Meningitis.

1
Meningitis.

• Dr Abdulrahman Al shaikh

2
definition

• Inflammatory disease of leptomeninges, the tissue
  surrounding the brain and spinal cord.
• The meninges consist of three parts the pia,
  arachnoid and dura maters.
• It involves the arachnoid mater and the
  cerebrospinal fluid in the subarachnoid space as
  well as in the cerebral ventricles.

3
Types

• Acute either pyogenic or viral.
• Chronic due to tuberculosis or fungal.

4
Pyogenic meningitis.
5
ETIOLOGICAL AGENT
"Normal" Adults (6-21 yrs)     Neisseria
meningitidis     Streptococcus pneumoniae
Children (3 months - 6 years)     Haemophilus
influenzae     Neisseria meningitidis    
Streptococcus pneumoniae     Staphylococcus
aureus     Mycobacterium tuberculosis Infants
(½ - 3 months)     Streptococcus, Group B    
Listeria monocytogenes     Escherichia coli

6
Neonates     Escherichia coli    
Streptococcus, Group B     Staphylococcus aureus
    Listeria monocytogenes     Streptococcus,
Group A Diabetics, alcoholics, elderly,
debilitated, diseased (untreated)     Listeria
monocytogenes     Streptococcus pneumoniae    
Treponema pallidum
7
(No Transcript)
8
Clinical feature.

• Fever and headache in majority.
• Headache severe and generalized.
• Most have fever but small percentage have
  hypothermia.
• CNS symptoms photophobia, and cloudy sensorium.
  Changes in mentation and level of consciousness,
  seizures, and focal neurological signs tend to
  appear later in the course of the disease.

9
Nuchal rigidity.

• The patients might not complain of neck stiffness
  but easy to find it by passive or active flexion
  of the neck will usually result in inability to
  touch the chin to the chest.
• Brudzinski sign refers to spontaneous flexion of
  the hips during attempted passive flexion of the
  neck.
• The kernig signs refers to the inability to allow
  full extension of the knee when the hip is flexed
  90 degree.

10
Other finding.

• Skin manifestation in form of petechiae and
  palpable purpura.( N. meningitides ).
• If sequelae of infection in other part of the
  body, there may the feature of that infection. (
  sinusitis and otitis).

11
Laboratory features.

• Increased WBC.
• Low platelets if there is intravascular
  coagulation.
• Electrolytes abnormalities mainly low sodium. (
  SIADH ).
• Blood culture at least one half have positive
  before antibiotics.

12
CSF.

• Can be diagnostic should be done in all only if
  there is contraindication.
• Can distinguish viral from bacterial.
• Gram stain should be done if suspected bacterial.

13
(No Transcript)
14
Complication.

• Cerebrovascular involvement.
• Cerebral odema.
• Hydrocephalus.
• Septic shock.
• Disseminated intravascular coagulation.
• Acute respiratory distress syndrome.

15
Treatment.

• Empiric ceftriaxone has a potent activity for
  causative organism except Listeria .
• Ampicilin should be added if Listeria infection
  possible.
• Dexamethazone reduced the complication.

16
H- influenza.

• Ceftriaxone 2 gm twice a day.
• Cefotaxime 2gm 6 hourly.
• Rifampicin 6oo mg daily for 4 days to clear the
  colonization.
• Should be treated 5 7 days.

17
Neisseria meningitis.

• Penicillin, but there resistant cases.
• Third generation cephalosporin.
• Treatment for 5 days at least.
• Rifampicin if penicillin used in treatment.
• Rifampicin or ciprobay for contact.

18
(No Transcript)
19
PREVENTION
Neisseria meningitidis - each dose of the
multivalent vaccine provides A, C, Y and W-135
capsular polysaccharides. Effective in children
over 3 months of age.        
Streptococcus pneumoniae - each dose of the
multivalent vaccine provides 23 types of capsular
        polysaccharide covering the majority of
strains causing meningitis. Recommended for
children         over 2 years of age.
                months of age.
Haemophilus influenzae each dose of the
monovalent vaccine provides the capsular
polysaccride from serotype b. organisms.
Recommended for children over 18 months of age.
20
Viral meningitis
21
ETIOLOGICAL AGENTS
     Mumps virus       Polio virus
      Coxsackie B virus        Echovirus      
Arboviruses        Human Herpesvirus 1 (Herpes
simplex 1 virus)         Lymphocytic
choriomeningitis viruses-Arenavirus         
Encephalomyocarditis viruses       Louping
ill virus          Pseudolymphocytic meningitis
virus           Hepatitis viruses          
Adenovirus            Rhinovirus           
Coxsackie A virus
22
CHRONIC MENINGITIS
NAMES OF DISEASE         Fungal meningitis
                                          Cryptoc
occosis                                  Torulosi
s                                              
Tubercular meningitis                      
                         Amoebic meningitis
                                             
Syphilitic meningitis
23
ETIOLOGICAL AGENTS
     Cryptococcus neoformans (Serotypes A,B,C,D)
     Treponema pallidum                          
                   ) All slow      Mycobacterium
tuberculosis                                 )
growers in       Naegleria fowleri               
                                   ) the CNS
      Human immunodeficiency virus               
            )       Coccidioides
immitis                                           
)  
24
Fungal meningitis-predisposing factors.

•   1.     Glucosteroid therapy
•     2.     Malignancy (particularly of the
  lymphoreticular system)
•     3.     Collagen - vascular disease.
•     4.     Sarcoidosis - a disorder involving
  many organs where there is formation of
  epithelioid cell             tubercles.
•     5.     Diabetes mellitus
•     6.     Pregnancy
•     7.     Alcoholism
•     8.     Genetic impairment of host defense
  mechanisms - 50. T-cell diseases (Di George
  Syndrome, Nezelof's syndrome)
•     9.     AIDS

25
Clinical feature fungal.

• 1.     Headache - frontal, temporal or
  retro-orbital. Most common feature and it becomes
  progressively more frequent and severe.
•  2.     Mental aberrations (from simple
  irritability to psychosis)
•  3.     Motor abnormalities (altered reflexes to
  paralyses)
•  4.     Cranial nerve dysfunctions (aphasia,
  visual disturbances, hearing loss)
•  5.     Cerebellar signs (dyssynergia, dysmetria,
  dysrhythmia, intentional tremor, slurring of
  speech)
•  6.     Evidence of increased intracranial
  pressure
•  7.     Fever in about 1/3 of patients

26
CSF in fungal

• 1.     Increased CSF pressure
•  2.     Protein is elevated
•  3.     Leukocytosis (40-400/mm3 - mostly
  mononuclear cells)
•  4.     Glucose is decreased (45 of blood
  glucose)
•  5.     C. neoformans present in India ink
  preparations
•  6.     Serological tests for cryptococcal
  antigen

27
TREATMENT

• 1.     Amphotericin B injected I.V. and into
  the subarachnoid space. NOTE This is poorly
   absorbed into CSF. Treat for 6 weeks. Toxic.
• 2.     Flucytosine (5-fluorocytosine)-penetrat
  es into all body fluids, including CSF. Less
  toxic but higher doses required.
• 3.     Miconazole-an imidazole derivative    
  
• 4.     Amphotericin B methyl ester    

28
Tuberculous meningitis.

• Clinical feature.
• Diagnosis.
• Treatment.

29
Clinical feature TB.

• Atypical presentations Rapid progressive as
  pyogenic or slow dementia.
• Stage 1 lucid with no focal neurological signs.
• Stage 11 are confused or focal signs such as
  hemiparesis or cranial nerve palsies.
• Stage 111 advanced illness with delirium ,
  stupor, coma and dense hemiplegia.

30
Diagnosis.

• High degree of suspicion.
• CSF high protein, low sugar and a mononuclear
  pleocytosis.
• Early in the illness the cellular reaction is
  atypical with low cell or polymorphonuclear
  leukocyte.
• AFB smear in 37.
• Polymerase chain reaction 70.
• CT Scan of the brain with contrast or MRI.

31
Treatment.

• INH, Rifampicin and pyrazinamid for 2 months then
  discontinue PYZ.
• In endemic areas where resistance to INH is high
  the streptomycin or ethambutol added.
• The duration for 12 months but if PYZ not
  tolerated the duration extended to 18 months and
  in case multiple drugs resistance for 18-24
  months.
• Steroid improve morbidity and mortality,
  prednisone 60 mg to be tapered over 4 weeks.
• Surgery in case of hydrocephalus or increase
  intracranial pressure.( deterioration in
  conscious level and stupor).