medical education

1. TOPIC PRESENTATION
MENINGITIS
 By- Dr Manoharlal Devasi
M.D General Medicine
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2. INTRODUCTION
MENINGITIS is inflammation
of the protective membrane
covering the brain and spinal
cord known as meninges,
in particular the arachnoid and
the pia mater.
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3. Types
 depending on duration - Acute - <2weeks , subacute 2-4
weeks,
chronic - >4weeks
 depending on cause -
- Bacterial meningitis
-Tuberculous meningitis
- Viral meningitis
- Fungal meningitis
- Parasitic meningitis
- Spinal meningitis
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4. Bacterial Meningitis
 Streptococcus pneumoniae (50%), Neisseria meningitidis
(25%), group B streptococci (15%), Listeria monocytogenes
(10%) and Haemophilus influenzae type b (<10% ).
 Risk factors include coexisting acute or chronic
pneumococcal sinusitis or otitis media, alcoholism,
diabetes, splenectomy, hypogammaglobulinemia,
complement deficiency, and head trauma with basilar skull
fracture and CSF rhinorrhea.
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5. 5
pathophysiolo
gy

6. Clinical features -
 The classic clinical triad of meningitis is fever, headache,
and nuchal rigidity, but the classic triad may not be present.
 Altered sensorium, vomiting, photophobia, seizures.
 Cranial nerve palsy( 3rd,4th,6th,7th,8th)
 Papilloedema.
 Kernig’s and Brudzinski’s signs are classic signs
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8. Diagnosis
 CSF study, MRI / CT
Brain.
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9. Treatment -
 IV Ceftriaxone - 2gm, 12hourly for 7-14 days
 IV Meropenem - 2gm, 8hourly for 7-14 days
 IV Vancomycin 1-2gm, 12hourly for 7-14 days
 Inj dexamethasone 10mg iv 6 hourly, started 20 min
before antibiotics, for 4 weeks with tapering dose, it
inhibits TNF-a production.
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10. Prevention - vaccines
 Meningococcal conjugate vaccine.
 Hib vaccine.
 Pneumococal conjugate vaccine.
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11. TUBERCULOUS MENINGITIS
 Tuberculous meningitis results from the hematogenous
spread of primary or postprimary pulmonary TB or from the
rupture of a subependymal tubercle into the subarachnoid
space.
 The disease often presents subtly as headache and slight
mental changes after a prodrome of weeks of low-grade
fever, malaise, anorexia and irritability.
 Typically, the disease evolves over 1–2 weeks, a course
longer than that of bacterial meningitis.
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12. complication
 Because meningeal involvement is pronounced at the base
of the brain, paresis of cranial nerves (ocular nerves in
particular) is a frequent finding and the involvement of
cerebral arteries may produce focal ischemia. The ultimate
evolution is toward coma, with hydrocephalus and
intracranial hypertension.
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13. Diagnosis
 CSF study.
 Culture of CSF is diagnostic in up to 80% of cases and
remains the gold standard.
 Real time automated nucleic acid amplification (the Xpert
TB/RIF assay) has a sensitivity of up to 80% and is the
preferred initial diagnostic option.
 Imaging studies (CT and MRI) may show hydrocephalus
and abnormal enhancement of basal cisterns or ependyma,
enchanced ring lesion called tuberculoma.
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14. CSF study
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15. MRI brain
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16. Treatment
 AntiTuberculosis drug - HRZE( isoniazid (300 mg/d),
rifampin (10 mg/kg per day), pyrazinamide (30 mg/kg per
day in
divided doses), ethambutol (15–25 mg/kg per day) for 2
months f/by HR for 10 month.
 Inj dexamethasone 0.4 mg/kg per day given IV with
tapering by 0.1 mg/kg per week until the fourth week.
 In special case, HIV patient should given antiTuberculosis
drugs and later ART after 8 weeks, to avoid IRIS( immune
resconstitution inflammatory syndrome )
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17. VIRAL MENINGITIS
 Clinical features are same
in all meningitis.
Diagnosis-
 serology- PCR for specific
virus.
 CSF study
 MRI brain.
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18. csf study
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19. Treatment
 IV acyclovir - 15-30 mg/kg/day in 3 divided dose for
14 days.
 Tab famciclovir - 500 mg, 8 hourly
 Tab valacyclovir -1000mg, 8 hourly
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20. FUNGAL MENINGITIS
 Fungal meningitis is rare; the most common cause is
Cryptococcus, Histoplasma, Blastomyces, Coccidioides,
candida, aspergellus.
 The fungi are usually inhaled (bird dropping) and then
spread by the blood to the central nervous system.
 Risk factors - immunocompromised conditions (HIV),
Steroids use, organ transplantation, malignancy.
 The most common complication of fungal meningitis is
hydrocephalus.
 Investigation- CSF study, serology, india ink stain, imaging
study.
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21. CSF study
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22. Treatment
 Inj amphotericin iv 3mg/kg/day for 14days.
 Tab flucytosine 100mg/kg/day for 14 days.
 Tab fluconazole 200mg od for 14 days .
 In cryptococcal meningitis - treatment is continued
for
1 year.
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23. PARASTIC MENINGITIS
 Angiostrongylus cantonensis (neurologic
angiostrongyliasis), Baylisascaris procyonis
(baylisascariasis; neural larva migrans), Gnathostoma
spinigerum (neurognathostomiasis), Naegleria
fowleri(amebic meningitis).
 These parasites normally infect animals not people. People
get infected primarily by eating infected animals or
contaminated foods.
 Investigation- csf study, serology, MRI brain.
 Treatment - no specific treatment.
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24. CSF study
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25. SPINAL MENINGITIS
 Injury may occur to motor and sensory nerve roots as they
traverse the subarachnoid space and penetrate the meninges.
 These cases present as multiple radiculopathies with
combinations of radicular pain, sensory loss, motor weakness,
and urinary or fecal incontinence.
 Meningeal inflammation can encircle and damage the cord,
resulting in a myelopathy.
 Electrophysiologic testing (electromyography, nerve conduction
studies, and evoked response testing) may be helpful in
determining whether there is involvement of cranial and spinal
nerve roots.
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26. Chronic meningitis
 Chronic meningitis is suspected when a characteristic
neurologic syndrome exists for >4 weeks and is associated
with a persistent inflammatory response in the
cerebrospinal fluid (CSF).
 Five categories of disease account for most cases of
chronic meningitis:
(1) meningeal infections
(2) malignancy
(3) autoimmune inflammatory disorders
(4) chemical meningitis
(5) parameningeal infections.
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27.  Causes - Mycobacterium tuberculosis, Borrelia burgdorferi,
Syphilis, Actinomyces, Nocardia, Brucella, Tropheryma
whipplei, Leptospirosis, virus, fungus, parasite, malingancy,
SLE, sarcoidosis, wegeners.
 Persistent headache, hydrocephalus, cranial neuropathies,
radiculopathies, and cognitive or personality changes are
the cardinal features.
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28.  Diagnosis- csf study , MRI brain , meningeal biopsy
 Treatment - emprical antibiotics,antiviral,antifungal.
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29. THANK YOU
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