MENINGITIS

MA. CATHERINE N. NAPOLIS

 MENINGITIS
-inflammatory response of the leptomeninges
and CSF-filled subarachnoid space usually
caused by infection.

Recall: Protective connective

tissue coverings that encircle the
spinal cord and brain.
(1) dura mater
(2) arachnoid mater
(3) pia mater
Principal Routes of Microbial Entry in Central Nervous System

Pathogen

Hematogenous Peripheral Nervous

Spread
-Most common
-Arterial circulation
-Retrograde Venous
spread (anastomose with
veins of face)
Direct implantation Local Extension
System
-Congenital malformation -can originate from
-Readily accessible infected adjacent Example: Rabies
structures (i.e. sinuses,
teeth, skull, vertebrae)

Damage to Nervous System

§ Injury of neurons or glia (direct)

§ Microbial toxins (indirect)
§ Destrcutive effects of inflammatory response
§ Immune mediated mechanisms
MENINGITIS
Classification:
1. Acute Pyogenic Meningitis- Bacterial
2. Aseptic Meningitis- Acute/Subacute Viral
3. Chronic Meningitis- Tuberculous, Spirochetal, Cryptococcal
BACTERIAL/ ACUTE PYOGENIC
MENINGITIS
DEFINITION
o Acute purulent infection within the SAS
o Associated with CNS inflammatory reaction that
may result to:

§ Decreased consiousness § Seizures

§ Headache § Raised ICP
§ Neck stiffness § Stroke
§ Photophobia § Irritability

Thick layer of suppurative exudate covers the brainstem and cerebellum

EPIDEMIOLOGY

§ Most common form of suppurative CNS infection

Community-Acquired Bacterial Meningitis

Streptococcus pneumoniae (50%)
Adults
Listeria monocytogenes (10%)
Neisseria meningitidis (25%) Adolescents and young adults
Streptococcus agalactiae (15%)
Neonates
Haemophilus influenzae (<10%)
cause of recurring epidemics of meningitis every 8-12 years
ETIOLOGY
v Streptococcus pneumoniae
§ Most common cause of meningitis in adults >20 y/o
§ Mortality rate: 20%
§ Risk factors:
ü Pneumococcal Pneumonia ü Splenectomy
ü Acute chronic sinusitis ü Hypogammablobulinemia
ü Otitis media ü Complement deficiency
ü Alcoholism ü Head trauma w/ skull fracture
ü Diabetes ü CSF rhinorrhea
ETIOLOGY

vNeisseria meningitidis
§ incidence has ↓ with routine immunization
Ø 11-18 y/o with quadrivalent meningococcal glycoconjugate vaccine
§ petechial or purpuric skin lesion
§ can progress to death w/in hours of symptom onset
§ through nasopharyngeal colonization
§ can be asymptomatic (carrier state) or invasive meningococcal disease
ETIOLOGY

v Gram-negative Bacilli

§ cause meningitis in individuals with chronic and debilitating diseases:

ü diabetes
ü cirrhosis
ü alcoholism
ü chronic urinary tract infections

§ can complicate neurosurgical procedures (craniotomy) and head trauma associated

with CSF rhinorrhea or otorrhea.
ETIOLOGY

v Streptococcus agalactiae
q responsible for meningitis predominantly in neonates

q has been reported with increasing frequency in individuals aged >50

years, particularly those with underlying diseases.

vListeria monocytogenes
q increasingly important cause of meningitis in neonates (<1 month of age), pregnant women,
individuals >60 years, and immunocompromised individuals of all ages

§ ingesting foods contaminated by Listeria

§ contaminated coleslaw, milk, soft cheeses, and several types of “ready-to-eat”

foods, including delicatessen meat and uncooked hotdogs
ETIOLOGY
S. aureus and coagulase-negative Staphylococci
qimportant cause of meningitis that occurs following invasive
neurosurgical procedure

§ shunting procedures for hydrocephalus

§ complication of the use of subcutaneous Ommaya
reservoirs for administration of intrathecal chemotherapy
PATHOPHYSIOLOGY
CLINICAL PRESENTATION
q can progresses rapidly in a few hours or as a subacute infection that
progressively worsens over several days.

q clinical triad of meningitis:

ü fever
ü headache
ü nuchal rigidity pathognomonic sign of neck resists
meningeal irritation passive flexion
Note: Classic triad may not be present

q A decreased level of consciousness occurs in >75% of patients

and can vary from lethargy to coma.

q Other common complaints: fever, vomiting, nausea, photophobia

CLINICAL PRESENTATION

qKernig's sign

elicited with the patient in the supine position Thigh is flexed on the abdomen attempt to passively extend the knee elicit pain when
meningeal irritation is present
 CLINICAL PRESENTATION
qBrudzinski’s sign

Elicited with the patient in the supine position and is positive when passive flexion of the neck results in
spontaneous flexion of the hips and knees
CLINICAL PRESENTATION
q Seizures
§ part of the initial presentation of bacterial meningitis or during the course of the
illness in 20–40% of patients

qRaised ICP
§ expected complication and the major cause of obtundation and coma in this
disease.

Signs of increased ICP:

§ deteriorating or reduced level of consciousness
§ papilledema
§ dilated poorly reactive pupils
§ sixth nerve palsies
§ decerebrate posturing
§ Cushing reflex (bradycardia, hypertension, and irregular respirations)
DIAGNOSIS
CSF EXAMINATION

Spinal tap (lumbar puncture)

§ a local anesthetic is given, and a long hollow needle is inserted into the subarachnoid
space to withdraw cerebrospinal fluid (CSF)

§ the patient lies on his or her side with the vertebral column flexed.
Ø Flexion of the vertebral column increases the distance between the spinous processes of
the vertebrae, which allows easy access to the subarachnoid space.

§ performed in adults between the L3 and L4 or L4 and L5 lumbar vertebrae

Ø because this region provides safe access to the subarachnoid space without the risk of
damaging the spinal cord.

§ A line drawn across the highest points of the iliac crests, called the supracristal line, passes through the
spinous process of the fourth lumbar vertebra and is used as a landmark for administering a spinal tap
DIAGNOSIS
DIAGNOSIS
CSF EXAMINATION

(1) xanthochromic CSF; indicating the previous

presence of blood; (2) clear CSF; and (3) cloudy CSF.
Cloudy CSF is presumptive evidence of meningitis
CSF (CEREBROSPINAL FLUID)

• CLEAR, COLORLESS fluid

• Isotonic with serum (290–295 mOsm/L).
• The pH of CSF is 7.33 (arterial blood pH, 7.40; venous blood pH, 7.36).
• Sodium ion (Na+) concentration is equal in serum and CSF (≈138 mEq/L).
• Higher concentration of chloride (Cl–) and magnesium (Mg2+) ions than does serum.
• Lower concentration of potassium (K+), calcium (Ca2+), bicarbonate (HCO3—) ions
and glucose than does serum.
• concentration of protein (including all immunoglobulins) is much lower in the CSF as
compared with serum. Increased protein levels may indicate a CNS tumor.
• Presence of a FEW monocytes or lymphocytes (0 to 4 lymphocytes or mononuclear
cells per cubic millimeter), the presence of polymorphonuclear leukocytes is always
abnormal, as in bacterial meningitis.
DIAGNOSIS
§ blood cultures
§ neuroimaging studies (CT or MRI)
§ MRI is preferred over CT because of its superiority in demonstrating areas of cerebral
edema and ischemia.
§ latex agglutination (LA) test
§ detection of bacterial antigens of S. pneumoniae, N. meningitidis,
H. influenzae type b, group B Streptococcus, and E. coli K1 strains
§ specificity of 95–100% for S. pneumoniae and N. meningitidis
§ sensitivity of the CSF LA test is only 70–100% for detection of S. pneumoniae and 33–70%
for detection of N. meningitidis antigens, so a negative test does not exclude infection by
these organisms.
§ Limulus amebocyte lysate assay
§ gram-negative bacterial meningitis
TREATMENT