Meningitis

Presented by :Dr. Alaa Nugud

ABH- Medical Department
Definition
Acute infection of the meninges
causes
 Bacteria
Neisseria meningitides
Streptococcus pneumoniae
H.Influenzae
Listeria monocytogenes
Mycobacterium tuberculosis
 Viruses
Enteroviruses( echo, coxsackie, polio)
Influenza
Herpes simplex
HIV
 Other causative organisms
Toxoplasma
Histoplasma
Candida
 Non-infective causes
Malignant cells
Drugs (mainly NSAIDs, antibiotics and intravenous
immunoglobulins)
.Blood following subarachnoid haemorrhage
Inflammatory disease (Sarcoidosis ,SLE ,Behçet's disease)
Clinical Features
Features of Meningeal irritation
 Neck stiffness
 +ve Kernig’s sign
 +ve Brudzinki’s sign
 Photophobia

Features of Infection
 Fever
 Rigors

Features of ↑ ICP:
 Headache
 Vomiting
 Deterioration in the level of consciouness
 Seizures
Acute Bacterial Meningitis
♦ Meningitis belt
♦ epidemic zones
♦ sporadic cases
Meningococcal Meningitis
Caused by bean shaped gram –ve dipolococcus
N.Mengitides
The reservoir of Neisseria meningitidis is found in the
nasopharynx of asymptomatic carriers
Incubation period: 1-5 days.
Occur mostly in winter, may occur in epidemics
After a meningococcal bacteremia, it is possible for
the clinical picture of meningitis to occur.
In meningococcal septicemia a combination of
purpura and maculopapular exanthema occurs in
approximately 75% of cases
There are significant differences in the local distribution

N. meningitides groups B and C cause most disease

episodes in Europe

N. meningitides group A is found in Asia and Africa,

where it accountins for about 80% to 85% of
documented meningococcal meningitis cases in the
meningitis belt
S.Pneumoniae Meningitis
Predisposing factors:
 Otitis media
 pnumonia
 Sinusitis
 Spleenectomy
 Head trauma with basilar skull fracture

Otoneurological complications occur in up to 25% of

cases.
Listeria monocytogenes meningitis
More likely in:
Diabetics
Alcoholics
Immunocompromised
Pregnant women
Clinical picture of bacterial Meningitis
Abrupt onset
Triad of fever, headache, neck stiffness
Signs of meningeal irritation
Features of complication:
Progressive drowsiness
Cranial nerve palsies
Focal neurogical deficits
Sezuires
Septicemia, DIC, shock
SIADH
Investigations
CBC,PT,PTT
CRP
U&E (R/O SIADH)
Blood cultures
CT
LP
Managment
Don’t Delay The Treatment
If bacterial meningitis and especially if meningococcal disease
suspected, general practitioners should give benzylpenicillin
(1.2 g IM/IV) before urgent transfer to hospital
When the causative organism is unknown antibiotics will be
given empirically based on the clinical settings and age of
patient:
Patients with typical meningococcal rash are given
benzylpenicillin 2.4 g every 4 hours.
Patients <55 yrs: cefotaxime 2g 6 hourly
Patients >55yrs :Cefotaxime + Ampicillin 2g 4 hourly
Once organism is isolated , antibiotics are given according to
sensetivities
Adjunctive therapy
Consider adjunctive treatment with dexamethasone
(particularly if pneumococcal meningitis suspected in
adults) starting before or with first dose of
antibacterial
Avoid dexamethasone in
septic shock
 meningococcal disease
 if immunocompromised
meningitis following surgery
Manitol: when there is ↑ ICP due to cerebral oedema
Tuberculous Meningitis
The diagnosis is made more difficult by the insidious course of
the disease over a period of days to weeks
uncharacteristic symptoms such as a reduced state of general
health, night sweats, weight loss, and subfebrile temperatures.
Meningism is absent in a fifth of patients with TB meningitis
In 75% evidence of TB outside the CNS can be found.
The treatment of TB meningitis is isoniazid, rifampcin,
pyrazinamide and ethambutol for two months, followed by
isoniazid and rifampicin alone for a further ten months.
Steroids are always used in the first six weeks of treatment
(and sometimes for longer).
Analysis of the CSF
Glucose Protein Predominant cells and Appearance Diagnosis
concentration concentration cell count

⅔ - ½ blood 15−45 mg/dL Lymphocytes Clear Normal

glucose 5/mm3 Findings

< ½ blood 50−1500 mg/dL 90% granulocytes, Turbid Bacterial

glucose 500−20000 infection

< ½ blood 45−500 mg//dL Lymphocytes, Turbid/viscous TB

glucose 100-300 mm3

> ½ blood up Initially granulocytes, Clear/turbid Viral

glucose to 120 mg/dL, after 48 h lymphocytes infection
10-100 mm3