8. INTRODUCTION
It is an acute inflammation of meninges of brain
& spinal cord present with characteristic
combination of pyrexia, headache & meningium
(confusion or altered consciousness)
The inflammation may be caused by infection
with viruses, bacteria, or other microorganisms,
and less commonly by certain drugs
It can be life-threatening because of
inflammation's proximity to brain & spinal cord;
hence condition is classified as a medical
emergency
9. CLINICAL FEATURES
Acute onset of illness
High grade of fever
Severe headache
Nuchal rigidity & pain
Irritability & drowsiness
Photophobia & phonophobia
10. Features of rapid ICP (normally between 6 and 18 cm
water)
Projectile vomiting, blurring of vision, altered sensorium &
convulsions, loss of pupillary light reflex, & abnormal
posturing
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 be
accompanied by a characteristic rash
consists of numerous small, irregular purple or red spots
("petechiae") on trunk, LE, mucous membranes, conjuctiva, &
(occasionally) palms or soles
11. COMPLICATIONS
Meningitis can lead to serious long-term
consequences
deafness
epilepsy
hydrocephalus
cognitive deficits
if not treated quickly
15. Route of entry
Direct contact of the CSF by Contaminated lumbar
puncture, Sinusitis, Trauma
Otitis media
Through the blood stream
Incubation period
4- 24 hours
16. PATHOGENESIS
The large-scale inflammation that during meningitis
largely 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 immune
response.
17. The blood-brain barrier becomes more permeable,
leading to "vasogenic" cerebral edema (swelling of
brain due to fluid leakage from blood vessels)
Large numbers of WBC enter CSF, causing
inflammation 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 decreased
blood flow and a third type of edema, "cytotoxic"
edema
18. The three forms of cerebral edema all lead to an
increased ICP together with low BP often
encountered in acute infection,
Brain cells are deprived of oxygen & undergo
apoptosis (automated cell death)
19. SIGNS
Positive Kernig’s sign & Positive Brudzinski’s
Kernig's sign is assessed with patient lying supine, with hip
& knee flexed to 90 degrees.
Positive Kernig's sign - pain limits passive extension of knee
Brudzinski's sign – if positive, flexion of neck causes
involuntary flexion of knee & hip.
Jolt accentuation maneuver helps determine whether
meningitis is present in patients reporting fever &
headache
The patient is asked to rapidly rotate his head
horizontally; if this does not make the headache worse,
meningitis is unlikely
Papillary oedema
20. INVESTIGATIONS
Blood analysis
TLC is increased
DLC- neutrophillia
ESR- normal
Hb- normal
CSF analysis
Glucose decreased
Proteins increased (100-200mg/dl)
Cells – neutophillia (>90%)
CT or MRI scan is recommended prior to lumbar
puncture in suspects of risk
21. Gram stain to identify the organism
Culture & sensitivity test
Postmortem
The findings are widespread inflammation of pia
mater and arachnoid layers
Cranial nerves & spinal cord, may be surrounded with
pus
22. PREVENTION
For some causes of meningitis, prophylaxis can be
provided in long term with vaccine
against Haemophilus influenzae type B
Meningococcus vaccines
against Streptococcus pneumoniae with pneumococcal
conjugate vaccine (PCV)
Childhood vaccination with Bacillus Calmette-Guérin (BCG)
Short-term antibiotic prophylaxis is also a method of
prevention, particularly of meningococcal meningitis
rifampicin, ciprofloxacin or ceftriaxone can reduce their
risk of infection , but does not protect against future
infections
23. MANAGEMENT
High dose intravenous antibiotic
Penicillin, Cephalosporin
Rifampicin, norfloxacin, erythromycin
Mannitol to decrease the raised ICP
Corticosteroids can also be used to prevent
complications from overactive inflammation
IV fluids should be administered if hypotension or
shock are present
Mechanical ventilation may be needed if level of
consciousness is low, or if evidence of respiratory
failure
24. Seizures are treated with anticonvulsants
Hydrocephalus may require insertion of a
temporary or long-term drainage device
(cerebral shunt)
25. TUBERCULAR MENINGITIS
It can be seen as a part of primary TB in
children & a part of secondary TB in adults
The primary focus being in the lung
26. PATHOGENESIS
TB bacilli reached all parts of body & remains
dormant in meninges
When immunity is less the foci or bacilli will
rupture in CSF
Produce TB meningitis & lots of exudates
Obstruction of CSF circulation
Damage to lower cranial nerves
27. CLINICAL FEATURES
Gradually progressive disease
Gradual onset of fever associated with
headache, general weight loss & weakness
Loss of appetite
Raised ICP
Feature of lower cranial nerve paralysis (IX, X,
XI, XII)
Difficulty in speaking, swallowing etc
28. INVESTIGATIONS
Blood analysis
TLC nearly normal
DLC – lymphocytosis
ESR elevated
CSF analysis
Turbid & cloudy
High protein (500mg/ dl)
Borderline increase in glucose
Cell are increased (lymphocytosis)
Gram stain: gram positive
ZN stain: AF bacilli
CT scan with contrast: exudates can be seen
30. VIRAL MENINGITIS
It is also known as aseptic meningitis
Clinical presentation is similar to that of acute
pyogenic meningitis
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 traces
of DNA & detect presence of bacterial or viral DNA
in CSF
Assist in distinguishing various causes of viral meningitis
(enterovirus, herpes simplex virus 2 and mumps in those
not vaccinated for this)
Serology (identification of antibodies to viruses) may
be useful in viral meningitis
32. TREATMENT
Viral meningitis typically requires supportive
therapy only
Most viruses responsible for causing meningitis
are not amenable to specific treatment
Herpes simplex virus & varicella zoster virus may
respond to treatment with antiviral drugs such
as aciclovir
33. Mild cases of viral meningitis can be treated at
home with conservative measures such as fluid,
bed-rest, & analgesics.
Prognosis is good
Gradually recovers without any treatment
34. PT ASSESSMENT
History of presenting illness: acute or gradual onset of
illness, high grade fever
Past history
Infectious history, trauma, spinal anaesthesia, lumbar
puncture, 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 cranial
nerves
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, serology
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 exercise
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 only
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 position
41. PROMOTE VITAL FUNCTION
Improve respiratory capacity with positioning &
tech s/a glossopharyngeal breathing exercise in
respiratory paralysis
Keeping the neck in slight flexion improves
respiratory capacity
Specific positioning increase air entry in targeted
lobes
42. Massage & mechanical pressure provides reflex
stimulus to improve peristalsis (kneading/
stroking)
Facilitate swallowing with positioning, right
selection of food texture, oromotor stimulation
Maintaining cardio respiratory endurance with
active exercise of possible muscle work
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 mobility
exercise
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 environment
45. POSTURAL CORRECTION
Proper positioning in the lying, sitting & all
functional position
Use of braces, sitting & standing frames can be
helpful in children
Stretching & strengthening of key postural
muscles
Endurance training
46. GENERAL FITNESS EXERCISE
Early mobilization & early propped up position
Moving around the bed
Regular exercise with bouts of 15-20 min session
for 3-4 times a day
Then progress to 30-45 min of exercise
Maintenance can be done by 45- 60 min session
of exercise 3-5 times/wk
