Leading large scale change: a life at the interface between theory and practice
Meningitis Lec SMH.pptx
1. Shair Muhammad Hazara
PhD Public Health (fellow), MSPH, MSBE, BSN, Ped. N
E-mail address: hazara_27@hotmail.com
2. History
A 20-year-old medical student presents to the
Emergency Department feeling generally unwell. He
is wearing sunglasses and complains of a stiff neck
with a ‘pounding headache’. He has vomited twice.
On examination, he is Kernig's sign positive.
Observations
HR 121,
BP 101/77,
RR 20,
SpO2 98%,
Temp 38.3
Case-based discussion:1
2
4. History
A 20-year-old medical student presents to the
Emergency Department feeling generally
unwell. He is wearing sunglasses and
complains of a stiff neck with a ‘pounding
headache’. He has vomited twice.
On examination, he is Kernig's sign positive.
Observations
HR 121, BP 101/77, RR 20, SpO2 98%, Temp
38.3
Case-based discussion:1
4
5. Definition
Inflammation of the meninges due to infective
(bacterial, viral, or fungal) or non-infective causes
• S. pneumoniae and N.meningitidis are the
most common bacterial causes
• Enteroviruses are the most common viral cause
Epidemiology
• 5 per 100,000 population (NICE)
• Bacterial meningitis mortality: 25% in adults
• Viral meningitis mortality: <1%
Introduction
5
7. Bacteria
• Haematogenous spread (most common)
• Direct extension from a contiguous site
• Release of inflammatory mediators in the CSF
• Inflammation
• Cerebral oedema
• Raised ICP
Virus
• Enteroviruses spread via faecal-oral route
• Enter the CNS through haematogenous spread
• See above for the inflammatory response
Pathophysiology
7
10. Aetiology by age
Age Organism
0 to 3 months
• Group B streptococcus
• E. Coli
• Streptococcus pneumoniae
• Listeria monocytogenes
3 months to 6 years
• Streptococcus pneumoniae
• Neisseria meningitides
• Haemophilus influenzae b
6 months to 60 years • Neisseria meningitidis
• Streptococcus pneumoniae
> 60 years
• Streptococcus pneumoniae
• Neisseria meningitidis
• Listeria monocytogenes 10
11. Aetiology
Neisseria meningitidis
(Meningococcal meningitis)
• Colonises the nasopharynx – asymptomatic
carriers
• Droplet spread of respiratory secretions
• Vaccination:
• Men B and Men C
• Men ACWY
• Mortality: 10%
• Typically causes a non-blanching purpuric
rash
11
13. Aetiology
Group B streptococcus (Streptococcus agalactiae)
• Most common cause of neonatal
meningitis, pneumonia, and sepsis
• Colonises the vagina and transmitted during birth
• Currently not routinely screened for
• Intrapartum antibiotics
•Risk factors
• Prolonged membrane rupture
• Low birthweight
13
14. Streptococci
Beta-haemolytic Alpha-haemolytic Gamma-haemolytic
Group A streptococcus
• S.pyogenes
Group B streptococcus
• S.agalactiae
S.pneumoniae
S.viridans
Group D
streptococcus
• Enterococcus
14
Classified according to pattern of haemolysis on blood agar
• Alpha-haemolytic (partial haemolysis)
• Beta-haemolytic (complete haemolysis)
• Gamma-haemolytic (no haemolysis)
15. History
A 20-year-old medical student presents to the
Emergency Department feeling generally unwell.
He is wearing sunglasses and complains of a stiff
neck with a ‘pounding headache’. He has
vomited twice.
On examination, he is Kernig's sign positive.
Observations
HR 121, BP 101/77, RR 20, SpO2 98%, Temp 38.3
Question: 3
15
17. Clinical features
Symptoms Signs
Meningism
• Headache
• Photophobia
• Neck stiffness
Kernig’s sign
• When the hip is flexed and the knee is
at 90°, extension of the knee results in
pain
Fever Brudzinski sign
• Severe neck stiffness causes the hips
and knees to flex when the neck is
flexed
Nausea and vomiting Purpuric non-blanching rash
• Meningococcal disease
Seizures Pyrexia
Reduced GCS 17
21. Differentials
Viral meningitis
Bacterial
meningitis
Tuberculous
meningitis Encephalitis
• Acute onset
• Meningism
• Usually self
limiting
• Acute onset
• Meningism
• May be fatal
• Chronic onset
• Prodromal malaise
and fever
• Abnormal
cerebral
function
• +/- meningism
• CSF
interpretation
• CSF
interpretation
• CSF interpretation
• PCR and Ziehl-
Neelsen stain
• CXR
• CSF profile
may be
similar to viral
meningitis
21
22. History
A 20-year-old medical student presents to the
Emergency Department feeling generally unwell.
He is wearing sunglasses and complains of a stiff
neck with a ‘pounding headache’. He has vomited
twice.
On examination, he is Kernig's sign positive.
Observations
HR 121, BP 101/77, RR 20, SpO2 98%, Temp
38.3
Question: 4
22
28. History
A 20-year-old medical student presents to the
Emergency Department feeling generally unwell. He
is wearing sunglasses and complains of a stiff neck
with a ‘pounding headache’. He has vomited twice.
On examination, he is Kernig's sign positive.
Observations
HR 121, BP 101/77, RR 20, SpO2 98%, Temp
38.3
Question: 6
28
30. Management
Antibiotics
• Secondary care: IV cephalosporin (cefotaxime or ceftriaxone) +/- amoxicillin
• Primary care: IV or IM benzylpenicillin if there is evidence of a non-blanching
rash
Steroids
• Dexamethasone: administered before or at the same time as antibiotics
• Should be given within 12 hours of antibiotics
• If pneumococcal meningitis is confirmed, continue steroid
Anti-viral
• Aciclovir: if viral meningitis is suspected. Used to treat HSV and VZV
Adjunct
• IVF
• Analgesia and anti-pyretic 30
31. History
A 20-year-old medical student presents to the
Emergency Department feeling generally unwell. He
is wearing sunglasses and complains of a stiff neck
with a ‘pounding headache’. He has vomited twice.
On examination, he is Kernig's sign positive.
Observations
HR 121, BP 101/77, RR 20, SpO2 98%, Temp
38.3
Question: 7
31
33. Contact tracing
Meningitis is a notifiable disease
Meningococcal meningitis
• Prolonged close contact in a household setting in the preceding 7
days before onset of illness
• Exposure to respiratory droplets
• Ciprofloxacin 500mg one off dose to anyone who meets the
above criteria
• Rifampicin is an alternative
Pneumococcal meningitis
• Prophylaxis is not usually required 33
34. Complications
System Complication
Neurological • Sensorineural hearing loss
• Seizures
• Cerebral oedema
• Long-term cognitive and behaviour
deficit
• Abscess
• Hydrocephalus
Endocrine • Waterhouse-Friderichsen
syndrome
Other • Sepsis
34
37. Recap
• Meningitis is relatively rare but carries a high mortality
• The most common cause are enteroviruses
• S.pneumoniae and N.meningitidis is the most common bacterial cause
• The definitive investigation is with CSF analysis
• Management depends on the aetiology and involves:
• Antibiotics
• Antivirals
• Corticosteroids
• Ciprofloxacin prophylaxis is indicated for contacts of patients with
meningococcal disease
37
38. References
1. SVG by Mysid, original by SEER Development Team [1], Jmarchn / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)
2. Microman12345 / CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0)
3. Doc. RNDr. Josef Reischig, CSc. / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)
4. CDC / CC BY (https://creativecommons.org/licenses/by/2.5)
5. GrahamColm / CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0)
6. R. G. Wiener, Harlem Hospital / Public domain
7. Pam Cleverley, Perry Bisman, http://babycharlotte.co.nz / CC BY-SA (http://creativecommons.org/licenses/by-sa/3.0/)
8. Blausen.com staff (2014). "Medical gallery of Blausen Medical 2014". WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436. / CC BY
(https://creativecommons.org/licenses/by/3.0)
9. Amadalvarez / CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0)
All other images were made by BiteMedicine or under the basic license from Shutterstock and not suitable for redistribution
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