Clinical Cases Study for Meningitis

Tutorial clinical cases for meningitis

1. Meningitis Cases Dr. Sameh Ahmad Muhamad abdelghany Lecturer Of Clinical Pharmacology Mansura Faculty of medicine

2. Meningitis

3. CAS(1)

4. CHIEF COMPLAINT 4 The patient is currently unresponsive. Her history is from medical records and nursing staff at long-term care facility, who report somnolence and “talking outof her head.”

5. Present History 5 R.J. is a 67-year-old female resident of a local assisted-living facility , who presents to the ED with a 3-day history of worsening confusion and somnolence . Prior to her delirium, she also complained of headache and stiff neck . None of her friends/contacts at the nursing home have reported any signs or symptoms of illness, but her 10-year-old grandson who visited last week was recently diagnosed with pneumonia. She has a history of seizure disorder and one of her friends reported that she may have had some seizure-like activity yesterday .

6. Past History 6 Past Medical History: Type 2 DM diagnosed 1 year ago

7. PHYSICAL EXAMINATION 7 General Unresponsive, ill-appearing elderly female in acute distress Vital Signs BP 88/62 mm Hg, P 122, RR 20, T 38.8°C Neck and Lymph Nodes (+) Nuchal rigidity; (–) Kernig’s sign; (–) Brudzinski’s sign

8. PHYSICAL EXAMINATION 8 Chest Clear to auscultation bilaterally Other systems Other areas of examination was normal

9. LABORATORY 9 Cultures Blood cultures × 2: Pending CSF Gram stain: Gram-positive diplococci

10. CT scan 10 No acute abnormalities

11. Assessment 11 Sixty-seven-year-old female with signs, symptoms, and laboratory/diagnostic tests consistent with bacterial meningitis

12. Questions 12 Q1 . Which symptoms in this patient’s history suggest the diagnosis of bacterial meningitis? Q2: What do this patient’s CSF findings indicate? Q3: What is your first line of treatment? Q4: Why should empiric antibiotic therapy in bacterial meningitis include broad spectrum coverage with more than one agent?

13. Questions 13 Q5: What route of antibiotic administration is appropriate in bacterial meningitis? Q6: Measures for prevention of St. pneumonie meningitis?

14. Answer of Question 1 14 headache, fever, neck stiffness, and altered mental status Back

15. Answer of Question 2 15 Gram-positive diplococci indicate bacterial meningitis Back

16. Answer of Question 3 16 Start with empirical therapy till culture reveals the causative agent. Give ampicillin/ceftriaxone or ampicillin/ cefotaxime Back

17. Answer of Question 4 17 Empirical therapy should be directed at the most likely pathogen(s) include G+ve & G- ve bacteria so we need broad-spectrum to cover. Back Back

18. Answer of Question 5 18 Parenteral to achieve rapid & high concentrations in CSF Back

19. Answer of Question 6 19 Vaccines specified against Streptococcus pneumonia Back

20. CAS(2)

21. Scenario 21 A 4-week-old premature infant presents on the hospital neonatal unit with poor feeding, fever and increasing drowsiness. Lumbar puncture reveals 1200 WBC/ μL (80% of which are polymorphs), and low glucose and elevated protein levels. No organisms are seen on a Gram-stained smear of the CSF. The diagnosis is acute purulent meningitis.

22. Questions 22 Q1 . What are the likely etiological agents ? Q2: Which other investigations other than CSF culture might help in establishing the aetiological diagnosis ? Q3: What empiric antibiotic therapy should be commenced?

23. Answer of Question 1 23 This bacterial type of meningitis with the most common : Pneumococcal, Streptococcus pneumoniae (38%) Meningococcal, Neisseria meningitidis (14 %) Back

24. Answer of Question 2 24 It is important to collect blood cultures because neonatal meningitis is not uncommonly accompanied by bacteraemia . May Need radiological for chest x-ray - CT Back

25. Answer of Question 3 25 Given the range of potential pathogens, a combination of ampicillin or amoxicillin plus cefotaxime or ceftazidime would be the treatment of choice, unless the patient is known to have antibiotic-resistant bacteria such as MrSA or Gram-negative bacteria . Back Back

26. CAS(3)

27. Scenario 27 A 70-year-old man is being treated for meningitis due to Streptococcus pneumoniae that is moderately resistant to penicillin. Despite 7 days' treatment with intravenous cefotaxime , there has been little improvement in his clinical condition. A CT scan has shown meningeal inflammation consistent with meningitis, but no evidence of intracranial complications that might explain his poor clinical response.

28. Questions 28 Q1 . Why might there have been an inadequate response to treatment with? Q2: What is your decision to modify his antimicrobial therapy ?

29. Answer of Question 1 29 Cefotaxime alone may not adequately treat infections with penicillin-resistant pneumococci . Back

30. Answer of Question 2 30 Need to add vancomycin to overcome resistance Others: Meropenem , Linezolid if resistant to vancomycin occur Back

31. CAS(4)

32. Case 32 An 18-year-old man is referred as an emergency with suspected meningitis. He was given intravenous penicillin by the primary care doctor before admission to hospital. On examination he is fully conscious, and neck stiffness is elicited. He is haemodynamically stable and no rash is present.

33. Questions 33 Q1 . What investigations would you undertake to establish the diagnosis ? Q2 : What empirical therapy would you give ? Q3: What further action will be required if a diagnosis of meningococcal meningitis is likely ?

34. Answer of Question 1 34 Lumbar Puncture(CSF cell count,CSF chemistries,CSF gram stain,CSF culture) Blood cultures A complete blood count Back

35. Answer of Question 2 35 Start empirical therapy with vancomycin/ceftriaxone or cefotaxime till culture reveals the causative micro-organism. Back

36. Answer of Question 3 36 Treat with 3 rd generation cephalosporins (Cefotaxime) [alternative is penicillin G or ampicillin] Adjunctive therapy with dexamethasone Give prophylaxis to close contacts Back

37. THANK Y OU! ANY QUESTIONS?