVT Active & passive ankle & toe exercise Active limb exercise Limb elevation Early mobilization as soon as possible Propped up position in bed & bed mobilityexerciseDr.L.Surbala(MPTNeurology)
  44. 44. PROMOTE INTEGRATION OF SENSORY INPUT Stimulation by combined proprioceptive, visual &auditory input Cues & commands Demonstration of activity Sensory re education if necessary Training in different environmentDr.L.Surbala(MPTNeurology)
  45. 45. POSTURAL CORRECTION Proper positioning in the lying, sitting & allfunctional position Use of braces, sitting & standing frames can behelpful in children Stretching & strengthening of key posturalmuscles Endurance trainingDr.L.Surbala(MPTNeurology)
  46. 46. GENERAL FITNESS EXERCISE Early mobilization & early propped up position Moving around the bed Regular exercise with bouts of 15-20 min sessionfor 3-4 times a day Then progress to 30-45 min of exercise Maintenance can be done by 45- 60 min sessionof exercise 3-5 times/wkDr.L.Surbala(MPTNeurology)