Meningitis

1. MCQs & Case Discussion
MENINGITIS
- Dr. Ankur Kumar

2. 1. True about meningococcal meningitis is:
a. Causative agent is a gram –ve diplococci
b. Cases are the most important source of infection
c. Treatment with penicillin eradicates carrier state
d. Vaccine can be given in pregnancy

3. • Case Fatality Rate (CFR) of Meningococcal
meningitis : 80%
• With early diagnosis and treatment, CFR declines
to < 10%
• Meningococcal disease is endemic in India
• Treatment with Penicillin doesn’t eradicate the
carrier state in meningococcal meningitis
• Isolation of cases is not useful in epidemics of
meningococcal meningitis as carriers outnumber
case

4. 2. The following statements about
meningococcal meningitis are true, except:
a. The source of infection is mainly clinical cases
b. The disease is more common in dry and cold months
of the year
c. Chemoprophylaxis of close contacts of cases is
recommended
d. The vaccine is not effective in children below 2 years
of age

5. • Carriers are more important source of
infectionthan casesin:
– Meningococcal meningitis
– Diphtheria

6. 3. Vaccine for meningococcal meningitis should
be routinely given to:
a. Laboratory workers
b. Young adolescents
c. 4-8 years old children
d. Elderly population

7. Meningococcal Vaccine Recommendations:
Routinely:
– All adolescents 11-12 years age (1st dose at 11-12
years age, followed by Booster dose at 16 years age)
• Other groups:
– Adolescents 13-18 years
– Young people 19-21 years
–2 years and above (Splenectomized/Chronic diseases/
Lab workers/Travelers to endemic areas)

8. 4. Prophylaxis of meningococcal
meningitis is:
a. Ciprofloxacin
b. Rifampicin
c. Penicillin
d. Gentamycin

9. • Rifampicin 600 mg BD×2days OR
Meningococcal vaccine

10. Case-1
 The patient was a 45-year-old male with a long-standing
history of cirrhosis of the liver secondary to alcohol abuse,
chronic hepatitis C infection, and diabetes. The patient
presented to the emergency department with altered
consciousness, confusion, and agitation.
 A family member noted that the patient had nausea and
vomiting prior to arrival. No seizure activity or fevers were
noted.
 On physical examination his vital signs were normal but he
was confused and agitated, making a neurologic
examination not possible. Chest was clear to auscultation.
He was without rashes. He did have abdominal distension
with ascites.

11. Case-1
 Laboratory tests were significant for a peripheral white blood cell (WBC)
count of 27,800 cells/μl with 95% neutrophils. The patient was anemic and
had a blood glucose level of 483 mg/dl. Because of his high WBC count
and altered mental status, a lumbar puncture was performed, which
revealed an opaque cerebrospinal fluid (CSF) containing 5,600 red blood
cells (RBCs)/μl and 31,400 WBCs/μl with 95% neutrophils and 5%
monocytes.
 The patient’s CSF protein was 1,422 mg/dl and CSF glucose was 124
mg/dl. A Gram stain of the patient’s CSF is shown in Fig. The organism’s
susceptibility is shown in Fig.
 He was begun on vancomycin and ceftriaxone. The patient’s condition
deteriorated rapidly, and despite intubation and aggressive cardiac
resuscitation, he died of cardiopulmonary arrest in the emergency
department.
 Q. Based on the patient’s history and physical and laboratory findings, what
condition did this patient likely have? What would be your differential
diagnosis in this case? What did the CSF Gram stain tell you?

12. Gram Stain
Appearance
Colony on CA

13. Case-2
• A 3-year-old girl was brought to the emergency
room by her parents because of fever and loss of
appetite for the past 24 hours and difficulty in
arousing her for the past 2 hours. The
developmental history had been normal since
birth.
• She attended a day care center and had a history
of several episodes of presumed viral infections
similar to those of other children at the center.
Her childhood immunizations were current.

14. Case-2
• Temperature was 39.5°C, pulse 130/min, and respirations
24/min. Blood pressure was 110/60 mm Hg.
• Physical examination showed a well-developed and well-
nourished child of normal height and weight who was
somnolent.
• When her neck was passively flexed, her legs also flexed
(positive Brudzinski sign, suggesting irritation of the
meninges).
• Ophthalmoscopic examination showed no papilledema,
indicating that there had been no long-term increase in
intracranial pressure. The remainder of her physical
examination was normal.

15. Case-2
• The opening pressure was 350 mm of
cerebrospinal fluid (CSF) (elevated). The fluid was
cloudy. Several tubes of CSF were collected for
culture, cell counts, and chemistry tests.
• One tube was taken immediately to the
laboratory for Gram staining. The stain showed
many polymorphonuclear (PMN) cells with cell-
associated (intracellular) gram-negative
diplococcic.
• Q- Name the etiological agent. Which antibiotic
t/t should be taken?

17. • Suggestive of Neisseria meningitidis
• t/t
Intravenous cefotaxime therapy was started within
35–40 minutes of the patient’s arrival;
dexamethasone was also given. The patient was
treated with the antibiotic for 14 days and recovered
without obvious sequelae.
Further neurologic examinations and hearing tests
were planned for the future.
Rifampin prophylaxis was given to the other children
who attended the day care center

18. Case-3
 The patient was a 3½-week-old male who was
born at term by cesarean section. At birth he had a
left diaphragmatic hernia that was repaired soon
thereafter.
 He required intubation at that time and continued
to require respiratory support. Over a 24-hour
period, the infant developed bulging anterior
fontanelles, increased respiratory and heart rates,
wide fluctuations in blood pressure, and
difficulties maintaining adequate tissue perfusion,
and his peripheral white blood cell (WBC) count
increased from 6,300 to 13,700/μl. The child
began to have focal seizures as well.

19. Case-3
 A cerebrospinal fluid (CSF) examination showed 3,900
WBCs/μl with 92% neutrophils, a glucose level of 2
mg/dl, and a protein level of 350 mg/dl. A Gram stain
of the child’s CSF is shown in Fig. The organism
isolated from the CSF is shown in Fig.
 What is your diagnosis for this patient?
 What organism was most likely causing his infection?
 What other organism has similar Gram stain and
colonial morphology? What simple, rapid test would
you use to distinguish these two organisms?

20. Colonies on BA
Gram Stain Appearance

21. • GBS (Gr B streptococcus)
• Other- Listeria spp.
• Catalase test

22. Case-4
• A 10-year-old female presented in August to the
emergency department of a North Carolina hospital with a
3-day history of worsening headache and petechial rash.
• She began feeling ill approximately 1 week prior to
presentation, with increasing fatigue, intermittent chills,
and lower back pain. She had 1 day of nausea, vomiting,
and diarrhea, along with a yellowish nasal discharge.
• Her headache, which began 3 days previously, was
exacerbated by light and rapid movement. Over-the-
counter medications had no effect on her headache. The
patient stated that her “head hurts everywhere” and her
neck felt stiff.

23. Case-4
• In addition to the headache and general malaise, she
had a small pinpoint rash over her legs, trunk, and
upper extremities.
• The only known sick contacts were two younger
cousins with fever and rash. She had a history of a
tick bite earlier in the summer.
• The patient’s physical exam was within normal limits
with the exception of slight pain with neck flexion.
She had negative Brudzinski’s and Kernig’s signs.
Her laboratory tests, including a complete blood
count, sedimentation rate, and urinalysis, were within
normal limits.

24. Case-4
• Cerebrospinal fl uid (CSF) obtained by lumbar puncture
showed <1 red blood cell/μl and 32 white blood cells/μl with
31% neutrophils, 36% lymphocytes, and 33% monocytes. CSF
protein and glucose were both normal at 43 mg/dl and 54
mg/dl, respectively.
• CSF Gram stain showed no neutrophils and no organisms.
Bacterial cultures of blood and CSF were obtained, and a viral
PCR was ordered on the CSF. While remaining laboratory
results were pending, the patient was started on ceftriaxone and
doxycycline. However, once the PCR test was reported as
positive, all antibiotics were discontinued and the patient was
discharged home.
1. Did this patient have meningitis? Explain your answer.

25. • Case of Viral meningitis
• Enteroviruses include the coxsackieviruses (A and B), echoviruses,
polioviruses, and the numbered enteroviruses (e.g., enterovirus 71).
Recently, parechoviruses (formerly echoviruses 22 and 23) have
been shown to be genetically distinct from the enteroviruses.
Although parechoviruses are also associated with meningitis, it is
important to note that most enteroviral PCR tests will not detect
the parechoviruses.
• Enteroviruses belong to the family Picornaviridae, along with
rhinovirus and hepatitis A virus. The primary mode of enteroviral
transmission is the fecal-oral route, but it can also spread via the
respiratory route and by fomites.
• Approximately 85% of viral meningitis cases in the United States are
due to enteroviruses, although very few enteroviral infections result
in meningitis.
• In fact, most enteroviral infections are subclinical to mild. Similar to
other childhood exanthems, enteroviral infections in children may
present with only fever and rash, as was presumably the case for
this patient’s cousins. Enteroviral infections typically peak in the
spring to fall months in temperate regions.

26. Q -5
7. Can this organism causes meningitis?
 If yes, in which age group?

27. Answers
1. a
2. a
3. b
4. b

31. THANK
YOU