Approach To Meningitis and Encephalitis.pptx

1. Approach To Meningitis and
Encephalitis

2. BACTERIAL MENINGITIS
Inflammation of
meninges,
particularly
arachnoid and pia
mater associated
with invasion of
bacteria into sub
arachnoid space.

3. COMMON BACTERIAs…
Premature /Neonates (<3
months)
Group B
streptococci
Gram –ve
enterics Listeria
monocytogenes
Children <5 years
Haemophilus
influenzae B
Neisseria
meningitidis
Streptococcus
pneumoniae
Adults
N.meningitidis
S.pneumoniae
(80% cases)
L.monocytogenes(Risk
> 50 yrs)

4. CLINICAL SIGNS

5. CLINICAL SYMPTOMS

6. Investigations
Blood
•
•
•
•
•
•
FBC with differential
Blood cultures (aerobic and
anaerobic)
CRP/ESR/procalcitonin
HIV
Rapid plasma reagent
• Serum for acute serology (store for
paired convalescent sample in 3 to
4 weeks)
Heterophile antibodies (Epstein-
Barr virus)
Lyme disease tests Rickettsial
serologies
•
•
•
•
CSF
•
•
•
Opening pressure
Cell count and differential
Serum and CSF glucose
concentration
Protein concentration
Stains: Gram, India ink, AFB
Cultures: aerobic, anaerobic,
acid-fast bacillus, fungal
Cytology
•
•
•
•
•
•
Antibody testing (arboviral)
PCRs: enteroviral, West Nile virus,a
herpesvirus types 1 and 2)
CSF lactate (posttrauma or
neurosurgical)
•

9. Bacterial meningitis is a neurologic
emergency
Antimicrobial therapy
as soon as possible
(Must continue 48-72
hrs as empirical )
Choice of agents for empiric therapy determined by the
 patient’s age
 presence of predisposing conditions
 antimicrobial resistance
 Antimicrobial therapy should be modified as soon as the
pathogen has been isolated and in vitro tests have been
performed

10. EMPIRICAL THERAPY BASED
ON AGE AND
PATHOGENS
Less than 1 month
S.agalactiae (GBS)
Gram –ve enterics
L.monocytogenes
Ampicillin + Cefotaxime
OR
Ampicillin + Aminoglycoside

11. 1-23
months
S.pneumoniae
N.meningitidis
H.influenzae
S.agalactiae
Vancomycin + 3rd generation cephalosporin
(cefotaxime/ceftriaxone)

12. 2 years – 50
years
N.meningi
tidis
S.pneumo
niae
Vancomycin + 3rd generation
cephalosporin
(cefotaxime/ceftriaxone)

13. Above 50
years
• N.meningitidis
S.Pneumoniae Gram –ve
enterics L.monocytogenes
• Vancomycin + 3rd generation cephalosporin
(cefotaxime/ceftriaxone)

16. Encephalitis

17. • diagnosis that should
only be made if there
is tissue confirmation
• in practice:
–febrile illness, severe
headache reduced
consciousness
–surrogate markers of
brain inflammation
Encephalitis

18. Causes (1)

19. Causes (2)

20. • HSV- brain parenchyma in the temporal lobes,
sometimes with frontal or parietal involvement.
• Mumps virus - acute viral encephalitis, or a delayed
immune mediated encephalitis.
• Measles virus - post-infectious encephalitis, which can
sometimes have a acute haemorrhagic
leukoencephalitis.
• Influenza A virus - diffuse cerebral oedema
• Varicella zoster virus (VZV) -vasculitis

21. Infectious causes
of encephalitis

22. Non-infectious
causes of
encephalitis

24. • acute flu-like prodrome,
fever,
• severe headache
• nausea, vomiting
• altered consciousness
• seizures
• focal neurological signs
Clinical presentations
HSV-1 encephalitis
•febrile (91%)
•disorientation (76%)
•speech disturbances (59%)
•behavioural changes (41%)
•seizures (33%)
•Alterations in higher mental
function

26. Approach
• In the approach to the patient with
encephalitis, an attempt should be made to
establish an etiologic diagnosis.
• Although there are no definitive effective
treatments in many cases of encephalitis,
identification of a specific agent may be
important for:
– Prognosis,
– Potential prophylaxis,
– Counseling of patients and family members, and
– Public health interventions

27. History
•
•
•
•
•
from family members rashes
travel history
occupation and recreational activities
risk factors for HIV

28. Examinations
•
•
•
•
•
•
GCS
rashes, shingels, scar, bites, sign of
immunocompromised state, subtle seizure
meningism, and look for focal neurological signs
lower cranial neuropathies and myoclonus
(rhomboencephalitis or basal
meningoencephalitis)

29. • Body fluid specimens:
• – Cultures and analysis (i.e., antigen
detection and nucleic acid amplification
tests).
• Biopsy of specific tissues:
With culture, antigen detection, pcr and
histopathologic evaluation,
• Serologic testing
for specific IgM and acute-and-convalescent-
phase IgG antibody titers.

30. • MRI of the brain should be performed in
all patients, with CT used only if:
• MRI is unavailable, unreliable, or cannot
be performed.
• Neuroimaging findings may also
suggest disease caused by specific
etiologic agents.

31. EEG
• usually shows non-specific diffuse high
amplitude slow waves of encephalopathy,
• subtle epileptic seizures.
• Periodic lateralised epileptiform (HSV
encephalitis)

34. Targeted
Treatment
Virus Treatment
Herpes simplex virus Acyclovir
Varicella-zoster virus Acyclovir, ganciclovir can be considered an alternative;
adjunctive steroids to be considered
Cytomegalovirus the combination of ganciclovir plus foscarnet is recommended.
Cidofovir is not recommended (Poor BBB penetration)
Epstein-Barr virus Acyclovir is not recommended, the use of corticosteroids may
be beneficial
Human herpesvirus 6 Ganciclovir or foscarnet
B virus valacyclovir is recommended
Influenza virus oseltamivir
Measles and Nipah
virus
ribavirin
West Nile virus ribavirin is not recommended
Japanese encephalitis
virus
IFN-a is not recommended.
St. Louis encephalitis
virus
IFN-2a can be considered
HIV HAART
JC virus reversal of immunosuppression
(IDSA encephalitis guidelines, 2008) & (BIA encephalitis
guidelines, 2012).