it is about meningitis

1. CASE STUDY
Represent by :-
ROLL NO. :- 81 TO 93
MODERATOR :- DR.RISHI DIWAN SIR
( DEPARTMENT OF PATHOLPGY)

2. CASE STATEMENT
A 22 YEARS OLD MAN WAS COMPLAINING OF A
HEADACHE AND SAID THAT THE LIGHT HURT
HIS EYES. HIS GP WAS CALLED AND OBSERVED
THAT THE PATIENT WAS PYREXIAL AND DISORIENTATED
AND HAD A STIFF NECK .
A PROVISIONAL DIAGNOSIS OF MENINGOCOCCAL
MENINGITIS WAS MADE. HE GAVE THE PATIENT AN
INJECTION OF BENZYL PENICILLIN AND ARRANGED FOR
ADMITION TO HOSPITAL . ON ADMITION TO HOSPITAL IT
WAS NOTED THAT THE PATIENT DOVELOPED A
PETECHIAL RESHS THAT DID NOT BLANCH ON
PRESSURE AND HE WAS HYPOTENSIVE . BENZYL
PENICILLIN WAS CONTINUED, AWAITING THE RESULT OF
MICROBIOLOGY .PLEASE GIVE A DETAILED ACCOUNT OF
INVESTIGATION AND LIKELY POSITIVE FINDING ON THIS
CASE. WHAT SPECIAL TEST YOU WILL DO TO CONFIRM
THE DIAGNOSIS.

3. CLINICAL FEATURES
• PRESENTED COMPLAINS AT TIME OF
ADMITION
- HEADACHE
- PHOTO PHOBIA(LIGHT HURTS HIS EYES)
- PYREXIA
- DISORIENTATION
- STIFF NECK

4. Probable diagnosis
• Headache with Photophobia
shows that the person having a CNS problem and on
calling General presentation pyrexia and disorientation
(state of confusion ) also noted.
• CNS problems :-
-Meningitis
-Encephalitis
-Brain abscess

5. Explaination of clinical presentation of patient
• Headache :-
-Bacterial exotoxins, cytokines, and ↑ Intra Cranial Pressure
stimulate nociceptors in the meninges .
• Stiff neck :-
Flexion of the spine leads to stretching of the
meninges because In meningitis, traction on the inflamed meninges
is painful, resulting in limited range of motion through the cervical
spine .

6. • Photo phobia :-
Due to meningal irritation and involvement of the trigeminal nerve.
• Pyrexia :-
Endogenous cytokines affect the thermoregulatory neurons of the
hypothalamus, changing the central regulation of body temprature.
Bacteria produce exogenous substances (pyrogens) that can also
re-set the hypothalamic thermal set point.
• DISORIENTATION :-
↑ ICP → brain herniation → damage to the reticular formation .

7. • PETECHIAL RASH
Due to Meningococcemia by causative agent N. meningitidis.

8. Meningitis transformation
Meningitis
Pachymeningitis Leptomeningitis
Encephalitis
Brain abscess
(Tubular
encephalitis,Neuro
encephalitis)

9. Diagnosis
• CSF examination
• Blood test
• Diagnostic methods
– A careful evaluation of history
– A careful evaluation of infant’s signs and symptoms
– A careful evaluation of information on longitudinal changes
in vital signs and laboratory indicators

10. Lumber Puncture for CSF
examination

11. Cerebrospinal fluid (CSF) analysis may be
used to help diagnose a wide variety of
diseases and conditions affecting the brain
and spinal cord (central nervous system).
Infectious diseases such as meningitis and
encephalitis.Testing is used to determine if
infection is caused by bacteria,viruses or,
less commonly, by Mycobacterium
tuberculosis, fungi or parasites, and to
distinguish them from other conditions.

12. Collection and transport of CSF
• CSF is collected in three sterile container, each one for
cell count, biochemical analysis and bacteriological
examination.
• Fluid should be examined immediately after collection or
placed in incubator at 37*c.
• Transport of CSF to the lab must be as soon as possible.
• NOTE :- NEVER REFRIGRATE THE CSF AS
H.INFLUENZAE MAY DIE.

13. Normal CSF EXAMINATION
• CSF opening pressure: 50–180 mmH2O
Glucose: 40–85 mg/dL.
Protein (total): 15–45 mg/dL.
Leukocytes (WBC): 0–5/µL (adults / children); up to 30/µL
(newborns).
Gram stain: negative.
Culture: sterile.
Specific gravity: 1.006–1.009.
Gross appearance: Normal CSF is clear and colourless.
Differential: 60–70% lymphocytes; up to 30% monocytes
and macrophages; other cells 2% or less.

14. • Bacterial Meningitis
• CSF opening pressure : increases
• Glucose (mg/dL):Normal to marked decrease. <40 mg/dL.
• Protein (mg/dL)(Marked increase) > 250 mg/Dl
• WBCs (cells/µL)>500 (usually > 1000). Early: May be < 100.
• Cell differential :-Predominance of Neutrophils (PMNs)
• Culture :-Positive
• Opening Pressure:-Elevated
• Gram staining:- positive

15. Viral meningitis
• Opening CSF pressure :- normal or
slightly increased
• CSF glucose :- Normal
• CSF protein :- slightly increased

16. Blood examination
• Blood tests are performed for markers of
inflammation (e.g. C- reactive protein),as
well as blood cultures.

17. Isolation of the organism from CSF or blood.

18. Neisseria Meningitides
• Bean shaped
• Gram negative
• Aerobic, F. anaerobes,
• diplococci
• Bacteria surrounded by outer membrane
of lipids, membrane proteins and
lipopolysaccharide.

19. • The most important pathogen for
meningitis is NEISSERIA MENINGITIDES
because of its potential to cause epidemic.
Meningococcal Meningitis

20. Etiology
Neonates (<3
mo)
Children Adults Elderly (>65)
Group B
Streptococcus
Escherichia coli
Staph. aureus
Streptococcus
pneumoniae (pneu
mococcus)
Neisseria
meningitidis (meni
ngococcus)
Haemophilus
influenzae type B (l
ess common now
with the advent of
the HiB
vaccination)
Streptococcus
pneumoniae
Neisseria
meningitidis
(these two
organisms cause
80% of cases)
Streptococcus
pneumoniae
Neisseria
meningitidis
Listeria
monocytogenes

21. Pathogenesis
• A offending bacterium from blood invades the leptomeninges.
• Bacterial toxics and Inflammatory mediators are released.
– Bacterial toxics
• Lipopolysaccharide, LPS
• Teichoic acid
• Peptidoglycan
– Inflammatory mediators
• Tumor necrosis factor, TNF
• Interleukin-1, IL-1
• Prostaglandin E2, PGE2

23. • The outer membrane is surrounded by a
polysaccharide capsule that is necessary for
pathogenecity because it helps the bacteria
resist phagocytosis and complement-mediated
lysis. The outer membrane proteins and the
capsular polysaccharide make up the main
surface antigens of the organism.

24. Pathogenesis
Cont. to next slide…..

26. Transmission &
Communicability
• The main modes of transmission are direct contact and respiratory
droplets.
• Close contact like living in close quarters (like hostel dormitories)
and sharing of utensils enhance the risk of transmission
• The average incubation period is 3 - 4 days with a range of 2 to 10
days.
• This is also the period of communicability.
• The bacteria are rapidly eliminated from the nasopharynx after
starting antibiotics, usually within 24 hours

27. • Therapeutic principle
– Good permeability for Blood-brain barrier
– Drug combination
– Intravenous drip
– Full dosage
– Full course of treatment
Treatment
Antibiotic Therapy

28. Antibiotic Therapy
• Selection of antibiotic
– No Certainly Bacterium
• Community-acquired bacterial infection
• Nosocomial infection acquired in a hospital
• Broad-spectrum antibiotic coverage as noted below
– Children under age 3 months
» Cefotaxime and ampicillin
» Ceftriaxone and ampicillin (children over age 1months)
– Children over 3 months
» Cefotaxime or Ceftriaxone or ampicillin and
chloramphenicol

29. for
your
attention……