Meningoencephalitis by Sunil Kumar Daha

Please find the power point on Meningoencephalitis. I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you

1. Meningoencephelitis Sunil K umar Daha Janakpur , Nepal

2. Meningitis : inflammation of the leptomeninges and CSF within subarachnoid space Meningoencephelitis : involves meningitis and inflammation brain parenchyma

3. Viral Meningitis Most common cause of meningitis Usually benign and self limiting Clinical features: Headache (most severe) Irritability Rapid development of meningism High fever Focal neurological signs (rare)

4. Bacterial meningitis Clinical Features Headache Drowsiness Fever Neck stiffness Focal neurological signs (in severe cases) Photophobia Signs of meningial irritations Kernig’s sign Brudzinski’s sign

5. Tuberculous meningitis Follows Primary infection in childhood, or As a part of miliary TB Occurs more frequently in AIDS patient Clinical features: Headache Vomiting Low grade fever Lassitude Depression Confusion Behavior changes

6. Investigation CBC Culture( Blood, CSF) Lumbar puncture CT Scan

7. Management Viral meningitis No specific treatment usually self limiting Bacterial Meningitis: For unknown cause Patients with a typical meningococcal rash Benzylpenici llin 2.4 g i.v. 6-hourly Adults aged 18-50 years without a typical meningococcal rash Cefotaxime 2 g i.v. 6-hourly or, Ceftriaxone 2 g i.v. 12-hourly

8. 3. Patients in whom penicillin-resistant pneumococcal infection is suspected As for (2) but add: Vancomycin 1 g i.v. 12-hourly OR Rifampicin 600 mg i.v. 12-hourly 4. Adults aged over 50 years and those in whom Listeria monocytogenes infection is suspected (e.g. brain-stem signs, immunosuppression, diabetic, alcoholic) As for (2) but add: Ampicillin 2 g i.v. 4-hourly OR Co- trimoxazole 50 mg/kg i.v. daily in two divided d oses 5. Patients with a clear history of anaphylaxis to β- lactams Chloramphenicol 25 mg/kg i.v. 6-hourly, plus Vancomycin 1 g i.v. 12-hourly

9. For known cause Pathogen Regimen of choice Alternative agent(s) N. meningitidis Benzylpenicillin 2.4 g i.v . 4-hourly for 5-7 days Cefuroxime, ampicillin Chloramphenicol* Strep. pneumoniae (sensitive to β-lactams, minimum inhibitory concentration (MIC) < 1 mg/l ) Cefotaxime 2 g i.v . 6-hourly or ceftriaxone 2 g i.v . 12-hourly for 10-14 days Chloramphenicol* Strep. pneumoniae (resistant to β- lactams ) As for sensitive strains but add vancomycin 1 g i.v . 12-hourly or rifampicin 600 mg i.v . 12-hourly Vancomycin plus rifampicin* H. influenzae Cefotaxime 2 g i.v . 6-hourly or ceftriaxone 2 g i.v . 12-hourly for 10-14 days Chloramphenicol* Listeria monocytogenes Ampicillin 2 g i.v . 4-hourly + gentamicin 5 mg/kg i.v. daily Ampicillin 2 g i.v . 4-hourly plus co- trimoxazole 50 mg/kg daily in two divided doses

10. Management for tuberculous meningitis Chemotherapy should be started using one of the regimens including pyrazinamide Corticosteroids : improves mortality but not focal neurological damage Surgical ventricular drainage if obstructive hydrocephalus develops maintain adequate hydration and nutrition

11. Viral Encephalitis Etiology : Herpes simplex Arbovirus HIV Cytomegalo virus Flavi virus Clinical Features A cute onset of headache F ever F ocal neurological signs (aphasia and/or hemiplegia) Seizure Disturbance of consciousness

12. Investigations CT scan may show low-density lesions in the temporal lobes MRI More sensitive in detecting early abnormalities Lumbar puncture Should only be done after brain imaging has excluded mass Excess lymphocytes PCR for viral DNA

13. Management Anticonvulsant treatment raised intracranial pressure is treated with dexamethasone 8 mg 12-hourly Herpes simplex encephalitis responds to aciclovir 10 mg/kg i.v. 8-hourly for 2-3 weeks (to all patients suspected of viral encephalitis)

14. References Davidson’s Princples and practice of Medicine