Evauation of Meningitis and Management. Dr. K. Prashanth kumar Consultant Physician Oxygen hospitals , Vikrampuri. Evauation of Meningitis and Management. Dr. K. Prashanth kumar Consultant Physician Oxygen hospitals , Vikrampuri. What is meningitis? …….
Evauation of Meningitis and
Dr. K. Prashanthkumar
Oxygen hospitals , Vikrampuri.
Dr. K. Prashanthkumar
Oxygen hospitals , Vikrampuri.
1-the pia mater (closest to the CNS)
2-the arachnoid mater
3-the dura mater (farthest from the CNS).
The meninges contain cerebrospinal fluid (CSF).
Meningitis is an inflammation of the meninges, which, if severe, may become encephalitis, an inflammation of the brain.
-Trauma to head or spine.
Potentially life threatening disease.
One million cases per year world wide. 200,000 die annually.
Can affect all age groups but some are at higher risk.
Treatment available : antibiotics as per causative organism
Humans are the reservoir .
Pneumococcal meningitis is the most common type. Approximately 6,000 cases/yr
Haemophilus meningitis: Since 1985 Incidence has declined by 95% due to the introduction of Haemophilus influenza b vaccine.
Other bacterial meningitis caused by E-Coli K-1, Klebsiella species and Enterobacter species are less common overall, but may be more prevalent in newborns, pregnant women, the elderly and immunocompromised hosts.
Etiological Agent: Neisseria meningitidis
Clinical Features: sudden onset. F,H,N,V
Reservoir: Humans only. 5-15% healthy carriers
Mode of transmission: direct contact with patients oral or nasal secretions. Saliva.
Incubation period: 1-10 days. Usually 2-4 days
Infectious period: as long as meningococci are present in oral secretions or until 24 hrs of effective antibiotic therapy
Sporadic cases worldwide.
Meningitis belt sub-Saharan Africa into India/Nepal.
In US most cases seen during late winter and early spring.
Children under five and adolescent most susceptible. Overcrowding e.g. dormitories and military training camps predispose to spread of infection.
Definition: A syndrome characterized by acute onset of meningeal symptoms, fever, and cerebrospinal fluid pleocytosis, with bacteriologically sterile cultures.
Laboratory criteria for diagnosis:
CSF showing 5 WBC/cu mm
No evidence of bacterial or fungal meningitis.
Confirmed: a clinically compatible illness diagnosed by a physician as aseptic meningitis, with no laboratory evidence of bacterial or fungal meningitis
Aseptic meningitis is a syndrome of multiple etiologies, but most cases are caused by a viral agent
Enteroviruses (Coxsackie's and echovirus): most common.
-Herpes Simplex Virus
-Humans for Enteroviruses, Adenovirus, Measles, Herpes Simplex, and Varicella
-Natural reservoir for arbovirus birds, rodents etc.
Modes of transmission:
-Primarily person to person and arthopod vectors for Arboviruses
-Variable. For enteroviruses 3-6 days, for arboviruses 2-15 days
Treatment: No specific treatment available.
Most patients recover completely on their own.
Types:62 different types known:
-23 Coxsackie A viruses,
-6 Coxsackie B viruses,
-28 echoviruses, and 5 other
-90% of all viral meningitis is caused by Enteroviruses
-Second only to "common cold" viruses, the rhinoviruses.
-Estimated 10-15 million/ more symptomatic infections/yr in US
Who is at risk?Everyone.
How does infection spread?Virus present in the respiratory secretions & stool of a patient.
Direct contact with secretions from an infected person.
Parents, teachers, and child care center workers may also become infected by contamination of the hands with stool.
When bacteria cause disease i.e. meningococcal disease the body can be affected in different ways:
Meningitis - bacteria enter the blood stream and travel to the meninges and cause inflammation.
Septicaemia - when bacteria are present in the blood stream they can multiply rapidly and release toxins that poison the blood. (The rash associated with meningitis is due to septicaemia.)
Meningitis and septicaemia often occur together.
Meningitis and meningococcal septicaemia may not always be easy to detect, in early stages the symptoms can be similar to flu. They may develop over one or two days, but sometimes develop in a matter of hours.It is important to remember that symptoms do not appear in any particular order and some may not appear at all.
:Babies and Young Children
-High temperature, fever, possibly with cold hands and feet
-Vomiting or refusing feeds
-High pitched moaning, whimpering cry
-Blank, staring expression
-Pale, blotchy complexion
-Baby may be floppy, may dislike being handled, be fretful
-Difficult to wake or lethargic
-The fontanelle (soft spot on babies heads) may be tense or bulging.
-High temperature, fever, possibly with cold hands and feet.
-Vomiting, sometimes diarrhoea.
-Joint or muscle pains, sometimes stomach cramps.
-Neck stiffness (unable to touch the chin to the chest)
-Dislike of bright lights.
The patient may be confused or disorientated. Fitting may also be seen.
A rash may develop.
One of the physically demonstrable symptoms of meningitis is Kernig's sign. Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees.
Another physically demonstrable symptoms of meningitis is Brudzinski's sign. Severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed.
In the early stages, signs and symptoms can be similar to many other more common illnesses, for example flu. Early symptoms can include fever, headache, nausea (feeling sick), vomiting and general tiredness.
The common signs and symptoms of meningitis and septicaemia are shown above. Others can include rapid breathing, diarrhoea and stomach cramps. In babies, check if the soft spot (fontanelle) on the top of the head is tense or bulging.
One sign of meningococcal septicemia is a rash that does not fade under pressure (see Glass test)
-This rash is caused by blood leaking under the skin. It starts anywhere on the body. It can spread quickly to look like fresh bruises.
-This rash is more difficult to see on darker skin. Look on the paler areas of the skin and under the eyelids.
A rash that does not fade under pressure will still be visible when the side of a clear drinking glass is pressed firmly against the skin.
If someone is ill or obviously getting worse, do not wait for a rash. It may appear late or not at all.
A fever with a rash that does not fade under pressure is a medical emergency.
Be aware, be prepared
Meningitis and meningococcal septicaemia (blood poisoning) are serious diseases that can affect anyone at any time. Teenagers and studentsin particular, are at increased risk.Most young people in the UK have already had the MenC vaccine. If you havent or cant remember, gettingvaccinated now is a good way to protect yourself.
But remember, vaccines cant preventall forms of meningitis and septicaemia.So it is very important that you are aware of the signs and symptoms so that you can get medical help urgently if you become ill.
-Timely reporting and records keeping
-Updating information daily.
-Alleviating public anxiety and concerns
-Collaborating with health partners
Etiology - in Adults
Opening pressure>180 mmH2OWhite blood cells10/ L to 10,000/ L; neutrophils predominate Red blood cells Absent in no traumatic tap Glucose <2.2 mmol/L (<40 mg/dL)CSF/serum glucose <0.4Protein>0.45 g/L (>45 mg/dL)
Gram's stain Positive in >60%CulturePositive in >80%
Latex agglutination May be positive in patients with meningitis due to S. pneumoniae, N. meningitidis, H. influenzae type b, E. coli, group B streptococci
Limulus lysate positive in cases of gram-negative meningitis PCR Detects bacterial DNA
One of the most common problems resulting from meningitis is hearing loss.Anyone who has had meningitis should take a hearing test.
Use of bactericidal agents
Choice of agent
Treatment - Empiric
Enteric Gram negative rods
A spectacular reduction in H. influenzae meningitis has been associated with the near universal use of a vaccine against this organism in developed countries since 1987
Dexamethasone as adjunctive therapy in bacterial meningitis. A meta-analysis of randomized clinical trials since 1988. JAMA 1997; 278:925
Guidelines for the use of systemic glucocorticoids in the management of selected infections.
J Infect Dis 1992; 165:1
Spectrum of complications during bacterial meningitis in adults. Results of a prospective clinical study. Arch Neurol 1993; 50:575
Acute bacterial meningitis in adults.
N Engl J Med 1993; 328:21.
Birth - 4 wks: GBS, E.coli
Newborn & Infants: non-specific
Waterhouse-Friderichsen syndrome: massive haemorrhage of adrenal glands secondary to sepsis: adrenal crisis-low B.P, shock, DIC, purpura, adreno-cortical insufficiency
Bacterial Viral TB
Cells10-100,000 <2,000 250-500
Glucoselow normal very low
ProteinN-INC N-INC N-INC
G-Staingen +ve -ve +ve Zn
Early diagnosis essential
Less than 2 months of age:
Over 2 months:
Children 5mg/kg bd x 2/7
Adults: 600 mg bd x 2/7
Cefuroxime IM x 1 dose
Just do T/S and await result
Onset of Petechiae within 12 hrs
Absence of meningitis
Shock (BP 70 or less)
Normal or low WCC
Normal or low ESR