meningitis

During my 1st &2nd year of residency period , i used to teach Anatomy and Orthopaedics for foreign undergraduate medical students. At last year i taught Neurology for one batch. so i posted some of my collections for competely educational purpose coz i believe in knowledge ...inseted of deleting these ppts , they may me useful for others so i shared it ....

1. Dr. Sunil Pahari , 3 rd year resident Yangtze university , jingzhou central hospital , hubei , china 10/11/2017 1 Meningitis General Overview MENINGITIS

2. Clinical description 10/11/2017 2 Meningitis is a disease caused by the inflammation of the protective membranes covering the brain and spinal cord known as the meninges. The inflammation is usually caused by an infection of the fluid surrounding the brain and spinal cord. Meningitis can be life-threatening because of the inflammation's proximity to the brain and spinal cord; therefore the condition is classified as a  medical emergency .

3. Meninges 10/11/2017 3 The meninges is the system of membranes which envelops the central nervous system. It has 3 layers: Dura mater Arachnoid mater Pia mater Subarachnoid space - is the space which exists between the arachnoid and the pia mater, which is filled with cerebrospinal fluid.

4. Causes of Meningitis 10/11/2017 4 - Bacterial Viral Fungal Ricketsial ( Rocky mountain spotted fever) - Parasitic/ protozoal - Physical injury - Cancer - Certain drugs ( mainly, NSAID’S) Severity/treatment of illnesses differ depending on the cause. Thus, it is important to know the specific cause of meningitis.

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7. 10/11/2017 7 Bacterial - Haemophilus influenzae - Listeria - Meningococcus   - Pneumococcus - Group A Streptococcus  - Group B Streptococcus

8. 10/11/2017 8 Bacterial meningitis may present acutely (symptoms evolving rapidly over 1-24 hours), sub acutely (symptoms evolving over 1-7days), or chronically (symptoms evolving over more than 1 week).

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10. 10/11/2017 10 Premature babies and newborns  (< 3 months ): E. coli.  group B streptococci, . Older children:  Neisseria meningitidis and Streptococcu pneumoniae   and those under five by  Haemophilus influenzae  type B A dults :   N. meningitidis  and   S. pneumoniae   (80% of all cases) of bacterial meningitis, with increased risk of   L. monocytogenes  (>50yrs) Bacterial

11. Route of infection 10/11/2017 11 Major routes of leptomeninges infection Bacteria are mainly from blood. Uncommonly, meningitis occurs by direct extension from nearly focus ( mastoiditis , sinusitis) or by direct invasion ( dermoid sinus tract, head trauma, meningo-myelocele ).

12. pathogenesis 10/11/2017 12 Susceptibility of bacterial infection on CNS in the children Immaturity of immune systems Nonspecific immune Insufficient barrier ( Blood-brain barrier ) Insufficient complement activity Insufficient chemo taxis of neutrophils Insufficient function of monocyte-macrophage system Blood levels of diminished interferon (INF) - γand interleukin -8 ( IL-8 )

13. pathogenesis 10/11/2017 13 Susceptibility of bacterial infection on CNS in the children Specific immune Immaturity of both the cellular and Humoral immune systems Insufficient antibody-mediated protection Diminished immunologic response Bacterial virulence

14. 10/11/2017 14 Bacterial toxics and Inflammatory mediators are released. Bacterial toxics Lipopolysaccharide, LPS Teichoic acid Peptidoglycan Inflammatory mediators Tumor necrosis factor, TNF Interleukin-1, IL-1 Prostaglandin E2, PGE2

15. 10/11/2017 15 Bacterial toxics and inflammatory mediators cause Suppurative inflammation. Inflammatory infiltration Vascular permeability alter Tissue edema Blood-brain barrier destroy Thrombosis Csf exudates result into hydrocephalus. Brain cell death

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17. Triad of meningitis 10/11/2017 17 Fever Headache Neck stifness

18. Symptoms of meningitis 10/11/2017 18 Meningitis and meningococcal septicemia may not always be easy to detect, in early stages the symptoms can be similar to flu.  They may develop over one or two days, but sometimes develop in a matter of hours It is important to remember that symptoms do not appear in any particular order and some may not appear at all.

19. Clinical manifestation 10/11/2017 19 Bacterial meningitis may present acutely (symptoms evolving rapidly over 1-24 hours) in most cases. Symptoms and signs of upper respiratory or gastrointestinal infection are found before several days when the clinical manifestations of bacterial meningitis happen. Some patients may access suddenly with shock and DIC. Toxic symptom all over the body Hyperpyrexia Headache Photophobia Painful eye movement Fatigued and weak Malaise, myalgia, anorexia, Vomiting, diarrhea and abdominal pain Cutaneous rash Petechiae , purpura

20. Clinical manifestation 10/11/2017 20 Clinical manifestation of CNS Increased intracranial pressure Headache Projectile vomiting Hypertension Bradycardia Bulging fontanel Cranial sutures diastasis Coma Cerebral hernia Meningeal irritation sign Neck stiffness Positive Kernig ’ s sign Positive Brudzinski ’ s sign

21. 10/11/2017 21 Clinical manifestation of CNS Transient or permanent paralysis of cranial nerves and limbs may be noted. Deafness or disturbances in vestibular function are relatively common. Involvement of the optic nerve, with blindness, is rare. Paralysis of the 6 th cranial nerve , usually transient, is noted frequently early in the course.

22. 10/11/2017 22 Kernig’s sign ; One of the physically demonstrable symptoms of meningitis is Kernig's sign. Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees.

23. Brudzinski's sign 10/11/2017 23 Another physically demonstrable symptoms of meningitis is Brudzinski's sign. Severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed.

24. Skin rashes 10/11/2017 24 Is due to small skin bleed All parts of the body are affected The rashes do not fade under pressure Pathogenesis: a. Septicemia b. wide spread endothelial damage c. activation of coagulation d. thrombosis and platelets aggregation e. reduction of platelets (consumption ) f. BLEEDING 1.skin rashes 2.adrenal hemorrhage Adrenal hemorrhage is called Waterhouse- Friderichsen Syndrome.It cause acute adrenal insufficiency and is uaually fatal

25. ‘ Glass Test’ 10/11/2017 25 A rash that does not fade under pressure will still be visible when the side of a clear drinking glass is pressed firmly against the skin. If someone is ill or obviously getting worse, do not wait for a rash. It may appear late or not at all. A fever with a rash that does not fade under pressure is a medical emergency.

26. Aseptic meningitis 10/11/2017 26 Definition: A syndrome characterized by acute onset of meningeal symptoms, fever, and cerebrospinal fluid pleocytosis , with bacteriologically sterile cultures. Laboratory criteria for diagnosis : CSF showing ≥ 5 WBC/cu mm No evidence of bacterial or fungal meningitis. Case classification Confirmed : a clinically compatible illness diagnosed by a physician as aseptic meningitis, with no laboratory evidence of bacterial or fungal meningitis Comment Aseptic meningitis is a syndrome of multiple etiologies, but most cases are caused by a viral agent

27. Viral - Enterovirus ( coxsackie , echovirus) - Arboviral (mosquito-borne diseases) - Influenza Herpes simplex virus type2 ( especially in infants) Varicella zoster HIV Mumps measles 10/11/2017 27

28. Viral Meningitis 10/11/2017 28 Etiological Agents: Enteroviruses (Coxsackie's and echovirus): most common. -Adenovirus - Arbovirus -Measles virus -Herpes Simplex Virus -Varicella Reservoirs: -Humans for Enteroviruses , Adenovirus, Measles, Herpes Simplex, and Varicella -Natural reservoir for arbovirus birds, rodents etc. Modes of transmission : -Primarily person to person and arthopod vectors for Arboviruses Incubation Period: -Variable. For enteroviruses 3-6 days, for arboviruses 2-15 days Treatment : No specific treatment available . Most patients recover completely on their own .

29. Fungal Cryptococcus Coccidiodes Histoplasma Mucormycosis Aspergillus Candida (yeasts) Parasitic/ protozoal Angiostrongylus Toxoplama Hydatid Amoeba Plasmodium Cysticercosis 10/11/2017 29

30. Symptoms can be the same for Viral and Bacterial 10/11/2017 30

31. COMPLICATIONS 10/11/2017 31 subdural effusion Hydrocephalous Hyponatrenia ( SIADH) damage hearing loss / blindness nd brain ( subdural effusion) Hearing loss seizure Hydrocephal Mental retardness ure

32. DIAGNOSIS 10/11/2017 32 Tests that may be done include: For any patient who is suspected of having meningitis, lumbar puncture (" spinal tap") is done for CSF examination . Blood culture Chest x-ray CSF examination for cell count, glucose, and protein CT scan of the head Gram stain, other special stains, and culture of CSF

33. DIAGNOSIS (contd..) 10/11/2017 33 Specimen: CSF, blood, urine culture Blood tests and imaging Blood tests  are performed for markers of inflammation (e.g. C-reactive protein, complete blood count), as well as blood cultures. Most important is CSF examination by LP. Blood tests are done when it is C/I In severe forms of meningitis, monitoring of blood electrolytes may be important; for example,  hyponatremia  is common in bacterial meningitis.

34. DIAGNOSIS (contd..) Lumbar puncture A lumbar puncture is done by positioning the patient, usually lying on the side, applying  local anesthetic , and inserting a needle into the  dural sac . CT or MRI scan is recommended prior to the lumbar puncture. The CSF sample is examined for presence and types of  white blood cells, red blood cells, protein content and glucose level .  Gram staining  of the sample may demonstrate bacteria in bacterial meningitis (60% cases). C/I: Mass in the brain (tumor or abscess) or the  intracranial pressure (ICP) is elevated. Gram stain   of meningococci from a culture showing Gram negative (pink) bacteria, often in pairs 10/11/2017 34

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36. 10/11/2017 36 Latex agglutination - The clumping of cells such as bacteria or RBCs in the presence of an antibody. The antibody or other molecule binds multiple particles and joins them, creating a large complex. Positive in meningitis caused by  Streptococcus pneumoniae ,  Neisseria meningitidis ,  Haemophilus influenzae ,  Escherichia coli  and  group B streptococci . . DIAGNOSIS (contd..)

37. 10/11/2017 37 Limulus amebocyte lysate (LAL): A n aqueous extract of blood cells ( amoebocytes ) from the horseshoe crab, ( Limulus polyphemus ) . LAL reacts with bacterial endotoxin or lipopolysaccharide (LPS), which is a membrane component of “Gram negative bacteria”. Polymerase chain reaction(PCR) is a technique used to amplify small traces of bacterial DNA DIAGNOSIS (contd..)

38. TREATMENT: ANTIBIOTIC 10/11/2017 38 Therapeutic principle Good permeability for Blood-brain barrier Drug combination Intravenous drip Full dosage Full course of treatment

39. ANTIBIOTIC THERAPY 10/11/2017 39 Selection of antibiotic No Certainly Bacterium Community-acquired bacterial infection Nosocomial infection acquired in a hospital Broad-spectrum antibiotic coverage as noted below Children under age 3 months Cefotaxime and ampicillin Ceftriaxone and ampicillin . Children over 3 months Cefotaxime or Ceftriaxone or ampicillin and chloramphenicol

40. ANTIBIOTIC THERAPY 10/11/2017 40 Certainly Bacterium Once the pathogen has been identified and the antibiotic sensitivities determined, the most appropriate drugs should selected. N meningitides : penicillin, - cephalosporin S pneumoniae : penicillin, - cephalosporin, Vancomycin H influenza: ampicillin, cephalosporin S aureus : penicillin, nefcillin , Vancomycin E coli: ampicillin, chloramphenicol , - cephalosporin Course of treatment 7 days for meningococcal infection 10 ～ 14 days for H influenza or S pneumoniae infection More than 21 days for S aureus or E coli infection 14 ～ 21 days for other organisms

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42. COMPLICATION TREATMENTS 10/11/2017 42 Subdural effusions Subdural pricking Draw-off effusions on one side is 20-30ml/time. Once daily or every other day is requested. Ependymitis Ventricular puncture — drainage Pressure in ventricle be depressed. Ventricular puncture may give ventricle an injection of antibiotic. Hydrocephalus Operative treatment Adhesiolysis By-pass operation of cerebrospinal fluid Dilatation of aqueduct SIADH (Cerebral hyponatremia ) Restriction of fluid supplement of serum sodium diuretic

43. MENINGOCOCCAL 10/11/2017 43 PENICILLIN G is DOC In case of resistance – Ceftriaxone,cefotaxime Uncomplicated course--7 day course. All close contacts should receive chemoprophylaxis – 2 day regimen of rifampicin 600 mg every 12 hrs * 2days/ciprofloxacin 750 mg od/ azithromyxin 500 mg OD/ceftriaxone 250 mg OD Who are close contacts --- nasopharyngeal secretions,kissing,toys,beverages use.

44. THANK YOU 10/11/2017 44