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Meningitis

Meningitis. `acute infection of the CNS The clinical syndrom : Bacterial meningitis Viral minigitis Encephalitis Brain abscess. Meningitis : Acute infection within the subarchanoid space. Bacterial Meningitis: Bacterial meningitis reflects infection of the arachnoid

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Meningitis

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  1. Meningitis • `acute infection of the CNS • The clinical syndrom: • Bacterial meningitis • Viral minigitis • Encephalitis • Brain abscess

  2. Meningitis: • Acute infection within the subarchanoid space. • Bacterial Meningitis: • Bacterial meningitis reflects infection of the arachnoid mater and the CSF in both the subarachnoid space and the cerebral ventricles

  3. Bacterial meningitis is Medical emergency • The mortality rate of untreated disease approaches 100 percent

  4. Case scenario • 26 yrs old female presented to private : • C/O :earache and eventually ended with • Ventilator dependent quadriplegia

  5. March 13 :Ist visit to private doctor • C/O: earache • Dx : Otitis media • RX : Cipro • March 16: 2nd visit to another physician: • Headache , neck pain , fever and vomiting • DX :Gastroenteritis • RX: Phenergan

  6. March 16 , 9pm : To Emergency deptc/o confusion and inability to follow commands Exam: Fever , stiff neck DX: Meningitis VS Phenergan side effect Action : CT-scan brain…CT-scan is normal---- CSF study : Result? What do you think ? Normal or abnormal

  7. Cloudy , • Cells : WBC >6000 mainly polys. • Gram stain : Gram positive dipplococci • Action (2hrs from start ) : Cefitriaxone 2gm BID What happen

  8. Patient deteriorated and connected to ventilator after developing quadriplegia. • Q:How do you assesss the management : A) Well managed from the start b) The first private doctor had done a mistake c)The 2nd private physician is ignorant d) The ER doctor has the job very well 100% e) All are bad doctors ?

  9. Clues to DX • Clues in the patient's clinical history ? • What are these ? • Symtoms : • Contacts • Travel • Surgery • Discharging ear • URTI

  10. Symptoms of fever, altered mental status, headache, and nuchal rigidity • one or more of these findings are absent in many patients with bacterial meningitis

  11. fever, neck stiffness, and altered mental status • Triad : 99 to 100 percent have at least one • Almost no patients have a normal temperature • Fever ..95 percent • Nuchal rigidity …88 percent • Mental status is altered in…78 percent

  12. GENERAL PRINCIPLES OF THERAPY • Avoidance of delay • Effects of delay: • ■In a prospective study of 156 patients with pneumococcal meningitis, a delay in antibiotic treatment of more than three hours after hospital admission was a strong and independent risk factor for mortality

  13. Retrospective cohort study of 286 patients with community-acquired bacterial meningitis, early and adequate administration of antibiotic therapy in relation to the onset of overt signs of meningitis was independently associated with a favorable outcome, defined as mild or no disability

  14. Causes of delay : • 1. Atypical presentation : retrospective study of 119 adults with bacterial meningitis : • the most dramatic clinical predictor of death was the absence of fever at presentation • Lowering the threshold for initiation of therapy may be prudent, but there is no clear guideline

  15. 2. Delay due to imaging: • CT scan of the head to exclude an occult mass lesion that could lead to cerebral herniation during subsequent CSF removal . • Although commonly performed, a screening CT scan of the head is NOT necessary in the majority of patients

  16. Retrospective study of 119 adults with bacterial meningitis noted above, withholding antibiotics until a CT scan and lumbar puncture were done was strongly associated with a delay of >6 h to the first dose of antibiotic

  17. Case 1 Time :8:15am • 14 years old boy who arrived recently from nigeria presented with history of URTI for the last 4 days ,when he was given antihistamine. • 12 hours before arrival to ER he started to have : • Headache (mod severe) associated with vomiting. • What is next ?

  18. Ask about : Photophobia , myalgia ,GIT symptomes, lethargy, • Contact with sick patient closely. • Previous vaccination • Any earache ,or ear discharge. • What is next

  19. Examination : • Conscious state : OK • Temperature : 40 • Ear , nose and throat exam • Skin examination : • Look for meningeal irritation…..How

  20. Nuchal rigidity • Pathognomonic Sign for :meningeal irritation • Kernig s sign : + • Brudzniski sign:+

  21. Time :8:38am • The boy was resisting the flexion ? • Impression ? • Next ? • To Rule in or out the possibility of CNS infections? What do you mean by CNS infection ? How to answer the above mentiones TASK?

  22. Time is 8:50am • Lumbar puncture to study the CSF : What exactly you will do? Appearance : Couldy Cell count : Biochemistry: Glucose & Protein Gram stain : Culture:

  23. Causes : • Pneumococcal (The commonest in adult) • Haemophilus influenzae(uncommon in vaccinated • Meningococcal infection • Listeria monocytogens (neonate ,above 50 ,pregnant women)

  24. Skin exam: • Petechiae on the lower limbs. Very strong clue to the diagnosis of MENINGOCOCCAL infection The likely diagnosis is : Meningococcal meningitis

  25. What is next time :9.14am • Start Antibiotics ? • Bacteriocidal • Parentral • Consider the epidemiology of the organism: a. Aetiology b. antibiotics Susceptibility (Global emergence andPrevalenceofPenicillin- Resistant Strain of Strep. pneumonia What to give ?

  26. 1. supportive care : IVF • 2. Antibiotics :blind therapy : • 3.Isolation and prevention • Pencillin G 20-24 million unit/day q 4hrs • But ,we have to cover broadly until identification and drug Susceptibility. D.O.C.: Cefitriaxone 2gm 12hrly + vancomycin 1gr 12hrly

  27. Cell count : WBC:4200 Ploy 89% Biochemistry:Glucose 1.8mmol/l (ratio <0.4) Protien : 120mg/dl (30—45 mg/dl) Gram stain : Culture: Gram negative intracellular dipplococci.

  28. Action : stop vancomycin • Isolation for one day. • Antibiotic for 7 days • Chemoprophylaxis: for • 1. Index xase • 2. close contacts : contacts with oropharyngeal secretion : wife , children who are sharing toys

  29. prophylaxis • Candidates for chemoprophylaxis against meningococcal disease include the following: • All household contacts • Childcare or nursery school contacts during the 7 days before illness onset • Contacts directly exposed to index case secretions through kissing, sharing toothbrushes or eating utensils, or other markers of close social contact during the 7 days before illness onset • Persons who had mouth-to-mouth resuscitation or unprotected contact during endotracheal intubation in the 7 days before illness onset . • Contacts who frequently slept or ate in the same dwelling as the index patient during the 7 days before illness onset

  30. prevention

  31. is a gram-negative diplococcus that is carried in the nasopharynx of otherwise healthy individuals. It initiates invasion by penetrating the airway epithelial surface. • Most sporadic cases (95-97%) are caused by : serogroupsB, C, and Y, while. • while in epidemics : The A and C strains are observed (< 3% of cases).

  32. Vaccination:Neisseriameningitidis: Quadrivalent ( A, C, Y, W-135) meningococcal conjugate vaccine • Two doses of MCV4 are recommended for adolescents 11 through 18 years of age: the first dose at 11 or 12 years of age, with a booster dose at age 16.

  33. recommended for high-risk groups: recommends the vaccine for: • First-year college students living in dormitories. • Laboratory personnel who are routinely exposed to meningococcal bacteria • military recruits. • Anyone traveling to, or living in, a part of the world where meningococcal disease is common, such as parts of Africa. • Anyone who has a damaged spleen, or whose spleen has been removed. • Anyone who has persistent complement component deficiency (an immune system disorder). • People who might have been exposed to meningitis during an outbreak.

  34. Meningococcal conjugate vaccine (MCV4) is the preferred vaccine for people 55 years of age and younger. • • • Meningococcal polysaccharide vaccine (MPSV4) has been available since the 1970s. It is the only meningo-coccal vaccine licensed for people older than 55. • Both vaccines can prevent 4 types of meningococcal disease, including 2 of the 3 types most common.

  35. Case 2 : • 21 year old saudi man presented to TNT department c/o • Fever and ear discharge for 2 days . • Patient denied other smptomes • T: 38.2 • DX .Otitis media • RX amoxacillin 500 mg TID for one wk • 2days late patient condition got woarse?

  36. Time 10.34 am • Started to have : severe Headache , and feeling unwell , and vomiting ,so presented again to ENT doctor? • What he should do ?

  37. a. Consider amoxicillin resistant organism and change the antibiotic b. Reassure him that antibiotics needs more time to produce effect c. Refer him to ER department immediately and communicate with the physician in charge d. Add another antibiotic for synergism What do you think is happening ?

  38. On arrival to ER : Time 11.12am • T: 39 • Sick looking • Systemic examination are normal • Ear : dry and purluent discharge • What is next? • Look for sign of minigeal irritation.

  39. CSF Analysis: • Turbid • Under pressure • Sent for full study • What is next? • Likely diagnosis

  40. Menigitis complicating otitis media • Organism : Pnumococcal

  41. Pneumococcal meningitis • The commonest cause in adult > 20 yrs • Account for 50% • Risk factors:1. pnumonia • 2. acute sinusitis • 3.otitis media • 4. alcoholism • 5. Diabetes , splenectomy , • 6. head trauma with basilar skull fracture • Mortality : 20% despite antibiotics therapy

  42. Treatment: • Cefitriaxone or cefotaxime and Vancomycin • All isolates should be tested for pencillin and cefitriaxone sensitivity. • CSF result: • WBC: 1520 Polys :79% • Glucose is low , protein :145mg/dl • Gram stain :

  43. Gram positive intracellular dipplococci Dx :Streptococcal pnumonia Antibiotic :cefitriaxone 2gmm BID for 14 days Adjunctive therapy: Dexamethazone Dexamethasone 4mg iv 6hrly for 5 days {1st dose should be before (20 min)or at start of AB. …later than 6 hrs : not useful …… benefit ?

  44. Prospective trial : • In adults, corticosteroids, given before or along with the first dose of antibiotics, reduce morbidity and mortality in patients with pneumococcal meningitis but not in others • hearing loss, • long-term neurologic sequelae, and • death

  45. Case 3 • 34 year old pregnant women who presented to he GP c/o: • Fever ,backpain, arthralgia and myalgia • She gave History of taking food ouside : • Sandwish of hotdoge • Reassured and given analgesics • 7 days late she presented with woarsening headache !........What is next ?

  46. Neck stiffness : None CSF:clear Cell count: wbc :320 neut 74% Glucose and protein :normal Gram stain: gram positive bacilli Diagnosis ?

  47. Listeria monocytogens: gram positive rods Grow over a brosad temp range including frig Follow ingestion of contaminated food, and enter through the GIT Cause meningitis in: 1.Neonates 2.Elederly 3.Pregnant women

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