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APPROACH TO MENINGITIS
Brain
abscess
Meningitis
Associated with
seizures and focal
neurological
symptoms
Encephalitis
Neoplasm
Associated with
seizures and
altered mental
status
Associated with
seizures and focal
neurological
symptoms
Non infective
causes:
SLE
Associated with
other features of
SLE
Features
Meningitis
Bacterial
-headache
-fever
-altered mental status
-ACUTE
-focal neurological
symptoms
-other symptoms like
SEPTICEMIA, JOINT
PAINS AND RASHES
Viral
-headache
-fever
-meningismus
-SELF LIMITING
-sub acute
Tuberculosis
-headache
-LOW GRADE
fever
-CHRONIC
-progresses to
altered
sensorium
Fungal
-headache
-fever
-IMMUNO
COMPROMISED
Signs of meningismus
Kernig and Brudzinski signs
The classic Brudzinski sign refers to
spontaneous flexion of the hips during
attempted passive flexion of the neck.
Kernigs sign
hip and knee are flexed to a right angle
knee is slowly extended
the appearance of resistance or pain during
extension of the patient's knees beyond 135
degrees constitutes a positive Kernig's sign
Mechanism
protective reaction to prevent the pain or
spasm of the hamstring muscles induced by
stretch of the inflamed and hypersensitive
nerve roots
Brudzinksis sign
one hand behind the patient's head and the
other on chest in order to prevent the patient
from rising
Reflex flexion of the patient's hips and knees
after passive flexion of the neck constitutes a
positive Brudzinski sign
Mechanism
passive flexion of the neck stretches the nerve
roots through the inflamed meninges, leading
to pain and flexion movements of lower
extremities.
Clinical use ?
are not very sensitive
when absent, should not be inferred as there
is no evidence of meningitis.
high specificity
if Kernig's or Brudzinski's sign is present, there
is a high likelihood for meningitis.
Meningitis
inflammatory disease of the leptomeninges, and is
defined by an abnormal number of white blood cells in
the cerebrospinal fluid (CSF).
Risk factors
suppressed immune system
Not receiving mumps, Haemophilus influenzae type b, and
pneumococcal vaccines.
Age
Living and working with large groups of people (e.g., military
bases, child care facilities).
Contact with domestic animals (e.g., dairy farmers, ranchers)
and pregnant women acquire listeriosis.
Head injuries and brain surgery
Types of meningitis
Acute meningitis
Recurrent meningitis
Chronic meningitis
Causes
Bacteria
Community-acquired - S. pneumoniae, N. meningitidis, gp B streptococcus
Post-op or hospital acquired MRSA, Ps. Aeruginosa
H.influenzae common in children
In the very young and very old Listeria monocytogenes
Viruses
TB
Fungi
cryptococcus
Pathology
Bacteria in nasopharynx
Cross the endothelium
Resistant to phagocytosis in blood
Enters choroid plexus
Enter CSF and resist phagocytosis
Inflammatory reaction
Recurrent meningitis
Complications
Septic shock, including disseminated intravascular
coagulation (DIC)
Coma with loss of protective airway reflexes
Seizures, which occur in 30-40% of children and
20-30% of adults
Cerebral edema
Thwaites scoring
Prognosis
Systemic complications
Neurologic complications
impaired
In bacterial meningitis..
decreased level of consciousness on admission
onset of seizures within 24 h of admission,
signs of increased ICP,
young age (infancy) and age >50,
the presence of comorbid conditions including
shock and/or the need for mechanical ventilation,
delay in the initiation of treatment.
DecreasedCSF glucose concentration (<2.2
mmol/L [<40 mg/dL]) and markedly increased
CSF protein concentration (>3 g/L [> 300 mg/dL
Recap
Acute meningitis is commonly caused by
viruses and bacteria
Chronic meningitis - TB most commonly in
India
In HIV patients-Cryptococcus
Recurrent meningitis Mallorets
As in the case of
57 year old woman presented with history of high grade fever
for 2 months, intermittent holocranial headache for 2 months
and non projectile non bilious vomiting 5-10 minutes after
food for the past 2 months.
No h/o dizziness/blurring of vision/diplopia
No h/o seizure/stroke/syncope
O/E: concious, oriented, febrile
No pallor, icterus, clubbing, cyanosis, lymphadenopathy, pedal
edema
Neck stiffness present
Emperical antibiotics
Transfer to critical care facility
NO
YES
No other contraindications
for lumbar puncture
LUMBAR
PUNCTURE
CT Brain
NO mass, hydrocephalus
or any contraindications
for lumbar puncture
Blood studies
A complete blood count (CBC) with differential
Serum electrolytes, to determine SIADH
Serum glucose (which is compared with the CSF
glucose)
Blood urea nitrogen (BUN), creatinine and liver
profile
coagulation profile and platelet count to suspected
DIC or any liver problems
Lumbar puncture
This is performed immediately providing there
are no signs of raised intracranial pressure.
Video
ContraIndications for LP
1. Immunocompromised state
2. History of CNS disease (eg, mass lesion, stroke,
or focal infection)
3. Seizure within 1 week of presentation
4. Papilledema
5. Abnormal level of consciousness
6. Focal neurologic deficit (eg, dilated nonreactive
pupil, gaze palsy, or arm or leg drift)
Gram stain
Direct microscopy
Neisseria
meningitidis
Haemophilus
influenzae
Streptococcus
pneumoniae
Cryptococcus
neoformans
Culture
The utility of cultures is most evident when LP is delayed until
head imaging can rule out the risk of brain herniation, in
which cases antimicrobial therapy is rightfully initiated
before CSF samples can be obtained.
These cultures include the following:
Blood - 50% positive in meningitis caused by H influenzae, S
pneumoniae, or N meningitidis
Nasopharynx
Respiratory secretions
Urine
Skin lesions
Streptococcus pneumoniae
Niesseria meningtidis
Haemophilus influenzae
Our case..
Special tests
Latex agglutination or counter-immunoelectrophoresis (CIE) of blood, urine, and CSF
for specific bacterial antigens.
polymerase chain reaction [PCR] for the
diagnosis of herpes simplex virus (HSV)
meningitis.
CT