PYOGENIC MENINGITIS.pptx. very common Topic

PYOGENIC MENINGITIS.

1. DR: M Sajid Noor FCPS TRAINEE UNIT 3

2. . 9 month old master Rustam weighing 7 kg resident of thatta admitted through ER with complain of fever ………………………………..10 days fits…………………………………….2 days

3. HOPC

4. PAST HISTORY Medical history hx of fever and loose motion one month back ,admitted in thatta hospital for 2 days Surgical History un remarkable

5. Vaccination UN VACCINATED DEVELOPMENTAL NORMAL

6. FAMILY HISTORY Second issue of consanguineous marriage one brother of 4 years of age ,he is healthy and alive All the family members are healthy and no any chronic illness in family

7. SOCIOECONOMIC Belong to poor class family, source of water is tap water

8. EXAMINATION sick looking irritable baby with GCS 15/15 laying on bed with no dysmorphic features H/R 120/mi R/R 26/min temp 100 B.p 90 / 60 A-,,J-,cy-. cl -E-

9. ANTHROPOMETRY WEIGHT 7kg 3 rd centile Height 75 cm 3 rd centile Foc 44 cm 3 rd centile

10. CNS Ant fontanella normal Neck Retracted ,neck stiffness positive Kernig s sign negative Brudzinski s sign negative Tone; increased in all four limbs Power; moving all four limbs against gravity Reflexes; brisk Planter; B/L up going

11. Systemic examination ABDOMEN soft, not distended, non tender, no hepatosplenomegaly CHEST bilateral equal entry HVB CVS s1 + s2+ o

12. PROVISIONAL DIAGNOSED Meningitis Cerebral malaria Encephalitis

13. CBC 30-8-2016 HB 8.4g/dl TLC 39,500 N% 79 L % E M 18 4 2 PLT 924x10 3

14. uce urea 19 crea o.6 calcium 8.1 sodium 142 Potassium 4.5 chloride 100 Rbs 100

15. CSF D/R Physical Examination 1.o cc colour pale yellow APP; C .turbid Glucose………………….60 Proteins………………….295 Chlorides,,,,,,,,,,,,,,,,,,,,108 white cells/cu m.m ……………500 Redcells / cu m.m …………..300 Polymorphs………………80 Lymphocytes……………20

16. CSF GRAM STAINING GRAM POSITIVE COCCI SEEN BINAX TEST. POSITIVE CSF PCR AWAITED

17. MRI BRAIN IMPRESSION Mildly dilated ventricular system with tranependymal csf seepage,in view of history of fever and fits p1ossibility of complicated meningitis can be considered. Focal subdural signal abnormality seen in right pareital region appearing hyperintense on T2 and hypointense on T1 and flair images It is causing mild compression effect over adjacent brain parenchyma,this suggestive of sub dural collection

18. FINAL DIAGNOSED PYOGENIC MENINGITIS ( due to streptococcus pneumoniae )

19. MANAGEMENT PLANE Inj ceftrixone=----------- 700mg iv/OD Inj dexa ----------1.4mg iv/TDS Inj. Vancomycine --------140mg/TDS Inj. Phenytoin dose--------20mg/BD Inj valium……………1.4mg iv/ sos Maintance fluid given Monitoring electrolytes regulerly Watch for fits Monitoring vitals

20. What is meningitis? …… The brain and spinal cord are covered by connective tissue layers collectively called the meninges which form the blood-brain barrier. 1-the pia mater (closest to the CNS) 2-the arachnoid mater 3-the dura mater (farthest from the CNS). The meninges contain cerebrospinal fluid (CSF). Meningitis is an inflammation of the meninges , which, if severe, may become encephalitis, an inflammation of the brain .

21. Causes of Meningitis -Bacterial Infections -Viral Infections -Fungal Infections (Cryptococcus neoformans Coccidiodes immitus) -Inflammatory diseases (SLE) Cancer -Trauma to head or spine.

22. Bacterial meningitis … .. Etiological Agents: Pneumococcal, Streptococcus pneumoniae (38%) Meningococcal, Neisseria meningitidis (14%) Haemophilus influenzae (4%) Staphylococcal, Staphylococcus aureus (5%) Tuberculous, Mycobacterium tuberculosis

23. Bacterial Meningitis Potentially life threatening disease. One million cases per year world wide . 200,000 die annually. Can affect all age groups but some are at higher risk. Treatment available : antibiotics as per causative organism Humans are the reservoir . Pneumococcal meningitis is the most common type. Approximately 6,000 cases/yr Haemophilus meningitis: Since 1985 Incidence has declined by 95% due to the introduction of Haemophilus influenza b vaccine. Other bacterial meningitis caused by E-Coli K-1, Klebsiella species and Enterobacter species are less common overall, but may be more prevalent in newborns, pregnant women, the elderly and immunocompromised hosts.

24. What is Meningococcal disease? Etiological Agent: Neisseria meningitidis Clinical Features: sudden onset. F,H,N,V Reservoir: Humans only. 5-15% healthy carriers Mode of transmission: direct contact with patients oral or nasal secretions. Saliva. Incubation period: 1-10 days. Usually 2-4 days Infectious period: as long as meningococci are present in oral secretions or until 24 hrs of effective antibiotic therapy Epidemiology: Sporadic cases worldwide. “Meningitis belt” –sub-Saharan Africa into India/Nepal. In US most cases seen during late winter and early spring. Children under five and adolescent most susceptible. Overcrowding e.g. dormitories and military training camps predispose to spread of infection.

25. Aseptic Meningitis 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

26. Viral Meningitis 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 .

27. Non Polio Enteroviruses Types : 62 different types known: -23 Coxsackie A viruses, -6 Coxsackie B viruses, -28 echoviruses, and 5 other How common? -90% of all viral meningitis is caused by Enteroviruses -Second only to "common cold" viruses, the rhinoviruses. -Estimated 10-15 million/ more symptomatic infections/yr in US Who is at risk? Everyone. How does infection spread? Virus present in the respiratory secretions & stool of a patient. Direct contact with secretions from an infected person. Parents, teachers, and child care center workers may also become infected by contamination of the hands with stool.

28. The difference between Meningitis and Septicaemia When bacteria cause disease i.e. meningococcal disease the body can be affected in different ways: Meningitis - bacteria enter the blood stream and travel to the meninges and cause inflammation. Septicaemia - when bacteria are present in the blood stream they can multiply rapidly and release toxins that poison the blood. (The rash associated with meningitis is due to septicaemia.) Meningitis and septicaemia often occur together.

29. Symptoms for meningitis and meningococcal septicaemia : : Babies and Young Children -High temperature, fever, possibly with cold hands and feet -Vomiting or refusing feeds -High pitched moaning, whimpering cry -Blank, staring expression -Pale, blotchy complexion -Stiff neck -Arched back -Baby may be floppy, may dislike being handled, be fretful -Difficult to wake or lethargic -The fontanelle (soft spot on babies heads) may be tense or bulging.

30. Older Children and Adults -High temperature, fever, possibly with cold hands and feet. -Vomiting, sometimes diarrhoea. -Severe headache. -Joint or muscle pains, sometimes stomach cramps. -Neck stiffness (unable to touch the chin to the chest) -Dislike of bright lights. -Drowsiness. The patient may be confused or disorientated. Fitting may also be seen. A rash may develop.

31. 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.

32. 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.

33. In the early stages, signs and symptoms can be similar to many other more common illnesses, foe example flu. Early symptoms can include fever, headache, nausea (feeling sick), vomiting and general tiredness. The common signs and symptoms of meningitis and septicaemia are shown above. Others can include rapid breathing, diarrhoea and stomach cramps. In babies, check if the soft spot ( fontanelle ) on the top of the head is tense or bulging.

34. One sign of meningococcal septicaemia is a rash that does not fade under pressure (see ‘Glass test’) -This rash is caused by blood leaking under the skin. It starts anywhere on the body. It can spread quickly to look like fresh bruises. -This rash is more difficult to see on darker skin. Look on the paler areas of the skin and under the eyelids.

35. ‘Glass Test’ 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 .

36. What to do if you suspect meningitis or septicaemia: Contact your GP immediately. If you GP is not available, go straight to your nearest accident and emergency department. Describe the symptoms carefully and say that you think it could be meningitis or septicaemia Early diagnosis can be difficult. If you have seen a doctor and are still worried, don’t be afraid to ask for medical help again

37. Meningitis and meningococcal septicaemia (blood poisoning) are serious diseases that can affect anyone at any time. Teenagers and studentsin particular, are at increased risk.Most young people in the UK have already had the MenC vaccine. If you haven’t or can’t remember, gettingvaccinated now is a good way to protect yourself. But remember, vaccines can’t preventall forms of meningitis and septicaemia.So it is very important that you are aware of the signs and symptoms so that you can get medical help urgently if you become ill. Be aware , be prepared

38. Public Health Importance Challenges: -Educating public -Timely reporting and records keeping -Updating information daily. -Alleviating public anxiety and concerns -Collaborating with health partners Opportunities : -Educating public -Communication -Strengthening partnerships

39. Distribution of WBC count in CSF specimens, by site, among persons of all ages presenting with suspected acute bacterial meningitis. Jennifer C. Moïsi et al. Clin Infect Dis. 2009;48:S49-S56 © 2009 by the Infectious Diseases Society of America

40. Background characteristics of countries in which an evaluation of the Binax NOW immunochromatographic test of Streptococcus pneumoniae antigen was conducted. Jennifer C. Moïsi et al. Clin Infect Dis. 2009;48:S49-S56 © 2009 by the Infectious Diseases Society of America

41. Percentage of CSF specimens positive for Streptococcus pneumoniae by culture, latex agglutination test (Latex), or an immunochromatographic test (ICT) of pneumococcal antigen (NOW S. pneumoniae Antigen Test; Binax ), among children aged <5 years. Jennifer C. Moïsi et al. Clin Infect Dis. 2009;48:S49-S56 © 2009 by the Infectious Diseases Society of America