meningitis case-study

meningitis case-study summary for apprach to case of meningitis by DR/mohamed abdelaziz ali -egypt

1. Approach to Approach to
A case of meningitisA case of meningitis
Presented by
DR MOHAMED ABDELAZIZ
march 2012

2. MENINGES

3. MENINGES

4. MENINGITISMENINGITIS
Meningitis is an inflammatory response Meningitis is an inflammatory response
to infections of the meninges and to infections of the meninges and
CSF,CSF,caused by bacteria, viruses, fungi,
and other organisms such as protozoa
and rickettsia.

5. Types of MeningitisTypes of Meningitis
Pyogenic Bacterial meningitisPyogenic Bacterial meningitis
Aseptic (viral) meningitisAseptic (viral) meningitis
Tubercular meningitisTubercular meningitis

6. Case studyCase study
an infant, a 9 month old girl,presents to casuality an infant, a 9 month old girl,presents to casuality
with history of fever,vomiting and loose stool over the with history of fever,vomiting and loose stool over the
last 3 days. She had a brief convulsion just before last 3 days. She had a brief convulsion just before
arrival at the hospital in the form of a generalized arrival at the hospital in the form of a generalized
colonic siezure with uprolling of the eyes, which colonic siezure with uprolling of the eyes, which
settled spontanously. Mum fells that the child has not settled spontanously. Mum fells that the child has not
been herself for the last few days and seems irritable been herself for the last few days and seems irritable
most of the time.most of the time.
On examination the infant is febrile at 39C, drowzy On examination the infant is febrile at 39C, drowzy
and irritable but had apprpriate reactions on being and irritable but had apprpriate reactions on being
handled,is midly dehydrated and has cool handled,is midly dehydrated and has cool
peripheries. Her throat is slightly inflamed.peripheries. Her throat is slightly inflamed.

7. This infant appear s acutly unwell with fever but This infant appear s acutly unwell with fever but
no obvious source of infection is discribed.no obvious source of infection is discribed.
You must concern about bacterial infection You must concern about bacterial infection
causing septic shock and meningitis.causing septic shock and meningitis.
What are the most important differntial What are the most important differntial
diagnosis?diagnosis?

8. MENINGITIS-DIFFERENTIAL DIAGNOSISMENINGITIS-DIFFERENTIAL DIAGNOSIS
Brain abscessBrain abscess
EncephalitisEncephalitis
Epidural abscessEpidural abscess
Bacterial endocarditis with septic embolismBacterial endocarditis with septic embolism
Subarachnoid hemorrhageSubarachnoid hemorrhage
TumorTumor

9. Neonates
E. Coli
Proteus
Group B Streptococci
Listeria monocytogenes
Enterococcus, Enterobacter,
Klebsiella, Salmonella,
What are the most common
causing pathogen?

10. Pre School ChildrenPre School Children
–Hemophilus influenzaeHemophilus influenzae
–Neisseria meningitidisNeisseria meningitidis
–Streptococcus pneumoniaeStreptococcus pneumoniae
–Mycobacterium tuberculosisMycobacterium tuberculosis

11. Older Children and AdultsOlder Children and Adults
–Neisseria meningitidis (Meningococcus)Neisseria meningitidis (Meningococcus)
–Streptococcus pneumoniae Streptococcus pneumoniae
–Mycobacterium tuberculosisMycobacterium tuberculosis
–Listeria monocytogenesListeria monocytogenes
–Hemophilus influenzaeHemophilus influenzae
–Staphylococcus aureusStaphylococcus aureus

12. What examination findings and observations What examination findings and observations
would you like to establish immediately?would you like to establish immediately?
Look for focusLook for focus
Ears:otitis media,mastoiditis.Ears:otitis media,mastoiditis.
Throat:tonsilitis,epiglottitis,glandular Throat:tonsilitis,epiglottitis,glandular
fever,quinzy.fever,quinzy.
Skin:imptigo,cellulitis,abscess.Skin:imptigo,cellulitis,abscess.
Chest:bronchiolitis,upper respiratory tract Chest:bronchiolitis,upper respiratory tract
infection,pneumonia.infection,pneumonia.
Abdomen:appendicitis,perforations,abscess.Abdomen:appendicitis,perforations,abscess.
Bone and joint:osteomylitis,septic arthritis.Bone and joint:osteomylitis,septic arthritis.

13. Look for focusLook for focus
blood:septecaemia,toxic shock,acute viraemia.blood:septecaemia,toxic shock,acute viraemia.
renal:urinary tract infection,pyelonephritis.renal:urinary tract infection,pyelonephritis.
gastrointestinal tract:viral or bacterial GE.gastrointestinal tract:viral or bacterial GE.
CNS:encephalitis or brain abscessCNS:encephalitis or brain abscess

14. What are the clinical picture?What are the clinical picture?
Bacterial meningitis usually presents in two Bacterial meningitis usually presents in two
patternspatterns
–Acute - common with S. pneumoniae and N. Acute - common with S. pneumoniae and N.
meningitidesmeningitides
–Subacute - preceding URI like symptoms, Subacute - preceding URI like symptoms,
more common with H. influenza and other more common with H. influenza and other
pathogenspathogens

15. HeadacheHeadache
Fever Fever
DrowsinessDrowsiness
Neck stiffnessNeck stiffness
Nausea and vomitingNausea and vomiting
IrritabilityIrritability
Aversion to lightAversion to light
RestlessnessRestlessness
Altered mental status (Stupor,Coma)Altered mental status (Stupor,Coma)
SeizureSeizure
Menngococcal meningits - Purpural rashes(70% )Menngococcal meningits - Purpural rashes(70% )
Most common
CLINICAL PRESENTATIONCLINICAL PRESENTATION

16. Skin rashesSkin rashes
Is due to small skin bleedIs due to small skin bleed
All parts of the body are affecedAll parts of the body are affeced
The rashes do not fade under pressureThe rashes do not fade under pressure
Pathogenesis:Pathogenesis:
a. Septicemiaa. Septicemia
b. wide spread endothelial damage b. wide spread endothelial damage
c. activation of coagulationc. activation of coagulation
d. thrombosis and platelets aggregationd. thrombosis and platelets aggregation
e. reduction of platelets e. reduction of platelets

18. What are the signs and findings in physical What are the signs and findings in physical
examinations?examinations?
Bulging fontanelBulging fontanel
Focal neurological signsFocal neurological signs
Neck rigidity Neck rigidity
Ptosis, papilloedema,Ptosis, papilloedema,
Cushing’s triad (Bradycardia, Hypertension, Cushing’s triad (Bradycardia, Hypertension,
Altered respirations) Altered respirations)
Positive Kernig’s and Brudzinski’s signPositive Kernig’s and Brudzinski’s sign

19. KERNIG’S SIGNKERNIG’S SIGN
Patient placed supine with hips flexed 90 Patient placed supine with hips flexed 90
degrees. Examiner attempts to extend the leg degrees. Examiner attempts to extend the leg
at the kneeat the knee
Positive test elicited when there is resistance to Positive test elicited when there is resistance to
knee extension, or pain in the lower back or knee extension, or pain in the lower back or
thigh with knee extension due to meningeal thigh with knee extension due to meningeal
irritationirritation

21. BRUDZINSKI’S SIGNBRUDZINSKI’S SIGN
Patient placed in supine position and neck is Patient placed in supine position and neck is
passively flexed towards the chestpassively flexed towards the chest
Positive test is elicited when flexion of neck Positive test is elicited when flexion of neck
causes flexion at knees and/or hips of the causes flexion at knees and/or hips of the
patientpatient

23. What are the investigations requied for this What are the investigations requied for this
infantinfant
CT or MRI are indicated if there are focal CT or MRI are indicated if there are focal
neurological signs,raised ICP or prolonged neurological signs,raised ICP or prolonged
fever. These are helpful in detection of CNS fever. These are helpful in detection of CNS
complication of bacterial infections such as complication of bacterial infections such as
hydrocephalus,cereberal infract,brain abscess hydrocephalus,cereberal infract,brain abscess
and venous sinus thrombosis.and venous sinus thrombosis.
Lumber puncture :Lumber puncture :

24. MENINGITIS-DIAGNOSISMENINGITIS-DIAGNOSIS

25. ConditionConditionAppearanceAppearance WBC/mmWBC/mm
3 3
Predominant Predominant
typetype
GlucoseGlucose Total Total
ProteinProtein
NormalNormal ClearClear 0-5 0-5
lymphocyteslymphocytes
50-7550-75
>60% of >60% of
Blood Blood
glucoseglucose
15-4015-40
BacterialBacterial TurbidTurbid 100-10,000100-10,000
PMNPMN
<45<45 100-1000100-1000
ViralViral ClearClear 10- 200010- 2000
lymphocyteslymphocytes
NormalNormal 50-10050-100
FungalFungal CloudyCloudy <300<300
lymphocyteslymphocytes
<45<45 40-30040-300
TBTB CloudyCloudy <500<500
lymphocyteslymphocytes
<45<45 100-1000100-1000
CSF Patterns in Meningitis

26. OTHER INVESTIGATIONSOTHER INVESTIGATIONS
CBCCBC
–Normal WBC does not rule out meningitisNormal WBC does not rule out meningitis
Blood culturesBlood cultures
ElectrolytesElectrolytes
Renal functionRenal function
Serum glucoseSerum glucose
- Useful to compare with CSF glucose- Useful to compare with CSF glucose
Other relevant investigationsOther relevant investigations

27. Quick initiation of antibiotics is a mustQuick initiation of antibiotics is a must
Typical Meningococcal rashTypical Meningococcal rash
Benzyle Penicillin 2.4 G IV 6Benzyle Penicillin 2.4 G IV 6
thth
hrly hrly
Adults without Typical Meningococcal rashAdults without Typical Meningococcal rash
Cefotaxime 2 G IV 6Cefotaxime 2 G IV 6
thth
hrly or hrly or
Ceftriaxone 2 G IV 12Ceftriaxone 2 G IV 12
thth
hrly hrly
Pinicillin Resistant pnuemococciPinicillin Resistant pnuemococci
Cefotaxime or Ceftriaxone Cefotaxime or Ceftriaxone
+ Vancomycin 1gm IV 12+ Vancomycin 1gm IV 12
thth
hrly hrly
Alter antibiotic choices once CSF gram stain results are available .Alter antibiotic choices once CSF gram stain results are available .
What is the treat ment of this case?What is the treat ment of this case?
Bacterial MeningitisBacterial Meningitis

28. N . meningitidisN . meningitidis
Inj Benzyle Penicillin 2.4 G IV 6Inj Benzyle Penicillin 2.4 G IV 6
thth
hrly * 5-7 days hrly * 5-7 days
Strep. pneumoniaeStrep. pneumoniae / / H. influenaeH. influenae
InjInj Cefotaxime 2 G IV 6Cefotaxime 2 G IV 6
thth
hrly or hrly or
Inj Ceftriaxone 2 G IV 12Inj Ceftriaxone 2 G IV 12
thth
hrly * 10-14 days hrly * 10-14 days
Pinicillin Resistant pnuemococciPinicillin Resistant pnuemococci
InjInj Cefotaxime or Ceftriaxone Cefotaxime or Ceftriaxone
+ Inj Vancomycin 1gm IV 12+ Inj Vancomycin 1gm IV 12
thth
hrly hrly
Listeria monocytogenesListeria monocytogenes
Inj Ampicillin 2G iv 6 hrlyInj Ampicillin 2G iv 6 hrly
+ Inj Gentamycin 5g/kg iv * 8- 10 days+ Inj Gentamycin 5g/kg iv * 8- 10 days

29. Supportive CareSupportive Care
SteroidsSteroids
–Steroids thought to blunt effects of host inflammatory Steroids thought to blunt effects of host inflammatory
responseresponse
–Theoretical concern of steroids reducing permeability of Theoretical concern of steroids reducing permeability of
blood brain barrier to antibioticsblood brain barrier to antibiotics
Consider repeat LP 24-36 hours after initiating treatment to Consider repeat LP 24-36 hours after initiating treatment to
assure sterilization of CSF if resistant organism or poor assure sterilization of CSF if resistant organism or poor
response to treatmentresponse to treatment
Features of Septicaemia – ICU CareFeatures of Septicaemia – ICU Care

30. Why do we use steroids?Why do we use steroids?
Decreases inflammation which can lead to decreased Decreases inflammation which can lead to decreased
intracranial pressure.intracranial pressure.
May interrupt the cytokine mediated neurotoxic effects of May interrupt the cytokine mediated neurotoxic effects of
bacteriolysis, which are at a maximum during the first few bacteriolysis, which are at a maximum during the first few
days of antibiotic therapy.days of antibiotic therapy.
Proven reduction in morbidity, such as severe hearing loss, in Proven reduction in morbidity, such as severe hearing loss, in
children with HiB meningitis and Strep. Pneumo meningitis.children with HiB meningitis and Strep. Pneumo meningitis.
Proven reduction in mortality in adults and children with Proven reduction in mortality in adults and children with
tuberculous meningitis(particularly due to a reduction in tuberculous meningitis(particularly due to a reduction in
hepatitis secondary to treatment of TB.)hepatitis secondary to treatment of TB.)

31. When Do We Use Steroids?When Do We Use Steroids?
Therapy should be initiated shortly before or at Therapy should be initiated shortly before or at
the same time as the first dose of antibiotics, the same time as the first dose of antibiotics,
(likelihood of unfavorable outcome was much (likelihood of unfavorable outcome was much
higher in patients in whom dexamethasone higher in patients in whom dexamethasone
was given after antibiotics).was given after antibiotics).
Dexamethasone should not be given to adults Dexamethasone should not be given to adults
who have already received antibiotics, because who have already received antibiotics, because
it has not been shown to improve patient it has not been shown to improve patient
outcomes.outcomes.

32. What is the prognosis of this caseWhat is the prognosis of this case
Even with appropriate antibiotics, mortality Even with appropriate antibiotics, mortality
rate is significantrate is significant
–8% H.influenza, 8% H.influenza,
–15% Neisseria meningitidis, 15% Neisseria meningitidis,
–25% Pneumococcal25% Pneumococcal
Up to 35% of survivors have sequelae Up to 35% of survivors have sequelae
including deafness, seizures, blindness, including deafness, seizures, blindness,
paresis, ataxia, hydrocephalusparesis, ataxia, hydrocephalus

33. thank youthank you

34. VIRUSES
Enteroviruses (coxsackievirus, echovirus, poliovirus, enterovirus)
Arboviruses: Eastern equine, Western equine, Venezuelan equine, St. Louis encephalitis,
Powassan and California encephalitis, West Nile virus, Colorado tick fever
Herpes simplex (types 1 ,2)
Human herpesvirus type 6
Varicella-zoster virus
Epstein-Barr virus
Parvovirus B1 9
Cytomegalovirus
Adenovirus
Variola (smallpox)
Measles
Mumps
Rubella
Influenza A and B
Parainfluenza
Rhinovirus
Rabies
Lymphocytic choriomeningitis
Rotaviruses
Coronaviruses
Human immunodeficiency virus type 1

35. BACTERIA
Mycobacterium tuberculosis
Leptospira species (leptospirosis)
Treponema pallidum (syphilis)
Borrelia species (relapsing fever)
Borrelia burgdorferi (Lyme disease)
Nocardia species (nocardiosis)
Brucella species
Bartonella species (cat-scratch disease)
Rickettsia rickettsiae (Rocky Mountain spotted fever)
Rickettsia prowazekii (typhus)
Ehrlichia canis
Coxiella burnetii
Mycoplasma pneumoniae
Mycoplasma hominis
Chlamydia trachomatis
Chlamydia psittaci
Chlamydia pneumoniae
Partially treated bacterial meningitis

36. BACTERIAL
PARAMENINGE
AL FOCUS
Sinusitis
Mastoiditis
Brain abscess
Subdural-epidural empyema
Cranial osteomyelitis
FUNGI
Coccidioides immitis (coccidioidomycosis)
Blastomyces dermatitidis (blastomycosis)
Cryptococcus neoformans (cryptococcosis)
Histoplasma capsulatum (histoplasmosis)
Candida species

37. PARASITES
(EOSINOPHILIC)
Angiostrongylus cantonensis
Gnathostoma spinigerum
Baylisascaris procyonis
Strongyloides stercoralis
Trichinella spiralis
Toxocara canis
Taenia solium (cysticercosis)
Paragonimus westermani
Schistosoma species
Fasciola species
PARASITES
(NONEOSINOPHILI
C)
Toxoplasma gondii (toxoplasmosis)
Acanthamoeba species
Naegleria fowleri
Malaria

38. POSTINFECTIOUS
Vaccines:rabies, influenza, measles, poliovirus
D emyelinating or allergic encephalitis
SYSTEMIC OR
IMMUNOLOGICALLY
MEDIATED
Bacterial endocarditis
Kawasaki disease
Systemic lupus erythematosus
Vasculitis, including polyarteritis nodosa
Sj gren syndrome
ö
Mixed connective tissue disease
Rheumatoid arthritis
Beh et syndrome
ç
Wegener granulomatosis
Lymphomatoid granulomatosis
Granulomatous arteritis
Sarcoidosis
Familial Mediterranean fever
Vogt-Koyanagi-Harada syndrome

39. MALIGNANCY
Leukemia
Lymphoma
Metastatic carcinoma
Central nervous system tumor (e.g., craniopharyngioma, glioma,
ependymoma, astrocytoma, medulloblastoma, teratoma)
DRUGS
Intrathecal infections (contrast media, serum, antibiotics, antineoplastic
agents)
Nonsteroidal anti-inflammatory agents
OKT3 monoclonal antibodies
Carbamazepine
Azathioprine
Intravenous immune globulins
Antibiotics (trimethoprim-sulfamethoxazole, sulfasalazine, ciprofloxacin,
isoniazid)

40. MISCELLANEOUS

Heavy metal poisoning (lead, arsenic)

Foreign bodies (shunt, reservoir)

Subarachnoid hemorrhage

Postictal state

Postmigraine state

Mollaret syndrome (recurrent)

Intraventricular hemorrhage (neonate)

Familial hemophagocytic syndrome

Post neurosurgery

Dermoid-epidermoid cyst