Meningitis ppt.pptx

WELCOME TO
SEMINAR PRESENTATION ON
MENINGITIS
BY DR. JISA ADUNE(MD)
MODERATOR: DR. BIKILA
G.(Internist)
MUKE TURI HOSPITAL , JULY 22 /2014 E.C

Out line
• Introduction
• Definition
• Epidemiology And Etiology
• Classification
• Pathophysiology
• Clinical Manifestations
• Diagnosis
• Complications
• Treatment
• Prevention
Thursday, August 4, 2022 Meningitis 2

Introduction
Meninges Are Composed Of Three Membraneous
Connective Tissue Layers:
1. Dura Mater(dura):-tough, Thick External Fibrous Layer
2. Arachnoid Mater(arachnoid):- Thin Intermediate Layer.
3. Pia Mater (Pia):- Delicate Internal Vasculated Layer.
Acronomy:- DAP

Definition
• Meningitis Is An Inflammatory Disease Of The
Leptomeninges, The Tissues Surrounding The
Brain And Spinal Cord, In Response To An
Infection.
• Bacterial Meningitis Is One Of The Most
Potentially Serious Infections Occurring In
Infants And Older Children.

Classification
Meningitis Can Be Classified Based On:-
♣Undelying Cause:-
1. Bacterial:-
2. Viral
3. Fungal
♣Time Course Of Illness
1. Acute
2. Chronic
♣Type Of Inflammatory Response

Acute Bacterial MENINGITIS
Etiology
Most Often Responsible Organisms Are:-
1. Streptococcus Pneumoniae(⸞
50%)
2. Neisseria Meningitis (⸞
25%)
3. Group B Streptococci (⸞
15%)
4. Listeria Monocytogenes ((⸞
10%)
5. Haemophilus Influenzae Type B (<10%)

Etiology...
– During The 1st 2 Months Of Age
• Group B Streptococcus
• E Colli
• L. Monocytogens
– In Children 2 Months To 12 Years
• H.Influenza
• S. Pneumoniae
• N. Meningitis
– In Children Older Than 12 Years
• N. Meningitis
• S. Pneumoniae

Etiology...
• Virus:-(Herpes Simplex Virus, Varicella Zoster
Enteroviruses, Cytomegalovirus, Hiv, Etc),
• Fungal Infections:- (Cryptococcus Neoformans In
Immune-suppressed Host)
• Mycobacterium Tuberculosis

Clinical features
●Symptoms:-
• Classic Triad Of Bacterial Meningitis:- Fever
- Headache
- Neck Stiffness
• Up To 95% Of Patients With Bacterial Meningitis Have At Least Two
Of The Following Symptoms:-fever, Headache, Stiff Neck Or Altered
Mental Status.
• Seizure
• Other Symptoms Include:- Nausea, Vomiting, Photalgia, Sleepiness,
Confusion, Irritability, Delirium, And Coma.
• Atypical Presentation (E.G. Lethargy Without Fever) In The Elderly
And Immunosuppressed.

●Signs:
• Nuchal Rigidity
• Signs Of Meningeal Irritation:
- Kernig‘s Sign
- Brudzinski‘s Sign
• Funduscopic Findings:- Papilledema,
- Absent Venous Pulsations
• Focal Neurologic Signs, Cranial Nerve Palsies
• Skin Rash: Maculopapular, Petechial, Or Purpuric Rash

●Infants:
• Bulging Fontanelle( If Euvolemic)
• Paradoxic Irritation
• High Pitched Cry
• Hypotonia
• Seizures
• Risk Of Infection For Neonates < 72hrs

Pathogenesis

Diagnosis
Clinical Evidences:-
• History
• Objective Signs( Physical Findings):
MENINGEAL SIGNS SENSITIVITY SPECIFICITY
NUCHAL RIGIDITY 30% 68%
BRUDZINSKI’S SIGN 5% 95%
KERNIG’S SIGN 5% 95%
JOLT ACCENTUATION OF HEAD 95% 60%

Investigations:
• CBC
• LP:- Opening Pressure, CSF Analysis
• Blood Culture
• OFT
• Serum Electrolyte
• Blood Film
• Serum Glucose
• Brain Imaging(CT Or MRI)

CSF FINDINGS IN BACTERIAL MENINGITIS
Opening Pressure >180mmH2O
White Blood Cell 10/µL To 10,000/µL; Neutrophils Predominate
Red Blood Cells Absent In Non-traumatic Tap
Glucose <2.2mmol/L (<40mg/dL)
CSF/Serum Glucose <0.4
Protein >0.45g/L(>45mg/dL)
GRAM’S STAIN Positive in >60%
Culture Positive in >80%
Latex
Agglutination
May Be Positive In Patients With Meningitis Due To
Streptococcus Pneumoniae, Neisseria Meningitidis,
Haemophilus Influenzae Type B, Escherichia Coli,
Group B Streptococci
LIMULUS LYSATE Positive in cases of gram-negative meningitis
PCR Detects Bacterial DNA

Typical CSF Findings In Different Causes Of Meningitis
Agent Opening
pressure
WBC
Count/µL
Glucose
(mg/dL)
Protein
(mg/dL)
Microbiology
Bacterial
Meningitis
200-300 100-5000,
>80%PMNs
<40 >100 Specific pathogen
demonstrated in 60% of
gram stains and 80% of
cultures
Viral
Meningitis
90-200 10-300,
Lymphocytes
Normal,
Reduced InLCM
and Mumps
Normal,
But May Be
Slightly Elevated
Viral isolation, PCR
Assays
Tuberculus
Meningitis
180-300 100-500,
Lymphocytes
Reduced, <40 Elevated, >100 Acid-fast bacillus stain,
culture
PCR
Cryptococcal
Meningitis
180-300 10-200,
Lymphocytes
Reduced 50-200 India Ink, Cryptoccocal
Ag, Culture
Aseptic
Meningitis
90-200 10-300,
Lymphocytes
Normal Normal,
But May Be
Slightly Elevated
Negative Findings On
Workup
Normal
Values
80-200 0-5,
Lymphocytes
50-75 15-40 Negative Findings On
Workup

●Head CT/MRI To Rule Out Mass Effect Before
LP If Presence Of High-risk Feature:-
▪ Age >60 Years
▪ Immunocompromised
▪ Focal Neurologic Findings( Except For
Abducent/CN-VI Palsy.
▪ Papilledema
▪ History Of CNS Disease( If Only Deterioration)
▪ New And Early-onset Seizure Or
Change In Mental State
▪ Recent Head Trauma

• Differential Diagnosis:
1. Viral Meningoencephalitis
2. Rickettsial Disease
3. Subdural And Epidural Empyema
4. SAH
5. Hypersensitivity Meningitis, Chemical
Meningitis
6. Rocky Mountain Spotted Fever(RMSF)
7. Focal Suppurative CNS Infection

Treatment
Objectives:
• Rapid Eradication Of The Organisms From The CSF
• Prevent Death And Complications
• Amelioration Of Signs And Symptoms
Non Pharmacologic:
• Close Supervision With Regular Monitoring Of Vital
Signs And Neurological State.
• Institution Of Coma Care For Complicated Cases.

Treatment…
Duration Of Therapy Is 10 To 14 Days. However, It Can Be
Adjusted If The Specific Causative Pathogen Is Identified.
• Meningococcus: 7 Days
• Pneumococcus; 10- 14 Days
• H. Influenzae: 7- 10 Days
• Listeria Monocytogenes: At Least 21 Days
• Gram Negative Bacilli: At Least 21 Days
• Staphylococcus Aureus: At Least 14 Days

Treatment…
Microorganism Antibiotics Duration
Neisseria
Meningitides
Penicillin-sensitive Penicillin G
7 Days
Penicillin-resistant Ceftriaxone
S. Pneumoniae
Penicillin-sensitive Penicillin G
14 Days
Penicillin-
intermediate
Ceftriaxone
Penicillin-resistant Ceftriaxone + Vancomycin
H. Influenza Ceftriaxone 7 Days
Gram-negative Bacilli Ceftriaxone 21 Days
P. Aeruginosa Ceftriaxone 21 Days
L. Monocytogenes Ampicillin + Gentamicin 21 Days

Empirical Antimicrobial Therapy
Empirical Therapy Of Bacterial Meningitis
Age Or Condition Antimicrobial Therapy
Neonate(< 1 Month) Ampicillin + Cefotaxime
Infants 1-3 Months Ampicillin + Cefotaxime Or Ceftriaxone
3 Month-50 Yr Cefotaxime Or Ceftriaxone + Vancomycin
> 50 Yr Ampicillin+ Cefotaxime Or Ceftriaxone + Vancomycin
Immunocompromised State Vancomycin + Ampicillic + Ceftazidime
Post -Traumatic/PostSurgery Vancomycin + Ceftazidime

Specific Antimicrobial Therapy
● MENINGOCOCCAL MENINGITIS
Index Case And All Close Contacts Should Receive
Chemoprophlaxis:-
Rifampin (600mg BID For 02 Days) For Adults And
10mg/Kg/Dose BID For 02 Days In Children > 1 Yr.
Alternative,
Azithromycin 500mg po stat or
ceftriaxone 250mg im stat in adults.
Ciprofloxaccillin 500mg PO Stat
NB.Rifampin is not recommended in pregant women

PNEUMOCOCCAL MENINGITIS
• 2 Weeks Course Of Intravenous Antimicrobial
Therapy Is Recommended.
• Susceptible Strain-ceftraxone,cefotaxime, Or
Cefepimd And Vancomycin.
• Resistant Strain-vancomycin As 1st Choice.
• Rifampicin Can Be Added To Vancomycin For
Its Synergistic Effect, But Not As Monotherapy.

LISTERIA MENINGITIS
• 1st Line:-
Ampicillin 2gr IV QID +/- Gentamicin 2mg/Kg/Dose
Loading, Then 7.5mg/Kg/Day IV TID With Dose
Adjustment.
• Alternative
Trimethoprim 10-20mg/Kg/Day + Sulfamethoxazole
50-100mg/Kg/Day IV QID

STAPHYLOCOCCAL MENINGITIS
• Nafcillin 50-100mg/Kg/Day IV QID
• Vancomycin For Methicillin Resistant Staphlococci And
Patients Allergic To Penicillin.

Adjunctive Therapy For Bacterial Meningitis
Dexamethasone:
Exerts Its Beneficial Effect By Inhibiting The Synthesis Of
Il-1 And TNF- At The Level Of mRNA, Decreasing CSF
Outflow Resistance, And Stabilizing The Blood Brain
Barrier.
Should Be Started 20min Before, Or Not Later Than
Concurrent With, The First Dose Of Antibiotics.
10mg IV QID For 4 Days( Not More Than 4 Days).
It Best Works Against Streptococcal Meningitis Thus May
Be Omitted If Etiologic Agent Identified Earlier.

Complications
Immediate Complications:-
• Septic Shock, DIC
• Coma With Loss Of Protective Airway
Reflexes
• Seizures, Which Occur In 30-40% Of Children
And 20-30% Of Adults.
• Cerebral Edema

Delayed Complications:-
• Decreased Hearing Or Deafness
• Cranial Nerve Palsies
• Multiple Seizures
• Focal Paralysis
• Subdural Effusion

Acute Bacterial Meningitis Prognosis Mortality:
• 3-7% For - H. Influenzae, N.Meningitidis, GBS
• 15% For L.Monocytogenes
• 20% S. Pneumoniae
Poor Prognostic Signs, The Risk Of Death!
1. Decreased Level Of Consciousness On Admission
2. Onset Of Seizure Within 24hr Of Admission
3. Signs Of Increased ICP
4. Bimodal Ages: Younger(infancy) And Age > 50
5. Delayed Initiation Of Treatment

SUB-ACUTE MENINGITIS
Clinical Feature:-
• Unrelenting Headache, Stiff Neck Low Grade
Fever And Lethargy For Days To Several Weeks.
• Cranial Nerve Abnormalities
• Night Sweating

SUB-ACUTE MENINGITIS
Etiologies:-
Common Causative Organisms Include:
• M. Tuberculosis,
• C. Neoformans,
• H.Capsulatum,
• C.Immitis,
• T.Pallidum

Tuberculus meningitis
●May Present With:-
• Stage I:- No Change In Mental Status,
- No Neurologic Deficit
- No Hydrocephalus
• Stage II: - Confusion,
- Neurologic Deficit
• Stage III: Stupor/Lethargy
●Treatment:-
• Anti-TB For 6-12 Months(2RHZE/10RH)
• Dexamethasone (12-16mg/Day) OR 10mg IV QID For Adults for
3weeks,then Tapered Over 3 Weeks).

C.Neoformance
A) In Non-HIV, Non-transplant Patients:
●Induction Therapy With
Amphotericin B 0.7mg/Kg/ IV Daily
+
Flucytosin 100mg/Kg/Day Qid For Atleast 4 Weeks
If CSF Culture Results Are -Ve After 2 Weeks Of Treatment.
• Treatment Should Be Extended For Total Of 6 Weeks In
Patients With Neurologic Complications.
●Consolidation Therapy- Fluconazole 400mg/Day For 8 Wks

Meningitis Due To C.Neoformance….
B) Organ Transplant Recipients:
• Liposomal Amphotericin B 3-4mg/Kg/Day Or
Amphotericin B Lipid Complex 5mg/Kg/Day
+
• Flucytosine S100mg/Kg/Day In 4 Divided Doses For
Atleast 2 Weeks Or Until CSF Culture Is Sterile.
• Follow Csf Yeast Culture For Sterilization Than The
Cryptococcal Antigen Titer
• Then, Fluconazole 400-800mg/Day(6-12mg/Kg) PO For
8-10 Weeks.

Meningitis Due To C.Neoformance….
C) Patients With HIV Infection:
AmB Or Lipid Formulation + Flucytosine For Atleast
2weeks, Followed By Fluconazole For Atleast 8 Weeks

Syphilitic Meningitis
1st Line:-
• Acqueous Penicillin G 3-4 Million Units IV q4hr For
10-14 Days.
Alternative:-
• Procaine Penicillin G 2.4 Million Units IM Daily +
500mg Probenecid QID FOR 10-14 Days
Continuation Phase:- Benzanthine Penicillin G
IM Once A Week For 3 Weeks.

Chronic Meningitis
• Diagnosed When A Characteristic Neurologic
Sydromes Exists For >4 Weeks.
• Five Categories Of Disease Account For Most Cases:
1. Meningeal Infection
2. Malignancy
3. Autoimmune Inflammatory Disorders
4. Chemical Meningitis
5. Parameningeal Infection

• Symptoms And Signs
Symptoms Signs
Chronic Headache +/-Papilledema
Neck Or Back Pain/Stiffnass Brudzinski’s/Kernig/S Sign
Change In Personality Altered Mental Status9drowsiness,
Inattention,disorientation,memory Loss,frontal
Release Sign{grasp,suck,snout}, Perseveration
Facial Weakness Peripheral CN-VIII Paresis
Double Vision PARESIS OF CNs III,IV,VI
Diminished Vision Papilledema,optic Atrophy
Hearing Loss CN-VIII Paresis
Arm Or Leg Weakness Myelopathy Or Radiculopathy
Numbness In Arms Or Legs Myelopathy Or Radiculopathy
Urinary Retention/Incontinence Myelopathy Or Radiculopathy
Frontal Lobe Disfunction(hydrocephalus)
Clumsiness Ataxia

Chronic Meningitis….
• There Are Two Forms Of Chroic Meningitis:-
1st Symptoms Are Chronic And Persistent
- Mostly Bacterial
2nd Recurrent, Discrete Episodes Of Illness;
- Mostly Viral
-All Symptoms, Signs, and CSF Parameters Of
Meningeal Inflammation Resolve Completely
Between Episodes Without Specific Therapy.
- Only Suppportive Care Like Antipyretics Rather
Than Antibioytics.

REFERENCES
• HARRISON INTERNAL MDICINE 20th EDITION
• SURVEILLANCE OF BACTERIAL MENINGITIS,
ETHIOPIA, 2012-2013
• ETIOLOGY OF BACTERIAL MENINGITIS IN
ETHIOPIA, 2007-2011: A RETROSPECTIVE STUDY
• STG 4th Edition 2021
• Uptodate 21.6
• NICU GUIDELINE 2021 EDITION

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