Bacterial Meningitis - A Medical Emergency

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Bacterial Meningitis -A Medical Emergency
Swartz MN N Engl J Med 20043511826-1828
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Mortality Rates Associated with
Community-Acquired Bacterial Meningitis over the
Past 90 Years
Swartz MN N Engl J Med 20043511826-1828
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Bacterial Meningitis -A Medical Emergency

• Fever and neurologic symptoms
• Bacterial meningitis
• Aseptic meningitis

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Neurologic SymptomsWith Fever

• Epidural Abscess
• Subdural empyema
• Sinus septic thrombosis
• Collagen diseases

• Bacterial meningitis
• Aseptic meningitis
• Encephalitis
• Brain abscess

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Typical CSF Changes

• etiology protein glucose
  leukocytes
• bacterial meningitis 100-500
  100-10000, P
• viral meningitis 50-200 N
  lt1000, MN
• TB meningitis 100-500
  10-500, MN
• fungal meningitis 25-500
  25-500, MN
• brain abscess 75-500 N
  0-200, MN

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Bacterial MeningitisEtiology

• Neonates
• Gram (-) rods
• Strep group B
• Listeria monocytogenes
• Haemophilus influenzae b

• gt 3 months
• Haemophilus influenzae b
• Strep pneumoniae
• N. meningitidis

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Bacterial MeningitisClinical Presentation

1. "Looks Bad
2. Fever
3. Headache, nausea, vomiting
4. Irritability, restlessness
5. Sleepy
6. Confusion, mental signs
7. Back pain
8. Bulging fontanel / nuchal rigidity

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Bacterial MeningitisDiagnosis

1. LP mandatory (protein, glucose, cells, culture,
   Gram stain, antigen detection by latex, ELISA,
   CIE)
2. Blood culture always
3. CT? (search for focus)

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Bacterial MeningitisTreatment

1. Antibiotic regimen
2. Steroids
3. Fluid restriction?
4. Anticonvulsant medications?
5. Monitoring

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CSF Penetrationof Antibiotics

• adequate good with minimal with
  nil
• inflammation inflammation
• chloramphenicol ampicillin
  gentamicin clindamycin
• sulfa cefotaxime
  tobramycin benza pen
• TMP/SMX amikacin
  erythromycin ampho B
• metronidazole vancomycin
  ketoconazole polymyxin
• rifampin

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Bacterial MeningitisTreatment

1. Antibiotic regimen
2. Steroids
3. Fluid restriction?
4. Anticonvulsant medications?
5. Monitoring

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Bacterial MeningitisSequelae

• 1. Mortality 1-5 6. Motor
  abnormalities
• 2. Hearing loss 10-40 7. Seizures
  2-8
• 3. Language disorders 15 8. Hydrocephalus
• 4. Impaired vision 2-4 9. Cranial N
  palsy
• 5. Mental retardation 10 10. Ataxia
• (Sell et al)

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Bacterial Meningitisfactors affecting prognosis

• Age
• Specific cause
• Underlying disorders
• Delay in therapy
• Focal neurologic findings
• Bacterial load (animals)

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Aseptic Meningitis

• Bacterial partially treated, mycobacteria, T.
  pallidum, borrelia, leptospira
• Viral
• Rickettsia
• Fungal
• Protozoa
• Parameningeal foci (abscess, mastoiditis, sinus
  septic thrombosis)

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Viral Meningitis - USA

• Enteroviruses - 85
• Arboviruses - 5
• Mumps - 2
• Herpes simplex 2-5
• Others adeno, VZV, CMV, measles, rubella,
  influenza, parainfluenza, RSV

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Herpes simplex Encephalitis

• Presentation (Kohl, Ped C N Am 1998)
• Fever
  90-100
• Altered consciousness 80-100
• Headache 76-80
• Seizures 40-85
• Hemiparesis 33-40
• Cranial N palsy 30-35
• Behavioral changes 47-85

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Herpes simplex Encephalitis

• Laboratory findings (Kohl, Ped C N Am 1998)
• Abnormal CSF 90-97
• CSF pleocytosis 50-1000, lymph
• CSF RBCs 75-85
• CSF protein increased
• CSF glucose normal
• Culture negative
• PCR (type 1, 2) positive

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Herpes simplex Encephalitis Outcome

• Acyclovir
  Vidarabine placebo
  
• Mortality (1m) 16 36
  70
• Severe sequelae 34 72
• Moderate sequelae 10 15
• Minor or no impairment 46 13

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Recurrent Meningitis

• Communication of SAS with
• Skin - dermal sinus, meningomyelocele
• Paranasal sinuses, middle ear, nasopharynx
• due to fractures, cong malformations
• Parameningeal focus epidural, brain, mastoid
• Immune deficiency
• Unknown

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Thank You for the attention
Shai Ashkenazi