Christina, Gifty , James & Jonathan

CAUSES:
Infective : bacteria, viruses, protozoa, parasites,
fungi
Non infective : malignancy, inflammatory(SLE,
sarcoidosis)

 Acute: symptoms

last for a few days

-bacterial
-viral
Subacute: symptoms last for few days to weeks
common etiologies- M.tuberculosis, C.neoformans,
T.pallidum
etc.
Chronic : symptoms for >4 weeks and persistent
inflammatory response in CSF

They are due to inflammatory mediators and not directly

due to infection
1. Meningeal signs: positive KERNIGS sign,
BRUDZINZKIS sign, NECK STIFFNESS (invariably
present in 50% patients and their absence does not
rule out meningitis)
2. Raised ICT signs: headache, projectile vomiting
3. Septic signs: fever, arthritis, rashes, shock,
tachycardia, tachypnoea

4. Focal or generalised seizures

5. confusion, delirium, coma, irritability
5. 10-20% cases have nerve palsy
6. Occasionally FOCAL NEUROLOGICAL
DEFICITS like visual field defects,
dysphasia and hemiparesis can occur

 Head

injury
Sinusitis, mastoiditis, otitis media
Immunosuppressed states
Diabetes mellitus
Pneumonia
Alcoholism
CSF shunts
Iatrogenic( after LP)

 55

year old Mrs.B presented with high grade intermittent

fever with chills and rigors for 1 week along with
holocranial and intermittent headache and non bilious,
projectile vomiting for 3 days. She also complained of clear
watery discharge from the nose. There was no history of
trauma to the nose.
O/E febrile 100F
BP 120/80
CNS: neck stiffness present
Brudzinski and kernigs positive.
reflexes are 3+

 WBC

total- 245000, neutrophils-76%

CSF:
WBC-8000/cumm, neutrophils: 90%
Glucose- 22
Protein- 240
Gram stain- gram positive cocci, pus cells
No AFB seen
MRI

brain- chronic infarct in ACA territory, small foci of

acute infarct in frontal region
Tortuous B/L optic nerve with perioptic halo
Defect in cribriform plate of ethmoid bone

44 year old Mrs. M presented with holocranial headache and

intermittent high grade fever with chills for 6 months. She had
associated vomiting on and off. She also complains of loss of
appetite and loss of weight of 30 kg in the past 6 months. She had
an episode of tonic posturing with associated loss of
consciousness and irrelevant speech.
O/E febrile

Pulse 99/min
BP 100/60
CNS: neck stiffness present

B/L rectus palsy

deep tendon reflexes 2+
other functions normal

 WBC total- 6090

CSF
Total WBC- 220/cumm, lymphocytes: 81%
Glucose- 46 mg/dl
Protein- 118.5 mg/dl
MRI brain showed multiple ring enhancing

lesions in B/L
cerebral and cerebellar hemispheres suggestive of
tuberculomas
MRI spine showed diffuse meningeal enhancement along
the cord. There is diffuse thickening of nerve roots of
cauda equina with nodularity

 27

year old Mrs. A presented with complaints of

headache for 1.5 months, fever for one month and
seizures for a week prior to admission. She had history
of vomiting
O/E afebrile
Pulse 112/min
Bp 140/70mmhg
All systemic examinations were normal

 WBC

total- 15000

CSF

Total WBC 12/cumm

Glucose: 27 mg/dl
Protein: 48.6 mg/dl
AFB

smear negative
MRI brain
Hyperintensities in cortical sulci, leptomeningeal enhancement. An

arachnoid cyst is seen in the left anterior middle cranial fossa

 Results

in a benign and self limiting illness requiring no

specific therapy

 The

condition occurs mainly in children and young adults

with acute onset of headache and irritability

Headache

is usually the most common symptom.

Characterized as frontal or retro orbital, may be associated
with photophobia

There

may be a high pyrexia

 Constitutional

symptomsmalaise, myalgia, anorexia, nausea and vomiting,

abdominal pain, diarrhea

Mild

lethargy or drowsiness

No

profound alterations is consciousness

No

seizures or focal neurologic signs or symptoms

 Using

CSF PCR, Culture, and serology specific viral cause

can be found in 75-90% of cases

Most

Common
-Enteroviruses(coxsackieviruses,echoviruses)
-Herpes Simplex Virus 2
-Arthropod borne viruses
-HIV

 Less

Common
-Varicella Zoster virus
-Epstein-Barr virus
-Lymphocytic choriomeningitis virus

 CSF

examination

PCR
Viral

culture
Serologic Studies

Lymphocytic pleocytosis: 25-500 cells/microlitre

Normal or raised proteins

Normal glucose
(Decreased glucose mumps, suggestive more of fungal or tuberculous meningitis)

Normal or mildly elevated CSF pressure

Organisms not seen on gram staining of CSF

PMNs dominate echovirus 9,EEE,mumps

Extremely important to verify that the patient has not received antibiotics prior to lumbar puncture,
as this picture can also be found in partially treated bacterial meningitis

 Single

most important method for diagnosing viral meningitis

Diagnostic

procedure of choice in enteroviral and HSV

infections of the CNS

More
Also

sensitive than viral cultures

useful for diagnosis of CNS infection caused by

Mycoplasma pneumoniae which can mimic viral meningitis

 Poor
Used

sensitivity

for samples other than CSF

throat swabs - enterovirus, mumps and adenoviruses
blood
- Arboviruses, enteroviruses
feces
- Enteroviruses and adenoviruses
urine
- Mumps, Cytomegalo virus

 diagnostic
Increased

tool for many arbovirus CNS infection

IgG index and presence of CSF IgM antibodies

The delay between onset of infection and the hosts generation of a virus
specific antibody response does not aid to acute diagnosis and management

 Complete

and differential blood count

LFT and RFT
ESR
Electrolytes
Creatine kinase
MRI,CT

not necessary in uncomplicated viral

meningitis

 Partially

treated bacterial meningitis

Early stages of meningitis caused by fungus or
Mycobacteria
Mycoplasma, Listeria, Brucella, Leptospira, Rickettsia
Meningitis secondary to non inflammatory diseases
including hypersensitivity meningitis, SLE

 Most

common cause of viral meningitis. >85% of the cases

Diagnosis CSF RT PCR
Common in summer months
P/E- hand-foot-mouth disease, herpangina, hemorrhagic
conjunctivitis
Treatment - supportive

 HSV

2
- more common in females
-second most common cause of acute viral meningitis
in adults
-most common cause of recurrent meningitis

VZV

concurrent chicken pox, shingles

EBV cannot be cultured from CSF
Mumps lifelong immunity once episode treated

Symptomatic treatment
Analgesics
Antipyretics
Antiemetic
Fluid balance

Oral/IV Acyclovir HSV,VZV,EBV

Vaccination is an effective preventive measure against developing

meningitis caused by poliovirus, mumps and measles infection

Bacterial

meningitis is an acute purulent infection

within the sub-arachnoid space.
Most common form of suppurative CNS infection

AGE OF ONSET

COMMON

LESS COMMON

Neonate

Gram negative bacilli

(E.coli, Proteus)
Group B Streptococci

Listeria monocytogenes

Pre-school child

Hemophilus influenza
Neisseria meningitides
Streptococcus pneumonia

Mycobacterium tuberculosis

Older child/ Adult

Neisseria meningitides
Streptococcus pneumonia

Listeria monocytogenes
Mycobacterium tuberculosis
Staphylococcus aureus
(skull fracture)
Hemophilus influenza

 Acute, fulminant

Classic

triad

illness, progresses rapidly

fever
headache

nuchal rigidity
Altered level of consciousness vary from lethargy to
coma
Nausea, vomiting, photophobia
Seizures

 Rash

- Diffuse erythematous maculopapular rash

Petechiae on the trunk, lower extremities, in mucous
membranes and conjunctiva
Recurrent fever, joint pains
Pneumococcal and Haemophilus meningitis :
there maybe an associated otitis media
Pneumococcal meningitis:
findings of pneumonia, especially in older
patients and alcoholics

 Meningeal

signs (positive Kernigs sign, Brudzinskis sign

and opisthotonus)
Raised intracranial pressure signs
Septic signs ( fever, arthritis, behavioural changes,
rashes, petechiae (meningococcus), shock, DIC,
tachycardia, tachypnoea)
Focal or generalised seizures

Meningeal signs 50% of patients ( absence does not rule out)

10-20% - cranial nerve palsy ( 4, 6, 7) occurs
Foacl neurological deficits visual field defects, dysphagia, hemiparesis can
occur

 Only investigation which

Other investigations

superiority in
ischemia

confirms diagnosis CSF analysis

blood culture
PCR
CSF latex agglutination test
limulus amebocyte lysate assay
IMAGING-CT, MRI;MRI preferreddemonstrating cerebral oedema and
petechial lesions if present biopsy

Headache, fever, +/- nuchal rigidity

Stabilize, initial tests blood culture, pcr,
throat swab
Drowsy, focal signs?
(possible mass lesion, hydrocephalus, cerebral
oedema
ye
s

no

Obtain blood culture and start

empirical antimicrobial
therapy
No other contraindication to
lumbar puncture

CT brain or MRI

Lumba
r
punctu

No mass lesion, hydrocephalus or other

contraindication to lumbar puncture

Observation
Opening pressure

Elevated

appearance

Turbid

White blood cells

100- 50,000 Increased, neutrophils predominate

Red blood cells

Absent in non-traumatic tap

Protein

Markedly increased

Glucose

Decreased

Grams stain

Positive in >60%

Culture

Positive in >80%

 Viral meningoencephalitis , especially HSV

Rickettsial disease
Focal suppurative CNS infections, including

subdural and

epidural empyema, brain abcess

Non infectious CNS disorderssubarachnoid haemorrhage
carcinomatous/ lymphomatous
meningitis
drug induced hypersemsitivity
meningitis
meningitis associated with
inflammatory
disorders like sarcoid, SLE

 Untreated

mortality of around 80%

Swift action parenteral benzylpenicillin immediately when
bacterial meningitis is suspected, hospital admission
Before CSF examination empirical therapy recommended
(unknown cause)
After CSF examination specific antimicrobial therapy (
known cause)
Adjunctive corticosteroid therapy
Increased ICP ( emergency) elevation of patients head,
intubation, hyperventilation and mannitol

 Medical

emergency
Antibiotic therapy to be started within an hour of
patients presentation to doctor
Empirical antimicrobial therapy is started in patients
suspected with bacterial meningitis before CSF gram
stain and culture results

Indication

Antibiotic

Preterm infants to infants < 1 month

Ampicillin + cefotaxime

Infants 1-3 months old

Ampicillin + cefotaxime or ceftriaxone

Immunocompetent children >3 mo and adults <55 yo

Cefatoxime, ceftriaxone or cefepime +

vancomycin

Adults >55 yo and adults of any age with alcoholism

Ampicillin + cefotaxime, ceftriaxone or cefepime

+ vancomycin

Hospital-acquired meningitis, post-traumatic or

postneurosurgery meningitis, neutropenic patients, or patients
with impaired cell-mediated immunity

Ampicillin + ceftazidime or meropenem +

vancomycin

 Doxicycline

is added during tick season to treat tickborne bacterial infections

Metronidazole in patients with otitis, sinusitis or
mastoiditis.

Organism

Antibiotic

Neisseria meningitides
penicillin-sensitive
penicillin-resistant

Penicillin G or ampicillin
Ceftriaxone or cefotaxime

Streptococcus pneumoniae
penicillin-sensitive
penicillin-intermediate
penicillin-resistant

Penicillin G
Ceftriaxone or cefotaxime or cefepime
(Ceftriaxone or cefotaxime or cefepime)
+ vancomycin

Gram-negative bacilli
(except Pseudomonas spp.)

Ceftriaxone or cefotaxime

Pseudomonas aeruginosa

Ceftazidime oe cefepime or meropenem

Organism

Antibiotic

Staphylococci spp.
Methicillin-sensitive
Methicillin-resistant

Nafcillin
Vancomycin

Listeria monocytogenes

Ampicillin + Gentamicin

Haemophilus influenzae

Ceftriaxone or cefotaxime or cefepime

Streptococcus agalactiae

Penicillin G or ampicillin

Bacteroides fragilis

Metronidazole

Fusobacterium spp.

Metronidazole

Risk of death increases with

Decreased level of consciousness on admission
Onset of seizures within 24 hours of admission
Signs of increased ICP
Infancy and age >50
Delay in initiation of treatment

Granulomatous Suppurative Infectious disease

Main organ affected Lungs

Causative agent - Mycobacterium Tuberculosis

Children - Most commonly affected (Can occur at any

age)
Sub-Acute or Chronic course

Early Symptoms:
Lack of interest
Malaise
Fever
Anorexia
Urinary Retention
Constipation
Late Symptoms and Signs:
SIADH
Seizures

* Increased ICP due to Hydrocephalus:

- Change in intellect
- Altered Consciousness
- Urinary incontinence
- Gait Ataxia
* Movement Disorders
- Chorea
- Hemiballismus
- Athetosis
-Generalized Tremors
- Myoclonic Jerks

* Cranial Nerve palsies: (Hemiparesis/Hemiplegia)

- Blindness
- Diplopia
- Facial Palsy
- Deafness
* Kernigs Sign
* Brudzinskis Sign

 Pyogenic

meningits

Cryptococcal
Syphilitic

Meningitis

Meningitis

Neoplastic

Meningitis

 Caused

by Mycobacterium Meningitis

Occurs

as a part of widespread haematogenous spread

of mycobacteria in children.

Mostly

it occurs by re activation of a subpial focus of a

dormant lesion(Richs Focus)

Sub-Arachnoid space throughout the CNS is involved

Thick exudates cover the base of the brain
Blood vessels show inflammatory changes at the their
base
Exudates may block the foramina of Luschka and
Magendie Non communicating Hydrocephalus

CT Scan and MRI :

- Hydrocephalus
- Cerebral Infarcts
CSF Analysis :
- Pressure ^^
- Protein ^^ (100-800 mg/dl)
- Sugar decreased by 40%
- Cell counts elevated (Lymphocytic
- Cobweb formed CSF stands
- ADA levels elevated

VARIABLE

CUT OFF

AGE

>=23 YRS

+2

< 23 YRS

>=9000/cumm

+4

<9000/cumm

>= 14DAYS

-5

<14 DAYS

>=300

+3

<300

>=22%

+4

PERIPHERAL WHITE BLOOD

CELLS
PRODROME DURATION
CSF LEUCOCYTES
CSF NEUTROPHIL
PROPORTION

<22%

COUNT

SCORE0<= 4 TBM
SCORE>4
CONSIDER OTHERS

* Favoring Tb Meningitis:

Duration of illness > 5 Days

Headache +
CSF WBC count < 1000/mm3
Clear appearance of CSF
CSF lymphocyte count > 30%
CSF Protein content > 100 mg/dl

Anti Tb Chemotherapy:

Early Phase 1-2 Months (Intensive Therapy)

- Rifampicin
- Isoniazid
- Pyrazinamide
- Streptomycin
Late Phase 3-9 months
- Rifampicin
- Isoniazid

+ Prednisolone 40mg/day (Meningeal Adhesions & Arteritis)

If treatment is instituted before neurological deficits appear,

recovery may be complete.
Presence of focal defecits and change in consciousness before
therapy predict poor outcome.
Residual deficits
Dementia
Blindness
Deafness
Epilepsy
Hemiparesis
Paraparesis

 55

year old Mrs.B presented with high grade

intermittent fever with chills and rigors for 1 week along
with holocranial and intermittent headache and non
bilious, projectile vomiting for 3 days. She also
complained of clear watery discharge from the nose.
There was no history of trauma to the nose.
O/E febrile 100F
BP 120/80
CNS: neck stiffness present
Brudzinski and kernigs positive.
reflexes are 3+

 WBC

total- 245000, neutrophils-76%

CSF:
WBC-8000/cumm, neutrophils: 90%
Glucose- 22
Protein- 240
Gram stain- gram positive cocci, pus cells
No AFB seen
MRI

brain- chronic infarct in ACA territory, small foci of

acute infarct in frontal region
Tortuous B/L optic nerve with perioptic halo
Defect in cribriform plate of ethmoid bone

 44

year old Mrs. M presented with holocranial headache

and intermittent high grade fever with chills for 6 months.
She had associated vomiting on and off. She also complains
of loss of appetite and loss of weight of 30 kg in the past 6
months. She had an episode of tonic posturing with
associated loss of consciousness and irrelevant speech.
O/E febrile
Pulse 99/min
BP 100/60
CNS: neck stiffness present

B/L rectus palsy

deep tendon reflexes 2+
other functions normal

WBC total- 6090

CSF

Total WBC- 220/cumm, lymphocytes: 81%

Glucose- 46 mg/dl
Protein- 118.5 mg/dl
MRI

brain showed multiple ring enhancing lesions in

B/L cerebral and cerebellar hemispheres suggestive
of tuberculomas
MRI spine showed diffuse meningeal enhancement
along the cord. There is diffuse thickening of nerve

 27

year old Mrs. A presented with complaints of

headache for 1.5 months, fever for one month and
seizures for a week prior to admission. She had history
of vomiting
O/E afebrile
Pulse 112/min
Bp 140/70mmhg
All systemic examinations were normal

 WBC

total- 15000

CSF

Total WBC 12/cumm

Glucose: 27 mg/dl
Protein: 48.6 mg/dl
AFB

smear negative
MRI brain
Hyperintensities in cortical sulci, leptomeningeal enhancement. An

arachnoid cyst is seen in the left anterior middle cranial fossa

Pressure (mm
H2O)
80-200

WBC
(cells per
cumm)
1-3

Total
protein
(mg %)

Sugar
(mg %)

30-45

40-80

Microbiology

Acute pyogenic
meningitis

200-300

1000-20000

100-600

10-20

Gram staining,
Cultures

Tuberculous meningitis

180-300

50-500

80-120

30-50

Ziehl Neelsen
staining, Cultures

Viral meningitis

90-200

10-500

60-80

normal

Viral isolation,
PCR