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					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!

				
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