APPROACH TO A PATIENT WITH MENINGITIS Presented By Dr.EHTISHAM PGT MU-1 What is Meningitis: Meningitis is an inflammation of the meniniges,the lining that protects the brain and spinal cord. Causes: Infective • Non-Infective • Bacterial 1. Malignant • Viral Leukaemia • Fungal Lymphoma • Protozoal and 2. Inflammatory other Parasites SLE Sarcoidosis 1. BACTERIAL NEONATES Gram -ve bacilli Group B streptococci (1 Month) Listeria Monocytogenes PRE-SCHOOL CHILD H.Influenze Neisseria meningitides (1 Month -6 Years) Streptococcus pneumoniae Mycobacterium tuberclosis OLDER CHILD & ADULTS Neisseria meningitides Streptococcus pneumoniae Listeria Monocytogenes Mycobacterium tuberclosis H.Influenze 2. Viruses Herpes simplex Mumps Influenza HIV Varicella zoster Epstein-Barr 3. PROTOZOAL + other parasites Toxoplasma Amoeba Cysticercus 4. FUNGI Cryptococcus neuformans Candidiasis Histoplasma Blastomytes Brucella Bacterial meningitis Common medical emergency. Can occur for a number of reasons. as a result of infection by bacteria that already live in the nose and mouth,enters the blood n become lodged in meninges or mayb caused by the spread of an infection occuring near the brain,such as from ears or sinuses. or occurs as a complication of brain,head or neck surgery. RISK FACTORS Adults older than 65 years Children younger than 5 years Person with alcoholism Cancer patient esp those receiving chemotherapy Diabetic patient Those recently exposed to meningitis at home IV drug users People who have received transplants PRESENTATION OF A PATIENT CLASSIC SYMPTOMS; Headache Vomiting Fever Stiff neck Confusion Photophobia Seizures Contnd……. Recent upper respiratory infection(cold,sore throat) Any change in persons thinking like unusually sleepy, acting goofy, talking nonsense. LESS COMMON SYMPTOMS: A rash that looks like a bruise Localized weakness or loss of sensation especially in the face. Joint swelling and pain in one or more On examination: Neck rigidity Kerning’s sign Flex the hip at 90 degree and when the knees are passively extended, patient feels pain due to spasm of hamstrings. Brudzinki’s sign Forward flexion of the neck may cause involuntary knee and hip flexion. Rash 50% patients with meningococcemia purpuric rash develops mainly on extremities Meningococcal septicemia A more severe but less common form of meningococcal disease is meningococcal septicemia, which is characterized by rapid circulatory collapse and a hemorrhagic rash. TUBERCULOUS MENINGITIS Patient presents with: Headache Vomiting Fever Confusion Behaviour changes On EXAMINATION: Neck stiffness Cranial nerve palsy (usually oculomotor) Hemiplagia Coma Opthalmoscopy may reveal papilloedema VIRAL MENINGITIS Determining how many people get viral meningitis is difficult because it often remains undiagnosed and is easily confused with the FLU. The prognosis of viral meningits is much better than that for bacterial meningitis with most people recovering completely with simple treatment of the symptoms. FUNGAL MENINGITIS • This form of meningitis is rare in healthy people but those who have AIDS are at higher risk Complications 1) NEUROLOGICAL; Cranial nerve palsies Seizures Encephalopathy Deafness Blindness Obstructive hydrocephalus Behaviour disturbances Mental retardation Continued………. 2) Septic arthritis 3) Syndrome of inappropriate ADH secretion 4) Septicemia,DIC,shock Investigations: Blood cp Serum urea, creatinine and electrolytes LP CT Scan of brain to exclude mass lesion Chest X-ray (mostly shows features of TB or pneumonia) Lumbar puncture Before LP, fundus should always be checked for papilledema. LP needle is inserted between L3- L4. • CONTRA INDICATIONS FOR LP; Inc ICP Bleeding disorder CSF FINDINGS IN Conditio Cell MENINGITIS Cell Glucos Protein Gram n Type - e Stain Coun t Normal Lymphocyt 0- 60% of Upto -ve es 4mm3 blood 45mg /dl glucose viral Lymphocyt 10- Normal Normal -ve es 2000 Bacterial Polymorphs 1000- Elevated +ve 5000 Tuberculou Polymorphs 50- Elevated -ve s / 5000 Lymphocyt es / mixed Management Treatment of pyogenic meningitis of unknown cause 1) Patients with typical meningococcal rash Benzyl penicillin 2.4g iv 6 hrly 2) Adults aged 18-50 years without rash. Ceftriaxone or cefotaxime Treatment of bacterial meningitis when cause is known PATHOGEN DRUG OF CHOICE Meningococcus Benzyl Penicillin Strep.pneumoniae Sensitive to Beta- Ceftriaxone Lactams Ceftriaxone + Resistant to Beta- Vancomycin or Lactums Rifampicin H.Influenza Ceftriaxone Listeria Ampicillin +gentamicin Gram –ve bacilli Ceftriaxone Duration of therapy ORGANISM DURATION Meningococcus 7 days Strep.pneumoniae 10-14 days H.Influenza 7-10 days Gram –ve bacilli 3 weeks Adjunctive therapy To reduce Cerebral edema and raised ICP: • Steroids Mannitol For seizures • Diazepam • Phenytoin Prophylaxis of Meningococcal infection Given to close contacts of patients. 2-day course of rifampicin 600mg 12hrly. Single dose of ciprofloxacin 500mg. Vaccination Vaccines available for H.Influenza type B Strep.pneumoniae N.meningitides Treatment for Tubuerculous meningitis 1. ATT Duration of therapy is 12 months. 4 drugs for the initial 2 months. ISONIAZID,RIFAMPICIN, PYRAZINAMIDE,ETHAMBUTOL 3 drugs for the next 10 months. ISONIAZID,RIFAMPICIN, ETAHMBUTOL 2. Steroids 3. Surgical Ventricular Drainage If obstructive hydrocephalus Treatment for viral meningitis No specific treatment Bed rest Analgesics Maintenance of water electrolyte balance Treatment for Fungal meningitis Antifungals Analgesics Maintenance of water electrolyte balance Prognosis Nearly all people with viral meningitis and 70 to 80 percent of people with bacterial meningitis will recover, although that varies by age and health of the patient. Among those who recovers meningitis can result in permanent deficit.e.g deafness, blindness. Multiple choice questions QUESTION NO 1; • A 63 year old man presents with headache and pyrexia.LP suggests tuberculous meningitis. • What treatment should he be started on? • A- Rifampicin, Isoniazid, Pyrazinamide,Ethambutol • B- Rifampicin, Streptomycin • C- Rifampicin, Isoniazid Prednisolone • D- Rifampicin, Isoniazid, Ethambutol , Pyrazinamide,Prednisolone Question no 2; • A 74 year old female presents with headache,neck stiffness.following LP pt.was started on iv ceftriaxone.CSF culture shows LISTERIA.What is the most appropriate treatment? • A- Add iv ampicillin • B- Change to iv ampicillin and gentamicin • C- Add iv ciprofloxacin • D- Continue iv ceftiaxone QUESTION NO 3; • A patient presents with gradual onset of head ache,neck stiffness,photophobia,fluctuating concious level.CSF shows lymphocytosis but no organism on gram staining.CT san of brain is normal.what could be the causative organism? • A- E-coli • B- Staph aureus QUESTION NO 4; • A 19 years old man presents with two day H/O diffuse head ache n sore throat.He is pyrexial and is reluctant to have a fundoscopy due to photophobia.Serum Glucose 5.9mmol/L. • LP reveals appearance is clear. glucose 4.1mmol/L,protein 0.3g/L,lymphocytes are 2/mm cube.what is the most likely diagnosis? • A- Normal CSF result • B- Bacterial meningitis THANKYOU!