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Acute meningoencephalitis

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Acute meningoencephalitis Powerpoint presentation.
It comprises of acute meningitis and acute encephalitis, their clinical features, physical assesment, diagnosis and treatment.

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Acute meningoencephalitis

  1. 1. Acute Meningoencephalitis Intern. Sunder Chapagain 1
  2. 2. Acute Meningoencephalitis • meningoencephalitis is an acute inflammatory process involving the meninges and, to a variable degree, brain tissue. • Acute Bacterial Meningitis • Acute Viral Meningoencephalitis 2
  3. 3. 3
  4. 4. Acute bacterial meningitis • Etiology 4
  5. 5. Aseptic meningitis • Viral – Enterovirus (Echovirus, Coxsackie virus, Polio) – Herpes Simplex Virus-2 – Mumps: The commonest complication – Lymphocytic choriomeningitis virus • Fungal (in imuunocompromised) – Cryptococcus neoformans – Histoplasmosis, Candidiasis, Blastomyces 5
  6. 6. • Parasitic – Toxoplasmosis – Cysticercosis – Amoebiasis • Miscellaneous – SLE – Leukemia – Lymphoma 6
  7. 7. Risk Factors • Age • Low socioeconomic status • Head trauma • Splenectomy • Chronic diseases • Children with facial cellulitis, periorbital cellulitis, sinusitis and septic arthritis • Maternal infection and pyrexia at the time of delivery. 7
  8. 8. 8
  9. 9. 9
  10. 10. Clinical features Newborn & Infants: non-specific • Fever • Irritability • Lethargy • Vacant stare • Poor tone • Poor feeding • High pitched cry • Bulging anterior fontanelle • Convulsions • Opisthotonus 10
  11. 11. Older children 11
  12. 12. • Seizures • Alteration in mental status • Hypotension, fever or Hypothermia, Tachycardia (Septic shock) • Bleeding, Renal dysfunction (DIC) 12
  13. 13. Increased intracranial pressure (ICP) • Papilledema • Cushing’s triad – Bradycardia – Hypertension – Cheyne-Stokes Breathing • Projectile vomiting • Headache
  14. 14. Physical examination •Neck rigidity •Focal neurological signs •Ptosis •Cranial nerve palsies •Bulging fontanel
  15. 15. TB meningitis • Children 6 months – 5 years • Local microscopic granulomas on meninges • Meningitis may present weeks to months after primary pulmonary process • CSF: – Profoundly low glucose – High protein – Acid-fast bacteria (AFB stain) – PCR • Steroids + antitubercular agents – (2HRZE+ 10 HR) WITH steroid for 4-6 weeks 15
  16. 16. Stages • Stage 1: stage of invasion – Low grade fever, loss of appetite, vomiting, headache, photophobia, irritable, restless • Stage 2: Stage of meningitis – Neck rigidity, focal neurological deficits, isolated cranial nerve palsies, loss of sphincter control • Stage 3: Stage of coma – Loss of consciousness, altered respiratory pattern, dilated pupils, ptosis, ophthalmoplegia, coma 16
  17. 17. Neisseria meningitis (Meningococcemia) • Neisseria meningitidis: serotype Grp B commonest • Endotoxin causes vascular damage vasodilatation, third spacing, severe shock • Severe complication: Waterhouse-Friderichsen syndrome: massive haemorrhage of adrenal glands secondary to sepsis: adrenal crisis-low B.P, shock, DIC, purpura, adreno-cortical insufficiency 17
  18. 18. Morbiliform, non blanching petechiae to purpura involving mostly extensor surfaces Tumbler test 18
  19. 19. Investigations • Complete blood count • C- Reactive Protein • Renal function test • Serum glucose • Blood culture and sensitivity • If tubercular suspected – PCR – Chest X-ray – Mantoux test • Arterial blood gas • Fundoscopy • CT scan 19
  20. 20. CSF analysis 20
  21. 21. Management Medical emergency • Early diagnosis essential • Immediate optimum treatment • Intensive supportive therapy • Rehabilitation • Prophylaxis to family • Notification to Public Health 21
  22. 22. Treatment • Managed in Intensive Care Unit • Manage airway, breathing and circulation first • Management of raised ICP • Fluid management • Dexamethasone: only in Pneumococcal and H. Influenzae B, given 1-2 hours before antibiotics • Antibiotics • Inotropes: increasing aortic diastolic pressure and improving myocardial contractility 22
  23. 23.  ICP treatment • 3% NaCl, 5 cc/kg over ~20 minutes • May utilize osmotherapy (Mannitol) - if serum osmolarity <320 mOsm/L • Mild hyperventilation – PaCO2 <28 may cause regional ischemia – Typically keep PaCO2 32-38 mm Hg • Elevate head end of bed by 30o
  24. 24. Fluid management • Restore intravascular volume & perfusion • Monitor serum Na+ (osmolality, urine Na+): – If serum Na+ <135 mEq/L then fluid restrict (~2/3x), liberalize as Na+ improves – If severely hyponatremic, give 3% NaCl • SIADH – 4 - 88% in bacterial meningitis – 9 - 64% in viral meningitis • Diabetes insipidus • Cerebral salt wasting 24
  25. 25. Antibiotics • Best started within 60 min • Empirical therapy • Meningococcal meningitis – Benzyl penicillin 400-500,000 units/kg/day q 4 hour • Pneumococcus/ H. influenza – Ampicillin (if penicillin susceptible) 300 mg/kg/day IV q6 hour – Ceftriaxone (if penicillin resistant) 100-150 mg/kg/day q12 hour – Cefotaxime 150-200 mg/kg/day q8 hour – Vancomycin 60 mg/kg/day 25
  26. 26. Meningitis - Treatment duration • Gram negative organisms: 21 days • Pneumococcal (ampiclox/ceftriaxone): 10-14 days • H influenza: 7-10 days • Meningococcal: 7 days • No growth: 7-10 days • The CSF should be sterile within 24–48 hr of initiation of appropriate antibiotic therapy. 26
  27. 27. Dexamethasone use in meningitis • Consider if – H. influenza & Streptococcus pneumoniae – > 6 wks old • Dose: 0.6 mg/kg/day in 4 divided doses for 2 days • MOA: –  local synthesis of TNF-, IL-1, PAF & prostaglandins resulting in  BBB permeability,  meningeal irritation •  incidence of hearing loss • May adversely affect the penetration of antibiotics into CSF • May decrease fever, giving false impression of improvement 27
  28. 28. Prophylaxis • Rifampicin: – Children 5mg/kg bd x 2 days – Adults: 600 mg bd x 2 days • Pregnant contact: – Cefuroxime IM x 1 dose 28
  29. 29. Meningitis – Early complications • Encephalitis • Septic shock • DIC • Abscess • SIADH • Subdural effusion or empyema ~30% • Dural sinus thrombophlebitis • Stroke
  30. 30. Intermediate • Hydrocephalus • Cranial nerve palsy Late • Cerebral palsy • Hearing loss • Learning disability 30
  31. 31. Acute Encephalitis • Encephalitis is an acute inflammatory process affecting the brain • Viral infection is the most common and important cause, with over 100 viruses implicated worldwide • Symptoms – Fever – Headache – Behavioral changes – Altered level of consciousness – Focal neurologic deficits – Seizures 31
  32. 32. Etiology Non-Arbo viral • Herpes viruses (sporadic) – HSV-1, HSV-2 – varicella zoster virus – cytomegalovirus – Epstein-Barr virus – human herpes virus 6 • Adenoviruses • Influenza A • Enteroviruses, poliovirus • Mumps • Rabies Arbo-Viral (epidemic) • Flaviviridae – Japanese encephalitis – St. Louis encephalitis – West Nile • Togaviridae – Eastern equine encephalitis – Western equine encephalitis 32
  33. 33. – Herpes simplex virus (HSV) • the most common etiology of acute sporadic encephalitis – Arboviruses – arthropod-borne virus • outbreaks in summer time…mosquitos and ticks – Varicella zoster virus (VZV) • immunosuppressed patients 33
  34. 34. Japanese encephalitis • Most important cause of arboviral encephalitis worldwide • Transmitted by culex mosquito, which breeds in rice fields • Commonly involve Basal ganglia: Extra pyradimal symptoms • Post-immunization: Measles, Mumps 34
  35. 35. Herpes Simplex Encephalitis • Primary infection: On the mucosa of oropharynx, mostly asymptomatic • Following primary infection, a latent infection in trigeminal ganglion • Inflammation and necrotizing lesions in – Inferior and medial temporal lobe – Orbito-frontal lobe – Limbic structures 35
  36. 36. • Evolve over several days or acutely • Fever, headache, confusion, stupor, coma, seizures, status epilepticus • Personality changes, irritability, delirium • Temporal lobe seizures: Gustatory or olfactory hallucinations, anosmia 36
  37. 37. CSF Analysis • Increases CSF pressure • Cell count: 10-500 cells/mm3 • Lymphocyte predominance • Erythrocytes (in 80% of the cases) • Normal CSF findings in 10% • Xanthochromia: Due to lysis of RBC • Glucose (mg/dl): normal or low • Protein (mg/dl): >50 mg/dl • HSV PCR: For the first 24-48 hours, detecting HSV DNA by PCR in CSF: – specific (100%) and – sensitive (75-98%) 37
  38. 38. Neuroimaging • Contrast Enhanced MRI • Sensitive for early period HSV encephalitis • Edema in orbitofrontal and temporal regions • CT Scan – Less sensitive than MRI • EEG – If seizures are the features 38
  39. 39. Treatment • If shock/hypotension exists, crystalloid infusion • If unconscious, provide airway/breathing • Seizure, lorazepam 0.1 mg/kg, IV • Acyclovir IV, 14 – 21 days – Neonates and infant: 60 mg/kg/day in 3 divided doses – Children: 30 mg/kg in 3 divided doses • Reduce ICP: restrict fluid, hyperventilation • Acute psychosis: Haloperidol 39
  40. 40. References • Nelson Textbook of Pediatrics 20th edition • Essential Pediatrics, OP Ghai, 8th Edition • Harrisons textbook of Internal Medicine • AAP Guidelines 2016 40
  41. 41. Thank You 41

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