Noon conference

1. Noon Conference
Jackie Lemon, MD
4/11/2019

2. © 2016 Virginia Mason Medical Center
MRI w/w/o Contrast
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IMPRESSION:
1. Findings compatible with meningitis and possibly a
very thin subdural empyema around the left cerebral
hemisphere, likely secondary to the left-sided
mastoiditis.
2. Mild signal abnormalities in the anterolateral left
temporal lobe in the region of the gas bubble visible
on the prior CT, suspected to be cerebritis/early
brain abscess, although it is difficult to be confident
that the small hypointense structure is within the
brain rather than adjacent to it in the extra-axial
space.
3. Findings of ventriculitis without hydrocephalus.
4. No evidence of venous sinus thrombosis.

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Kohoot.it
https://create.kahoot.it/share/noon-
conference-april-2019/18e17f28-6c53-
4c97-a556-60522285dc8d
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Objectives
Review Bacterial Meningitis
- Kahoot Quiz & Take home points
- Useful UpToDate and MKSAP tables
- Review Questions

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Review
CSF Findings of Bacterial Meningitis vs Viral
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6. © 2016 Virginia Mason Medical Center
Review
Classic Triad of Bacterial Meningitis + other
notable signs
• Frequency: 36-51%, more common in elderly
• Pneumococcal meningitis vs. Meningococcal meningitis
(58% vs. 27%, p < 0.001)
• PE Signs:
– Fever, HA, Lethargy, N/V, Confusion, AMS
– Seizures, Obtundation, Focal Neurologic Symptoms
– Paralysis, Cognitive Impairment, Coma
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Review
Empiric Coverage
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8. © 2016 Virginia Mason Medical Center
Review
Empiric Coverage
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9. © 2016 Virginia Mason Medical Center
Review
When to LP vs CT?
- Concern for elevated ICP or CNS mass lesion.
- Ie, LP can lead to rapid decompression and subsequent
herniation
- FAILS
- Focal neuro deficits
- AMS
- Immunosuppressed
- Lesion (hx of mass, stroke, focal infection)
- Seizures
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MKSAP Questions
Q62
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MKSAP Questions
Q62 – Answer A
- Adjuvant Dexamethasone will improve outcomes in
patients with presumptive diagnosis of bacterial
meningitis due to Strep Pneumo
- Improvement in mortality from 34% to 14%
- Fewer short term neuro deficits and long term
hearing loss
- Give 15min before Abx
- Note: Treating increased ICP is most beneficial in
stuporous or comatose patients
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12. © 2016 Virginia Mason Medical Center
Take Home
Strep Pneumo & Steroids
– 1st dose: before or at 1st ABx dose
– Per Cochrane Review: Decrease in hearing loss
– May reduce: cerebral edema, increased ICP,
altered cerebral blood flow, cerebral vasculitis,
and neuronal injury by decreasing inflammatory
response, but does not reverse pretreatment
damage
– Addition of rifampin may be reasonable when
steroids given as vancomycin may not
adequately penetrate the central nervous
system when steroids are given to reduce
inflammation
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MKSAP Questions
Q25
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MKSAP Questions
Q25 – Answer A
- Apparently >50 is considered advanced age, so
you need Listeria coverage.
- 3rd gen Cephalosporin and Vanc will give you
coverage of Strep Pneumo and Neisseria
mengitides (80% of cases)
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15. © 2016 Virginia Mason Medical Center
MKSAP Questions
Q71
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16. © 2016 Virginia Mason Medical Center
MKSAP Questions
Q71 – Answer B
- Nosocomial Meningitis: Cover Gram Negatives
(Pseudomonas aeruginosa, Acinetobacter species,
and Enterobacteriaceae), Staph Aureus (aka
MRSA)
NSGY Related Meningitis
- Imaging: CT and MRI to assess for abscess or
mass affect
- Broader Abx coverage
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NEJM Knowledge+ Q
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A. EEG
B. CT Head Non-Contrast
C. Pneumococcal Urinary Antigen
D. MRI Brain
E. Lumbar Puncture

18. © 2016 Virginia Mason Medical Center
NEJM Knowledge+ Q
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A. EEG
B. CT Head Non-Contrast
C. Pneumococcal Urinary Antigen
D. MRI Brain
E. Lumbar Puncture

19. © 2016 Virginia Mason Medical Center
Sources
• MKSAP 17 Text and ID Questions
• MKSAP 18 Text
• NEJM Knowledge + Question Bank
• Dr. Shiels Noon Conference Slide Set
• Bacterial meningitis in adults, Dynamed. Updated 2019 Apr 04.
• Infectious Diseases Society of America (IDSA) guideline for
management of bacterial meningitis 2004.
• Clinical features and diagnosis of acute bacterial meningitis in
adults. UpToDate. Updated Aug 30 2018.
• Lancet Infect Dis 2016 Mar;16(3):339
• N Engl J Med 2004 Oct 28;351(18):1849
• Clin Infect Dis 2002 Jul 1;35(1):46
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20. © 2016 Virginia Mason Medical Center
Review
Duration of Treatment depends on pathogen
- H. influenzae - 7 days
- N. meningitidis - 7 days
- S. pneumoniae - 10-14 days
- S. agalactiae - 14-21 days
- aerobic gram-negative bacilli - 21 days
- L. monocytogenes - at least 21 days
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21. © 2016 Virginia Mason Medical Center
Kahoot Questions
1. Correct spelling of:
2. CSF: Opening Pressure
3. CSF: High WBC, Neutrophil
4. CSF: Gluc Low, Protein
5. Classic Triad
1. How often do you actually see this?
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22. © 2016 Virginia Mason Medical Center
Kahoot Questions
1. Nuchal Rigidity
1. Sen:
2. Spe:
3. Signs:
2. Petechia & palpable purpura: N.
men
3. Sz, Abscesses, FND: Listeria
4. Classic Triad: Strep Pneumo
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23. © 2016 Virginia Mason Medical Center
Kahoot Questions
1. Vaston Island: H Flu
1. Note: can still get the others in the
vaccinated population
2. Empiric: Immunocompetent, Strep
pneumo: CTX+Vanc+ Steroid
3. When Cefepime?
4. Empiric when need Listeria
Coverage: Add Ampicillin
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