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Meningitis Commonly Asked Questions. Stephen J. Gluckman, M.D. What are normal CSF findings?. Protein 0.45 gm/L Elevated with Diabetes Elevated with neuropathies of any cause Elevated with increasing age Elevated by bleeding into the CSF (SAH or traumatic) 0.01 gm/L for every 1000 RBC’s.

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meningitis commonly asked questions

MeningitisCommonly Asked Questions

Stephen J. Gluckman, M.D.

what are normal csf findings
What are normal CSF findings?
  • Protein
    • 0.45 gm/L
    • Elevated with Diabetes
    • Elevated with neuropathies of any cause
    • Elevated with increasing age
    • Elevated by bleeding into the CSF (SAH or traumatic)
      • 0.01 gm/L for every 1000 RBC’s
what are normal csf findings3
What are normal CSF findings?
  • Glucose
    • 60 % of blood glucose
      • In persons with hyperglycemia it takes several hours for CFS and blood glucose to equilibrate
    • Low CSF glucose
      • Bacterial infection
      • Tuberculosis, cryptococcosis, carcinomatous
      • SAH
      • Sarcoidosis
      • Occasional viral
what are normal csf findings4
What are normal CSF findings?
  • Cell count
    • <5 WBC (all mononuclear) and < 5 RBC considered “normal”
    • Traumatic tap
      • WBC/RBC ratio = 1:1000
  • Pressure
    • <20
      • In patients with bacterial meningitis
        • wide range
        • 40% >30, 10% < 14
can the csf reliably distinguish between a bacterial and non bacterial cause of meningitis
Can the CSF reliably distinguish between a bacterial and non-bacterial cause of meningitis?

Usually

Look at the whole pattern!

can the csf reliably distinguish between a bacterial and non bacterial cause of meningitis6
Can the CSF reliably distinguish between a bacterial and non-bacterial cause of meningitis?
  • Glucose
    • <2.5 suggests bacterial
    • < 0.5 highly suggests bacterial
  • Protein
    • > 2.5 suggests bacterial
  • Cell count
    • >500 suggests bacterial
    • >1000 highly suggests bacterial
  • % polys
    • >50 suggests bacterial
are there exceptions
Are there exceptions?
  • Early viral can have a predominance of polys
  • Some viral can have low CFS glucose
  • Listeria can have predominance of mononuclear cells rather than polys
  • TB can have predominance of polys
how much does prior administration of antibiotics alter the csf findings9
How much does prior administration of antibiotics alter the CSF findings?
  • 48-72 hours of prior intravenous antibiotic treatment has little effect on glucose, protein and cell count
    • It will rarely change the CSF from a “bacterial” to an “aseptic” formula
  • Prior antibiotic treatment will likely make the cultures negative.
what is the typical clinical presentation of bacterial meningitis
What is the typical clinical presentation of bacterial meningitis?
  • History
    • Headache: 75-90%
    • Photophobia: uncommon
  • Examination
    • Fever: 95%
    • Stiff Neck: 85%
    • Altered mental status: 80%
    • All three: 40%
    • Any one of the three: 100%
how good are kernig and brudzinski signs
How “good” are Kernig and Brudzinski signs?
  • Originally related to severe, advanced TB meningitis (not bacterial)
  • Not studied in a prospective study until 2002 (N=297)*
    • Sensitivity 5%
    • Specificity 95%

*Thomas KE et al. Clin Infect Dis. 2002;35:46-52

what are the common causes of bacterial meningitis
What are the common causes of bacterial meningitis?
  • It depends upon age and risk factors
    • Age
      • Neonates: listeria, group B streptococci, E. coli
      • Children: H. influenza
      • 10 to 21: meningococcal
      • 21 onward: pneumococcal >meningococcal
      • Elderly: pneumococcal>listeria
    • Risk factors
      • Decreased CMI: listeria
      • S/P neurosurgery or opened head trauma: Staphylococcus, Gram Negative Rods
      • Fracture of the cribiform plate: pneumococcal
what is the proper empirical antibiotic regimen for presumed bacterial meningitis
What is the proper empirical antibiotic regimen for presumed bacterial meningitis?

It depends upon the clinical situation

what is the proper empirical antibiotic regimen for presumed bacterial meningitis14
What is the proper empirical antibiotic regimen for presumed bacterial meningitis?
  • Neonates
    • 3rd generation cephalosporin and ampicillin
  • Children
    • 3rd generation cephalosporin
  • Normal adult
    • 3rd generation cephalosporin and vancomycin (if resistant pneumococci)
  • Problems with cell mediated immunity (AIDS, steroids, elderly)
    • Add coverage for listeria with ampicillin or co-trimoxazole
  • S/P CNS trauma or neurosurgery
    • Coverage for staphylococcus and gram negative rods with antipseudomonal beta-lactam and vancomycin
how important is the speed of initiating antibiotics in bacterial meningitis
How important is the speed of initiating antibiotics in bacterial meningitis?

It is important

But it is not the critical prognostic factor

how important is the speed of initiating antibiotics in bacterial meningitis16
How important is the speed of initiating antibiotics in bacterial meningitis?
  • The clinical outcome is primarily influenced by the severity of the illness at the time antibiotics are initiated
    • Severity based on
      • Altered mental status
      • Hypotension
      • Seizures
how important is the speed of initiating antibiotics in bacterial meningitis17
How important is the speed of initiating antibiotics in bacterial meningitis?
  • No factors
    • 9% with adverse outcome
  • One factor
    • 33% with adverse outcome
  • Two or three factors
    • 56% with adverse outcome

Therefore, though treatment should be administered ASAP, the impact of antibiotic delay is a function of the severity of disease at the time that treatment is initiated

steroids or no steroids
Steroids or no Steroids?

Steroids

(today)

steroids or no steroids19
Steroids or no Steroids?
  • Reduces morbidity and mortality*
  • Give before or at the same time as the first dose of antibiotics
  • Dose studied
    • Dexamethazone 10 mg Q6H x 4 days

*Only shown for pneumococcal meningitis in adults and haemophilus meningitis in children

do you need to do a ct scan before an lp
Do you need to do a CT scan before an LP?

Usually not

  • A CT scan should never delay therapy (obtain blood cultures)
do you need to do a ct scan before an lp21
Do you need to do a CT scan before an LP?
  • Prospective studies*
    • N = 412
    • Predictors of CNS mass lesion
      • History
        • > 60 years old
        • Immunocompromised
        • Hx of prior CNS disease
        • Hx of seizure w/in 1 week prior to onset
      • Examination
        • Focal neurological findings
        • Altered mental status
        • Papilledema

*Gopal et al. Arch Intern Med. 1999;159:2681-5

Hasbun and Abrahams. N Engl J Med 2001:345:1727-33

how contagious is meningitis are we at risk when we care for a patient
How contagious is meningitis?Are we at risk when we care for a patient?
  • Not really
  • The only bacterial meningitis that is spread from person to person is meningococcal
    • The risk is very low
      • Household contacts have about a 1% risk
      • Health care workers have not been shown to have a risk
      • After 24 hours of treatment this is no risk
what is aseptic meningitis
What is “Aseptic” meningitis?
  • It is a term used to mean non-pyogenic bacterial meningitis
  • It describes a spinal fluid formula that typically has:
    • A low number of WBC
    • A minimally elevated protein
    • A normal glucose
  • It has a much bigger differential diagnosis than viral meningitis.
what are the treatable causes of aseptic meningitis encephalitis syndrome
Infectious

HSV 1 and 2

Syphilis

Listeria (occasionally)

Tuberculosis

Cryptococcus

Leptospirosis

Cerebral malaria

African tick typhus

Lyme disease

Non-Infectious

Carcinomatous

Sarcoidosis

Vasculitis

Dural venous sinus thrombosis

Migraine

Drug

Co-trimoxazole

IVIG

NSAIDS

What are the treatable causes of aseptic meningitis/encephalitis syndrome?
what are the important things to know about aids associated cryptococcal meningitis
What are the important things to know about AIDS- associated cryptococcal meningitis?
  • Generally advanced with CD4 < 100
  • Sub-acute onset: fever, headache
    • Stiff neck is rare
  • Mortality with treatment is about 15%!
    • Predictors of death
      • Altered Mental status, low CSF WBC count, high CSF cryptococcal antigen titer
what are the important things to know about aids associated cryptococcal meningitis26
What are the important things to know about AIDS- associated cryptococcal meningitis?
  • CSF findings
    • Elevated pressure is the usual (>70%)
    • Rest of CSF findings are often unimpressive
      • WBC <50
      • Glucose: normal or slightly low
      • Protein: normal or slightly elevated
      • 25% have normal WBC, glucose and protein
    • CSF cryptococcal antigen: 95-100% sensitive
what are the important things to know about aids associated cryptococcal meningitis27
What are the important things to know about AIDS- associated cryptococcal meningitis?
  • Treatment
    • Medical
      • Induction: amphotericin B 0.7mg/kg x 2/52
        • (flucytosine)
      • Consolidation: fluconazole 400 mg x 8/52
      • Maintenance: fluconazole 200 mg
    • Pressure
      • Daily LP’s to keep opening pressure <20
      • If LP’s are still needed after 1 month shunt
meningitis who was awake
Meningitis – Who was awake?

Which of the following are true statements?

  • Early viral meningitis can have a predominance of polys
  • Some viral meningitis can have low CSF glucose
  • Listeria meningitis can have predominance of mononuclear cells rather than polys
  • All of the above
meningitis who was awake31
Meningitis – Who was awake?

Which of the following are true statements?

  • Early viral meningitis can have a predominance of polys
  • Some viral meningitis can have low CSF glucose
  • Listeria meningitis can have predominance of mononuclear cells rather than polys
  • All of the above
meningitis who was awake32
Meningitis – Who was awake?

To correct CSF protein concentrations for blood in the CSF the proper ratio is approximately 0.01 gm/L of protein for every 100 RBC’s

  • True
  • False
meningitis who was awake33
Meningitis – Who was awake?

To correct CSF protein concentrations for blood in the CSF the proper ratio is approximately 0.01 gm/L of protein for every 100 RBC’s

  • True
  • False
meningitis who was awake34
Meningitis – Who was awake?
  • Which of the following are true about cryptococcal meningitis?
    • a. A normal CSF effectively rules out cryptococcal meningitis
    • b. If the CSF pressure is elevated one should not remove more than 10 ml at a time
    • c. Everyone with HIV infection is at increased risk for cryptococcal meningitis.
meningitis who was awake35
Meningitis – Who was awake?
  • Which of the following are true about cryptococcal meningitis?
    • a. A normal CSF effectively rules out cryptococcal meningitis
    • b. If the CSF pressure is elevated one should not remove more than 10 ml at a time
    • c. Everyone with HIV infection is at increased risk for cryptococcal meningitis.

None