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  1. 1. MENINGITIS<br />Dr .PRAVEEN NAGULA<br />
  2. 2. MENINGITIS<br />MENINGITIS<br />
  3. 3. Introduction<br />Infection predominantly involves the subarachnoid space---MENINGITIS.<br />Brain tissue directly involved is called as ENCEPHALITIS.<br />Focal bacterial,fungal,parasitic infection involving brain tissue – CEREBRITIS –absence of capsule,ABSCESS presence of capsule. <br />Nuchal rigidity (STIFF NECK ) – pathognomonic sign of meningeal irritation-resistance to passive flexion.<br />Classical signs of meningeal irritation –KERNIG’S,BRUDZINSKI’S sign.<br />
  4. 4. MENINGES<br />
  5. 5. Meninges<br />
  6. 6. What is ?<br />MENINGISM :the symptoms and signs of meningeal irritation assosciated with acute febrile illness or dehydration without actual infection of the meninges…also called meningismus…PSEUDOMENINGITIS.<br />
  7. 7. KERNIG’S SIGN<br />Patient to be in supine position.<br />Thigh flexed on abdomen.<br />Knee flexed.<br />Attempt to passively extend knee elicit pain when irritation is present. <br />
  8. 8. BRUDZINSKI’S sign<br />Supine position.<br />Passive flexion of neck –spontaneous flexion of hips and knees.<br />Specificity and sensitivity of these tests –UNCERTAIN.<br />
  9. 9. Where they could be absent are? <br />Immunocompromised<br />Very young or elderly.<br />Severely depressed mental state.<br />False positive – cervical spine disease..<br />
  10. 10. IMPORTANT POINTS..<br />It is an emergency.<br />Empirical antibiotics to be started.<br />Do CT scan/MRI in case of immunocompromised,recent head trauma,focal neurological deficits ---LP – but AB not to be delayed.<br />No depressed level of consciousness –think of viral meningitis.<br />Immunocompetent ,consciousness good –can be treated on OP basis.<br />Failure of a patient to improve < 48 hrs – reevaluate the patient,repeat LP ,lab studies and neurological examination. <br />
  12. 12. It is an acute purulent infection within the subarachnoid space.<br />
  13. 13. Most common orgnaisms responsible for community acquired bacterial meningitis<br />S.pneumoniae 50%<br />N.meningitidis 25%<br />Group B streptococci - 15%<br />Listeriamonocytogenes 10%<br />Hemophilusinfluenzae  10%<br />
  14. 14. Based on age<br />
  15. 15. TRIAD OF MENINGITIS<br />
  16. 16. ETIOLOGY<br />PNEUMOCOCCAL –<br />from pneumonia,otitis media,alcoholism,diabetes,splenectomy,hypogammaglobulinemia,complement deficiency,head trauma.<br />20% mortality depsite antimicrobial Rx.<br />N.meningitidis-25% of all cases.<br />Petechiae or purpuric skin rash.<br />Fulminant –death within hours<br />ENTERIC gram negative – chronic debilitating diseases.<br />S.agalacticae -- >50 yrs of age.<br />L.monocytogenes–ingestion of food contaminated. <br />
  17. 17. PATHOGENESIS<br />Nasopharyngeal colonization –asymptomatic carrier.<br />Invasive meningeal disease<br />Depends on bacterial virulence factor ,host immune defense mechanisms<br />Deficiency of complement<br />Highly susceptible<br />
  18. 18. pathogenesis<br />
  19. 19. Much of the pathophysiology is due to direct consequence of chemokines,cytokines. <br />
  20. 20.
  21. 21. Clinical features<br />Decreased level of consciousness >75%<br />Nausea,vomiting,photphobia common<br />Classical triad –less sensitivity<br />Only two may be present nearly in all cases.<br />Seizure –initial presentation in 20-40% cases<br />Focal –focal arterial ischemia,cortical venous thrombosis,focal edema<br />GTCS– hyponatremia,anoxia,high dose penicillin.<br />RAISED ICP- >90 % have CSF pressure – 180mmH20<br />20% -- 400mm H20<br />Rash of meningococcemia – diffuse,petechial;<br />
  22. 22. DIAGNOSIS<br />CSF analysis<br />Blood cultures<br />CT scan/MRI --- LP <br />Latex agglutination – S.pneumoniae,N.meningitidis<br />Lumuluslysate –gram negative<br />In case of immunocompetent,no h/o head trauma,no evidence of papilledema –LP without CT scan<br />AB therapy to be started hrs before LP –no change in analysis,or visualization of organisms<br />
  23. 23. CSF analysis<br />
  24. 24. CSF glucose may be zero –<br />CSF/serum glucose corrects for hyperglycemia<br />CSF/s.glucose < 0.6<br />CSF/s.glucose < 0.4 – bacterial,fungal,tuberculosis,carcinomatosis<br />30 min to several hours to reach equilbrium with blood glucose levels –so can start 50 ml of 50 % D.<br />PCR –useful in pretreated pts,gram stain negative<br />MRI >CT for cerebral edema<br />Diffuse meningeal enhancement --gadolinium –increased permeability of BBB.<br />
  25. 25.
  26. 26. Differential diagnosis <br />HSV mimics bacterial meningitis –differentiated by CSF,EEG,neuroimaging.<br />RICKETTESIAL- rash—petechiae—necrosis—gangrene,distal<br />Non infectious – SAH,Chemical meningitis<br />Uveomeningeal syndrome – VogtKoyangiHarada syndrome<br />Subacute –M.tuberculosis,c.noeformans,h.capsulatum<br />
  27. 27. Treatment<br />BEGIN AB < 60 min<br />Empirical treatment –dexamethasone,cefotaxime or ceftriaxone,vancomycin,azithromycin,acyclovir,doxycycline.<br />Post op cases –ceftazidime,cefepime,meropenem,vancomycin<br />Then change according to culture reports<br />
  28. 28.
  29. 29. Meningococcal <br />PENICILLIN G is DOC<br />In case of resistance – Ceftriaxone,cefotaxime<br />Uncomplicated course--7 day course.<br />All close contacts should receive chemoprophylaxis – 2 day regimen of rifampicin 600 mg every 12 hrs * 2days/ciprofloxacin 750 mg od/azithromyxin 500 mg OD/ceftriaxone 250 mg OD<br />Who are close contacts --- nasopharyngeal secretions,kissing,toys,beverages use.<br />
  30. 30. pneumococcal<br />Cephalosporin plus vancomycin<br />If resistance – vancomycin<br />Rifampin can be added synergistic action<br />2 week course <br />Repeat LP after 24-36 hrs –sterilization of CSF –if not introventricularvancomycin<br />
  31. 31. Listeria and others<br />Ampicillin for 3 weeks<br />Gentamicin 2mg/kg/d loading – 7.5 mg/kg/d every 8hrs<br />TMP SMX –every 6hrs<br />STAPHYLOCOCCAL –vancomycin<br />Gram negative – 3 weeks of third generation cephalosporin.<br />
  32. 32.
  33. 33. Adjunctive therapy<br />Dexamethasone – decreases synthesis of IL1,TNF,stabilises BBB<br />20 min before AB Rx<br />Inhibits TNF production by macrophages only before activated by endotoxin.<br />Decreases penetration of vancomycin into CSF.<br />10 mg IV 30 min before AB every 6hrs -4 days.<br />
  34. 34. Raised ICP<br />Elevate head end of bed 30-45<br />Intubation<br />Hyperventilation PaCo2 – 25-30 mm Hg<br />mannitol<br />
  35. 35. prognosis<br />20% mortality –pneumococcal<br />15% - listerias<br />3-7% h.infleunzae,gram negative.<br />
  36. 36. Who are at risk of poor prognosis<br />Decreased level of consciousness at admission<br />Seziures < 24 hrs of onset<br />Raised ICP <br />Young age,>50 yrs<br />Mechanical ventilation<br />Delay in treatment<br /><40 mg /dl -glucose<br />>300 mg/dl -protein<br />
  37. 37. sequelae<br />Decreased intellectual function<br />Memory impairement<br />Seizures<br />Hearing loss<br />Gait disturbances<br />
  38. 38. SUMMARY<br />Acute bacterial meningitis is an emergency<br />Triad is seen less commonly<br />Pathognomonic feature is neck rigidity<br />Altered level of consciousness and seziures can be the presenting features.<br />S pneumoniae is the most common organism overall<br />Other organisms based on the age ,and clinical background<br />CSF analysis after CT scan is the rule…<br />PMNs,hypoglycoracchchia,raised proteins and pressure is the hallmark<br />PCR to be done only in negative cases<br />MRI for cerebral edema <br />
  39. 39. Antibiotics for a week in case of uncomplicated meninogcocci,2 weeks in s pneumoniae,3 weeks listeria.<br />All close contacts to be given chemoprophylaxis in case of meningococci with rifampicin 600 mg bid for 2 days.<br />Triad of meningitis is fever,headache,neckstiffness<br />Postoperative cases think of s aurues,gram negative.<br />Ampicillin to be given in case of suspicion of listeria for 3 weeks<br />S. pneumoniae has high mortality of 20%<br />
  40. 40. Antibiotic treatment not to be delayed for the results of investigations<br />Third generation cephalosporins,vancomycin,ampicillindurgs empirically will cover all organisms.<br />Dexamethasone for stabilisingBBB,to be given beofre AB.<br />HSV encephalitis is closest DD<br />1 week therapy in case of meningococci,2 weeks pneumoniae,3 weeks –listeria<br />Raised ICP –hyperventilate,raise head end,mannitol<br />Sequelae decrease on early management<br />20% mortality in case of s.pneumoniae<br />Thank you <br />