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Meningitis and Encephalitis
(clinical presentation & management)
Dr Ahmad Shahir Mawardi
Neurology Department
Hospital Kuala Lumpur
28th
May 2018
Outlines
1.Case illustration
2.Definition, causes
3.Clinical presentation
4.Management (History, Investigations,
Treatment, complications)
5.Algorithm
Case study 1
Role of Neurologist
• improvement in therapy
• proper isolation
• prophylaxis of contacts when required
• anticipation and management of the
neurologic complications
Definition
• fever
• headache
• meningismus with
inflammation in the
subarachnoid space
as evidenced by CSF
pleocytosis
Meningitis
• acute (hours to days), subacute, or chronic (>4/52)
• Infectious vs non-infectious (aseptic)
• The average age is 41.9 years.
• Acute meningitis is often infectious with a bacterial or
viral cause
*encephalitis, myelitis, or encephalomyelitis
Clinical presentation (1)
• The classic triad (fever, neck stiffness & altered mental
status) - 44%
• > 2/4 (headache, fever, stiff neck, or altered mentation) -
95%.
• An altered level of consciousness is present in 2/3 of
patients with bacterial meningitis
– absent in patients with viral meningitis unless coincident
encephalitis is present.
The absence of
nuchal rigidity,
Kernig sign, and
Brudzinski sign
should never be
used to exclude the
possibility of
meningitis
Clinical presentation (2)
• Lethargy or obtundation
• Coma - 20% (pnemocoocal > meningococcal)
• Seizures - 20 % (bact meningitis)
• Rash
– viral exanthem : enteroviruses, flaviviruses rash of
HFMD : Enteroviruses
– Hemorrhagic purpura: meningococcemia
• defined syndrome of otitis and upper respiratory
tract infection (in children)
Top 5 causes of bacterial meningitis
Viral & Culture-Negative (Aseptic) Meningitis
Prophylactic therapy
• meningococcal meningitis, rifampin prophylaxis, 600 mg
bd x 2/7, should be given to household contacts and
those with direct exposure to droplet secretions.
Within hours of antibiotic
administration, the yield of
bacterial culture falls(~
>50%), but other helpful CSF
parameters do not.
yield on Gram stain was reduced
by 16%
1.8 mmol/L
2.2 g/L
Investigations (1)
Blood
• FBC with differential
• Blood cultures (aerobic and
• anaerobic)
• CRP/ESR/procalcitonin
• HIV
• Rapid plasma reagent
• Serum for acute serology (store for
paired convalescent sample in 3 to
4 weeks)
• Heterophile antibodies
• (Epstein-Barr virus)
• Lyme disease tests
• Rickettsial serologies
CSF
• Opening pressure
• Cell count and differential
• Serum and CSF glucose
concentration
• Protein concentration
• Stains: Gram, India ink, AFB
• Cultures: aerobic, anaerobic,
acid-fast bacillus, fungal
• Cytology
• Antibody testing (arboviral)
• PCRs: enteroviral, West Nile virus,a
herpesvirus types 1 and 2)
• CSF lactate (posttrauma or
neurosurgical)
• A bloody tap will falsely elevate the CSF white cell count and
protein.
• To correct for a bloody tap,
– subtract 1 white cell for every 700 red blood cells/mm3
– 0.1 g/dl of protein for every 1000 red blood cells.
Question 1
Does all patients suspected with meningitis
will need CT brain prior to LP and what
are the reason(s)?
• Abnormal CT scans were found in 56 of 301 (24%) subjects in a
prospective study and were associated with
– age older than 60 years,
– immunocompromised states
– recent seizure
– focal neurologic deficits
– or inability to follow two consecutive commands or questions correctly
• The absence of these findings had a negative predictive value of
97%.
Question 2
• Role of steroid in bacterial meningitis?
• corticosteroids have been shown to reduce
morbidity and mortality in children and also
improve functional outcome when compared to
placebo in adults.
• Dexamethasone 10 mg IV 6 hourly x 4/7
– at the time of or immediately before the first dose of
antibiotics
• studies have only demonstrated the benefit in
higher-income countries.
Radiological findings
leptomeningeal enhancement
Radiological findings
• may be normal
• subtle hydrocephalus
• hyperdensity around basal cisterns
(especially in tuberculosis)
• leptomeningeal enhancement
• complications or sources of the meningitis
A: cerebral oedema
B: complete effacement of the
basal cisterns
C: communicating hydrocephalus
D: subdural collection
• hydrocephalus
• subdural empyema
• epidural empyema
• cerebritis and cerebral abscess
• infarction
• ventriculitis
• dural sinus thrombosis
SYSTEMIC COMPLICATIONS
• Hypotension, septic
shock and adult
respiratory distress
syndrome
• Hyponatraemia/Hyper
natraemia
• Arthritis
If gcs drop:
• Cerebral oedema
• Hydrocephalus
• Cerebral infarction
• Seizures
Encephalitis
• diagnosis that should
only be made if there
is tissue confirmation
• in practice:
– febrile illness, severe
headache reduced
consciousness
– surrogate markers of
brain inflammation
Encephalitis
Causes (1)
Causes (2)
• HSV- brain parenchyma in the temporal lobes,
sometimes with frontal or parietal involvement.
• Mumps virus - acute viral encephalitis, or a delayed
immune mediated encephalitis.
• Measles virus - post-infectious encephalitis, which can
sometimes have a acute haemorrhagic
leukoencephalitis.
• Influenza A virus - diffuse cerebral oedema
• Varicella zoster virus (VZV) -vasculitis
Infectious causes
of encephalitis
Non-infectious
causes of
encephalitis
• acute flu-like prodrome,
fever,
• severe headache
• nausea, vomiting
• altered consciousness
• seizures
• focal neurological signs
Clinical presentations
HSV-1 encephalitis
• febrile (91%)
• disorientation (76%)
• speech disturbances (59%)
• behavioural changes (41%)
• seizures (33%)
• Alterations in higher mental
function
History
• from family members
• rashes
• travel history
• occupation and recreational activities
• risk factors for HIV
Examinations
• GCS
• rashes, shingels, scar, bites, IVDU
• sign of immunocompromised state
• subtle seizure
• meningism, and look for focal neurological signs
• lower cranial neuropathies and myoclonus
(rhomboencephalitis or basal
meningoencephalitis)
Investigations
Investigations
EEG
• usually shows non-specific diffuse high
amplitude slow waves of encephalopathy,
• subtle epileptic seizures.
• Periodic lateralised epileptiform (HSV
encephalitis)
References
• Russell Bartt, Acute bacterial and Viral Meningitis,
Continuum Lifelong Learning Neurol 2012;18(6):1255–
1270
• Ewout S Schut, Jan de Gans, Diederik van de Beek,
Community-acquired bacterial meningitis in adults, Pract
Neurol 2008; 8: 8–23
• Tom Solomon, Ian J Hart, Nicholas J Beeching, Pract
Neurol 2007; 7: 288–305
Thank you

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Meningitis and Encephalitis

  • 1. Meningitis and Encephalitis (clinical presentation & management) Dr Ahmad Shahir Mawardi Neurology Department Hospital Kuala Lumpur 28th May 2018
  • 2. Outlines 1.Case illustration 2.Definition, causes 3.Clinical presentation 4.Management (History, Investigations, Treatment, complications) 5.Algorithm
  • 4.
  • 5. Role of Neurologist • improvement in therapy • proper isolation • prophylaxis of contacts when required • anticipation and management of the neurologic complications
  • 6. Definition • fever • headache • meningismus with inflammation in the subarachnoid space as evidenced by CSF pleocytosis
  • 7. Meningitis • acute (hours to days), subacute, or chronic (>4/52) • Infectious vs non-infectious (aseptic) • The average age is 41.9 years. • Acute meningitis is often infectious with a bacterial or viral cause
  • 8. *encephalitis, myelitis, or encephalomyelitis
  • 9. Clinical presentation (1) • The classic triad (fever, neck stiffness & altered mental status) - 44% • > 2/4 (headache, fever, stiff neck, or altered mentation) - 95%. • An altered level of consciousness is present in 2/3 of patients with bacterial meningitis – absent in patients with viral meningitis unless coincident encephalitis is present.
  • 10. The absence of nuchal rigidity, Kernig sign, and Brudzinski sign should never be used to exclude the possibility of meningitis
  • 11. Clinical presentation (2) • Lethargy or obtundation • Coma - 20% (pnemocoocal > meningococcal) • Seizures - 20 % (bact meningitis) • Rash – viral exanthem : enteroviruses, flaviviruses rash of HFMD : Enteroviruses – Hemorrhagic purpura: meningococcemia • defined syndrome of otitis and upper respiratory tract infection (in children)
  • 12. Top 5 causes of bacterial meningitis
  • 13.
  • 14.
  • 15. Viral & Culture-Negative (Aseptic) Meningitis
  • 16.
  • 17. Prophylactic therapy • meningococcal meningitis, rifampin prophylaxis, 600 mg bd x 2/7, should be given to household contacts and those with direct exposure to droplet secretions.
  • 18. Within hours of antibiotic administration, the yield of bacterial culture falls(~ >50%), but other helpful CSF parameters do not. yield on Gram stain was reduced by 16% 1.8 mmol/L 2.2 g/L
  • 19. Investigations (1) Blood • FBC with differential • Blood cultures (aerobic and • anaerobic) • CRP/ESR/procalcitonin • HIV • Rapid plasma reagent • Serum for acute serology (store for paired convalescent sample in 3 to 4 weeks) • Heterophile antibodies • (Epstein-Barr virus) • Lyme disease tests • Rickettsial serologies CSF • Opening pressure • Cell count and differential • Serum and CSF glucose concentration • Protein concentration • Stains: Gram, India ink, AFB • Cultures: aerobic, anaerobic, acid-fast bacillus, fungal • Cytology • Antibody testing (arboviral) • PCRs: enteroviral, West Nile virus,a herpesvirus types 1 and 2) • CSF lactate (posttrauma or neurosurgical)
  • 20.
  • 21. • A bloody tap will falsely elevate the CSF white cell count and protein. • To correct for a bloody tap, – subtract 1 white cell for every 700 red blood cells/mm3 – 0.1 g/dl of protein for every 1000 red blood cells.
  • 22. Question 1 Does all patients suspected with meningitis will need CT brain prior to LP and what are the reason(s)?
  • 23. • Abnormal CT scans were found in 56 of 301 (24%) subjects in a prospective study and were associated with – age older than 60 years, – immunocompromised states – recent seizure – focal neurologic deficits – or inability to follow two consecutive commands or questions correctly • The absence of these findings had a negative predictive value of 97%.
  • 24. Question 2 • Role of steroid in bacterial meningitis?
  • 25. • corticosteroids have been shown to reduce morbidity and mortality in children and also improve functional outcome when compared to placebo in adults. • Dexamethasone 10 mg IV 6 hourly x 4/7 – at the time of or immediately before the first dose of antibiotics • studies have only demonstrated the benefit in higher-income countries.
  • 27. Radiological findings • may be normal • subtle hydrocephalus • hyperdensity around basal cisterns (especially in tuberculosis) • leptomeningeal enhancement • complications or sources of the meningitis
  • 28. A: cerebral oedema B: complete effacement of the basal cisterns C: communicating hydrocephalus D: subdural collection
  • 29. • hydrocephalus • subdural empyema • epidural empyema • cerebritis and cerebral abscess • infarction • ventriculitis • dural sinus thrombosis
  • 30. SYSTEMIC COMPLICATIONS • Hypotension, septic shock and adult respiratory distress syndrome • Hyponatraemia/Hyper natraemia • Arthritis If gcs drop: • Cerebral oedema • Hydrocephalus • Cerebral infarction • Seizures
  • 31.
  • 32.
  • 33.
  • 35. • diagnosis that should only be made if there is tissue confirmation • in practice: – febrile illness, severe headache reduced consciousness – surrogate markers of brain inflammation Encephalitis
  • 38. • HSV- brain parenchyma in the temporal lobes, sometimes with frontal or parietal involvement. • Mumps virus - acute viral encephalitis, or a delayed immune mediated encephalitis. • Measles virus - post-infectious encephalitis, which can sometimes have a acute haemorrhagic leukoencephalitis. • Influenza A virus - diffuse cerebral oedema • Varicella zoster virus (VZV) -vasculitis
  • 41.
  • 42. • acute flu-like prodrome, fever, • severe headache • nausea, vomiting • altered consciousness • seizures • focal neurological signs Clinical presentations HSV-1 encephalitis • febrile (91%) • disorientation (76%) • speech disturbances (59%) • behavioural changes (41%) • seizures (33%) • Alterations in higher mental function
  • 43.
  • 44. History • from family members • rashes • travel history • occupation and recreational activities • risk factors for HIV
  • 45. Examinations • GCS • rashes, shingels, scar, bites, IVDU • sign of immunocompromised state • subtle seizure • meningism, and look for focal neurological signs • lower cranial neuropathies and myoclonus (rhomboencephalitis or basal meningoencephalitis)
  • 48. EEG • usually shows non-specific diffuse high amplitude slow waves of encephalopathy, • subtle epileptic seizures. • Periodic lateralised epileptiform (HSV encephalitis)
  • 49.
  • 50.
  • 51. References • Russell Bartt, Acute bacterial and Viral Meningitis, Continuum Lifelong Learning Neurol 2012;18(6):1255– 1270 • Ewout S Schut, Jan de Gans, Diederik van de Beek, Community-acquired bacterial meningitis in adults, Pract Neurol 2008; 8: 8–23 • Tom Solomon, Ian J Hart, Nicholas J Beeching, Pract Neurol 2007; 7: 288–305