meningitis meningitis outcome variable acute benign form of viral to rapidly fatal bacterial...
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MENINGITISMENINGITIS
OUTCOMEOUTCOME VARIABLEVARIABLE
Acute Acute BenignBenign Form of Viral Form of Viral
TOTO
Rapidly Rapidly FatalFatal Bacterial Meningitis Bacterial Meningitis
WITHWITH
Local Progressive mentalLocal Progressive mental
deteriorationdeterioration and death and death
Meningitis – inflammation of the Meningitis – inflammation of the meningesmeninges
Encephalitis – infection of the Encephalitis – infection of the brain parenchymabrain parenchyma
Meningoencephalitis – Meningoencephalitis – inflammation of brain + inflammation of brain + meningesmeninges
Aseptic meningitis – inflammation Aseptic meningitis – inflammation of meninges with sterile CSFof meninges with sterile CSF
Introduction Meningitis: inflammation of the
pia mater and the arachnoid mater, with suppuration of the cerebrospinal fluid
Symptoms of Symptoms of meningitismeningitis FeverFever Altered consciousness, irritability, Altered consciousness, irritability,
photophobiaphotophobia Vomiting, poor appetiteVomiting, poor appetite Seizures 20 - 30%Seizures 20 - 30% Bulging fontanel 30%Bulging fontanel 30% Stiff neck or nuchal rigidityStiff neck or nuchal rigidity Meningismus (stiff neck + Brudzinski + Meningismus (stiff neck + Brudzinski +
Kernig signs)Kernig signs)
Contraindications:Contraindications: ICP reported to increase ICP reported to increase
risk of herniationrisk of herniation– Cellulitis at area of tapCellulitis at area of tap– Bleeding disorderBleeding disorder
WHAT DETERMINE THE WHAT DETERMINE THE OUTCOME?OUTCOME?
1.1. Etiological organismEtiological organism
2.2. Speed and appropriation of Speed and appropriation of the the therapy.therapy.
MORTALITYMORTALITY
Bacterial Meningitis Bacterial Meningitis :: 40 % 40 %
CAUSES OF MENINGITISCAUSES OF MENINGITISINFECTIOUSINFECTIOUS NON-INFECTIOUSNON-INFECTIOUS
ViralViral Aseptic MeningitisAseptic Meningitis
BacteriaBacteria MalignancyMalignancy
MycobacterialMycobacterial SarcoidSarcoid
BrucellaBrucella behcet diseasebehcet disease
FungalFungal SLESLE
Viral Meningitis Generally benign, rarely fatal Enterovirus: around 80% of cases Other viruses: mumps, Epstein-Barr virus, Rare but serious forms: Herpes group viruses No specific preventive or curative treatment
for most except Herpes viruses Clears up on its own with no treatment in 3 to 8 days
Bacterial meningitis - Bacterial meningitis - OrganismsOrganisms NeonatesNeonates
– Most caused by Group B Most caused by Group B StreptococciStreptococci
– E coli, E coli, enterococci,enterococci, Klebsiella, Klebsiella, Enterobacter, Samonella, Serratia, Enterobacter, Samonella, Serratia, ListeriaListeria
Older infants and childrenOlder infants and children– Neisseria meningitidis, S. Neisseria meningitidis, S.
pneumoniae, tuberculosis, H. pneumoniae, tuberculosis, H. influenzaeinfluenzae
Causes of bacterial Causes of bacterial meningitismeningitis
Strep pneumonia………….37Strep pneumonia………….37 Neisseria meningitides…..13Neisseria meningitides…..13 Listeria monocytogenes….10Listeria monocytogenes….10 Other strept.species……….7Other strept.species……….7 Gram negative……………….4Gram negative……………….4 Haemophillus influenza……4Haemophillus influenza……4 No pathogens………………37No pathogens………………37
Review of 493 cases of adult meningitsReview of 493 cases of adult meningits(Durand NEJM 1993 )(Durand NEJM 1993 )
APPROACHAPPROACH TOTO PATIENTPATIENTWITH POSSIBLE MENINGITISWITH POSSIBLE MENINGITIS
I) I) Maintain diagnostic Maintain diagnostic VIGILANCEVIGILANCE
a.)a.) Suspect the diseases Suspect the diseases b.)b.) Look for classical features Look for classical features
1) Headache1) Headache
2) meningeal irritation….2) meningeal irritation….HOW?HOW?
3) Obtundation3) Obtundation
c.) Confirm or exclude the diagnosisc.) Confirm or exclude the diagnosis
II)II) INITIATE RAPID TRATMENTINITIATE RAPID TRATMENT
a.a. I.V.I.V. b.b. Large and Large and
sufficient sufficient dosedose c.c. Effective choiceEffective choice
INITIAL MANAGEMENTINITIAL MANAGEMENT APPROACHAPPROACH Recognition of the meningitis
syndrome. Rapid diagnostic evaluation. Emergent antimicrobial &
adjunctive therapy.
III.III. CONSIDER CHANGING CONSIDER CHANGING EPIDEMIOLOGY EPIDEMIOLOGY
A.)A.) Global emergence andGlobal emergence and Prevalence Prevalence of of Penicillin- Resistant Strain of Strep. Penicillin- Resistant Strain of Strep.
pneumonia.pneumonia.
B.)B.) Dramatic Reduction in invasive H.Dramatic Reduction in invasive H.
influenza disease secondary to use of influenza disease secondary to use of conjugate conjugate Haemophillus Type B- Haemophillus Type B- vaccinevaccine..
CC.).) Group B – Streptococci Group B – Streptococci Neonate Neonate Now Now > 50 > 50 also.also.
IV. IV. COMPLEXITIESCOMPLEXITIES OFOFEMPIRIC MANAGEMENTEMPIRIC MANAGEMENT
I FI F Focal SignFocal Sign PappiledemaPappiledema OR OR Focal Neurological Focal Neurological
deficit (often >deficit (often >VI NVI N))
? Brain abscess? Brain abscessChr.Chr. MeningitisMeningitis
DON’TDON’T Delay Administration Delay Administration of Antibioticsof Antibiotics
Bacterial Meningitis - Bacterial Meningitis - TreatmentTreatmentNeonatal (<3 mo)Neonatal (<3 mo) Ampicillin (covers Ampicillin (covers ListeriaListeria))
++ CefotaximeCefotaxime
– High CSF levelsHigh CSF levels– Less toxicity than Less toxicity than
aminoglycosidesaminoglycosides– No drug levels to followNo drug levels to follow
Management Algorithm for Management Algorithm for AdultsAdultsSuspicion of bacterial
meningitisYES
new onset seizure, papilledema, altered level of consciousness, or focal neurological deficit or delay in performance of diagnostic L.P
NO YESBlood c/s & Lumbar
punctureB/C stat
Dexamethasone + empirical Abx
Dexamethasone + empirical Abx
-ve CT-scan of the headCSF is abnormal
NO YES
YESPerform L.P+ve CSF gram stain
Dexamethasone + empirical Abx
Dexamethasone + targeted Abx
CASE ICASE IA 12 year old Nigerian boy A 12 year old Nigerian boy
who has arrived to Riyadh 2 days who has arrived to Riyadh 2 days prior to presentation - C/O prior to presentation - C/O severe headache & Photophobia?severe headache & Photophobia?
How do you approach & manage How do you approach & manage him?him?
Presence of fever & neck Presence of fever & neck stiffness.stiffness.
Neurological deficit & Fundus.Neurological deficit & Fundus. SkinSkin RASH RASH CSF examination:CSF examination: Opening pressure: 260 mm H20Opening pressure: 260 mm H20
& cloudy& cloudy WBCWBC: 1500/ ml. : 1500/ ml.
96% 96%
segmentedsegmented GlucoseGlucose:: 24mg / 24mg /
dldl ProteinProtein:: 200 mg. 200 mg.
MOST LIKELY DIAGNOSIS:MOST LIKELY DIAGNOSIS:– 11.. Neisseria m.Neisseria m.– 2.2. Strep. PneumoniaStrep. Pneumonia– 3.3. H. influenzaH. influenza– 4.4. Listeria monocytogenListeria monocytogen
EPIDEMIOLOGICAL FEATURESEPIDEMIOLOGICAL FEATURES OF OF MENINGOCOCCAL MENINGITISMENINGOCOCCAL MENINGITIS 1.1. Affect children + young Affect children + young
adult adult 2 – 20 years2 – 20 years
2.2. Epidemic usually sero group A & Epidemic usually sero group A & CC
3.3. Nasopharyngeal Acquisition Nasopharyngeal Acquisition
4.4. Predisposing in those with Predisposing in those with Terminal Terminal
Complement Complement deficiencies ( Cs ----- deficiencies ( Cs -----
C9 )C9 )
5.5. SKIN RASH SKIN RASH
a.a. Fulminate meningococcemia Fulminate meningococcemia withwith purpura purpura
b.b. Meningitis Meningitis withwith RASH RASH (Petechiae)(Petechiae)
c.c. Meningitis Meningitis withoutwithout RASH. RASH.
6.6. Mortality 3 - 10 %.Mortality 3 - 10 %.
7.7. D. O. Choice D. O. Choice Penicillin Penicillin I.VI.V..
CASE 2CASE 2A 26 YEAR OLD Saudi female who A 26 YEAR OLD Saudi female who has been C / O unwell & fever & has been C / O unwell & fever & cough and headache for the last 3 cough and headache for the last 3 days. Examination revealed ill – days. Examination revealed ill – looking women with sign of looking women with sign of consolidation consolidation R R Lung base.Lung base.
DIAGNOSISDIAGNOSIS::
Bacteria Pneumonia.Bacteria Pneumonia.
Organism?Organism?
Six (6) hours after admission, her Six (6) hours after admission, her headache became worse and she headache became worse and she became obstunded.became obstunded.
DIAGNOSIS:DIAGNOSIS: ?? MENINGITIS MENINGITIS CSF:CSF: WBC:WBC: 30003000 99% 99%
DMLDML Sugar:Sugar: ZeroZero Protein:Protein: 260 mg/dl. 260 mg/dl. Gram Stain: Gram Stain: Gram +Gram + DIAGNOSIS:DIAGNOSIS: Bacterial…..?Bacterial…..?
Epidemiological Features ofEpidemiological Features ofPneumococcal meningitisPneumococcal meningitis
The most common.The most common. CauseCause
The most killing. The most killing. 20 - 30 % 20 - 30 % DEATHDEATH
May be associated with other May be associated with other Focus:Focus:
a.a. PneumoniaPneumonia 25%25%
b.Otitis Media b.Otitis Media 30%30% c.c. SinusitisSinusitis 15 %15 % d. Head Trauma & CSF Leakd. Head Trauma & CSF Leak
10%10%.. E. splenectoy and SS disease..E. splenectoy and SS disease.. Global emergence of Penicillin – Global emergence of Penicillin –
Resistant.Resistant.
Case presentationCase presentation
30 years old sudanese male who 30 years old sudanese male who was to the ER in confusional state was to the ER in confusional state for few hours befor for few hours befor presentation ..history revealed presentation ..history revealed presence of two attacks of presence of two attacks of seizures in the same day with seizures in the same day with high fever…high fever…
EXAMINATIONEXAMINATION:: Looks unwell Looks unwell - Temp. - Temp.
39°C39°C Neck StiffnessNeck Stiffness - absent- absent FundsFunds - Bilateral - Bilateral
papilledemapapilledema Possible diagnosis:Possible diagnosis: 1.1. MeningitisMeningitis 2.2. Brain abscessBrain abscess 3. Subarachnoid. 3. Subarachnoid.
Hemorrhage…Hemorrhage…
MENINGITISMENINGITIS
1.1. Viral MeningitisViral Meningitis 2.2. Bacterial MeningitisBacterial Meningitis 3.3. Brucella & Brucella &
TuberculosisTuberculosis
PREVENTIONPREVENTION ::CHEMOPROPHYLAXISCHEMOPROPHYLAXIS
Neiseria meningitidisNeiseria meningitidis Eradication of Eradication of
nasopharyngeal carriagenasopharyngeal carriage..(post exposure ) for :..(post exposure ) for :
1)house hold contact1)house hold contact 2)Treating doctor who has 2)Treating doctor who has
examined patient very closelyexamined patient very closely
What drugs are recommonded:What drugs are recommonded:
Rifampicin 600 X 2 d Rifampicin 600 X 2 d Ciprofloxacin 500X1Ciprofloxacin 500X1
Ceftriaxon 125mg I.M X1 Ceftriaxon 125mg I.M X1
VACCINE TOVACCINE TO 1. Hib Type B vaccine 1. Hib Type B vaccine
1.Protection1.Protection
2. Eliminate 2. Eliminate
2.2. Meningococcal vaccine: A, C, Meningococcal vaccine: A, C, Y, W135Y, W135
- Up to 3 years adult - - Up to 3 years adult - Does not affect N. ph. Carriage Does not affect N. ph. Carriage …Does not provide …Does not provide herdherd immunity.immunity.
SupportiveSupportive No antibioticsNo antibiotics AnalgesiaAnalgesia Fever controlFever control Often feel better after LPOften feel better after LP No isolation - Standard No isolation - Standard
precautionsprecautions
Viral meningitis - Viral meningitis - TreatmentTreatment
Caes Caes 56 years saudi women presented to 56 years saudi women presented to
the infectious disease clinic c/o low the infectious disease clinic c/o low grade fever and night sweating for grade fever and night sweating for the last 6 wks…on detailed inquires the last 6 wks…on detailed inquires she admitted to have headache for 4 she admitted to have headache for 4 wks improving on analgesics..wks improving on analgesics..
EXAMINATION:EXAMINATION: T: 38.2..Fully consciousT: 38.2..Fully conscious Neck stiffnes..bilateral papillodemaNeck stiffnes..bilateral papillodema
LABORATORY LABORATORY RESULTS..RESULTS.. CSF:…xanthocromicCSF:…xanthocromic wbc 340 L: 85 %wbc 340 L: 85 % protein 1.5g sugar 25 mg protein 1.5g sugar 25 mg
WHAT IS YOUR ANYLASIS OF THIS WHAT IS YOUR ANYLASIS OF THIS CSF………..CSF………..
1) Partially treated bacterial 1) Partially treated bacterial meningitismeningitis
2) Aseptic meningitis2) Aseptic meningitis 3) Bruclla meningitis3) Bruclla meningitis 4) Tubercoulus meningitis4) Tubercoulus meningitis 5) OTHERS……..5) OTHERS……..
TREATMENTTREATMENT:: A.A. Principles of TherapyPrinciples of Therapy:: 1.1. Multiple drugs. ( INH& Rif.)Multiple drugs. ( INH& Rif.) 2.2. Educate the patient Educate the patient Long Long
therapy therapy 6/12 6/12
3. Tell about Potential side effects 3. Tell about Potential side effects
aa.. Orange sweat & tears with Orange sweat & tears with Rifampicin.Rifampicin.
b.b. HepatitisHepatitis with with INHINH..
4.4. Follow patient closelyFollow patient closely..
B. Commonly Used Drugs:B. Commonly Used Drugs:
1.1. INHINH (Isonized)(Isonized) a. Bactericidal a. Bactericidal inhibit inhibit
DNA DNA synthesissynthesis
b.b. Excellent tissue and Excellent tissue and CNS penetration.CNS penetration.
c.c. Acetylated with liver Acetylated with liver
Renal.Renal. d.d. ToxicityToxicity::
Hepatitis / P.Hepatitis / P.
Neuropathy.Neuropathy. 2.2. RifampicinRifampicin
a.a. Bactericidal Bactericidal inhibit inhibit RNA synthesis RNA synthesis b.b.Excellent tissue & CNS Excellent tissue & CNS
penetrationpenetration c.c. Hepatic excretionHepatic excretion d.d. Toxicity : Hepatitis / Toxicity : Hepatitis /
RASH RASH / Drugs / Drugs
interactioninteraction
MALARIAMALARIAFebrile illness caused by Febrile illness caused by
PlasmodiumPlasmodium..200 – 300,000,000 cases.200 – 300,000,000 cases.
700,000---2.7,000,000 death/year700,000---2.7,000,000 death/year more in rural area..more in rural area.. more during rainy seasonmore during rainy season
Human Human ---- --------- ----- Another Another
MosquitoMosquito
TransmissionTransmission
BITE OF FEMALE ANOPHELESBITE OF FEMALE ANOPHELES BETWEEN DUSK AND DAWNBETWEEN DUSK AND DAWN BLOOD TRANSFUSIONBLOOD TRANSFUSION CONTAMINATED NEEDLESCONTAMINATED NEEDLES CONGENITAL.CONGENITAL.
ETIOLOGYETIOLOGY Four species. Four species.
Death is mostly due to ..? Death is mostly due to ..?
SYPMTOMSSYPMTOMS------ Non-specific Non-specific
Headache & Headache & fatigue & fatigue &
muscle painmuscle pain
FeverFeverDXDX:: Viral infection..? Viral infection..?
Clinical Features:Clinical Features: Symptoms:Symptoms: 7 – 10 days7 – 10 days
Malaria Malaria Paroxysms.Paroxysms.Cold Cold Chills & Rigor & cold skinChills & Rigor & cold skin
HotHot Fever, warm skin Fever, warm skin
3-63-6hourshours deverevescencedeverevescence Marked Marked
sweating sweating
Between Paroxyms Between Paroxyms Well Well DX ?DX ?
SIGNSSIGNS
Spleen EnlargementSpleen Enlargement JaundiceJaundice FeverFever AnemiaAnemia
Clinical example:Clinical example:
An 18 years old Saudi An 18 years old Saudi pregnant young women pregnant young women originally from Jazan came C/O originally from Jazan came C/O Fever and headache.Fever and headache.
Exam: Exam: Pale, jaundiced, Pale, jaundiced,
Temp. - 39°CTemp. - 39°C
Spleen enlarged Spleen enlarged NEXT?NEXT?
CBC:CBC: WBC - 8000 WBC - 8000
Hb - 9.0Hb - 9.0
Platelets: Platelets: 90 90 MCU : 98MCU : 98
CXR:CXR: NormalNormal
DIAGNOSISDIAGNOSIS1.1. Index of suspicionIndex of suspicion
Travel hist.Travel hist. Incubation PeriodIncubation Period 2 WKS2 WKS Prophylaxis Prophylaxis -- Longer Longer
2.2. ? Malaria? Malaria 3.3. Blood smear :Thin & thickBlood smear :Thin & thick 4.4. Special DrugSpecial Drug
COMPLICATION:COMPLICATION: 1.1. CerebralCerebral MalariaMalaria encephalopathyencephalopathy SeizureSeizure Death 20%Death 20% 2.2. Black. Water FeverBlack. Water Fever non immunenon immune High degree High degree
of F.M.of F.M. HemolysisHemolysis
Malaria & Pregnancy:Malaria & Pregnancy:
1.1. Risk of low birth & abortion. Risk of low birth & abortion. 2.2. Risk of glucose , pulm. Risk of glucose , pulm.
oedemaoedema
TREATMENTTREATMENT
1.1. HistoryHistory 2.2. SmearSmear 3.3. SpeciesSpecies
TREATMENTTREATMENT 1.1. Uncontrolled airway Uncontrolled airway 2.2. I.V . infusion I.V . infusion
Blood glucose test, Blood glucose test, parasitemia, Hct.parasitemia, Hct. 4.4. Antimalaria. Antimalaria. a.a. Chloroquine p.o.Chloroquine p.o. b.b. MefloquineMefloquine C .C . Quinine AND DOXYCYCLINE Quinine AND DOXYCYCLINE D. ARTEMISININSD. ARTEMISININS E . ATOVAQUONE PLUS E . ATOVAQUONE PLUS
PROGUANELPROGUANEL 5.5. Fluid balanceFluid balance P. EdemaP. Edema Dehydration & ShockDehydration & Shock 6. Convulsion6. Convulsion DiazepamDiazepam 7.7. Blood C/ S……8) LP Blood C/ S……8) LP
DRUG TOXICITYDRUG TOXICITY
MEFLOQUINE : neuropsychiatric MEFLOQUINE : neuropsychiatric symptoms : mood symptoms : mood changes .encephalopathy…changes .encephalopathy…transienttransient
QUININE : Bitter taste , GIT upset QUININE : Bitter taste , GIT upset , cinchonism ( nausea, vomiting , , cinchonism ( nausea, vomiting , tinnitus , high tone deafness )tinnitus , high tone deafness )
Doxycycline ..GIT upset, vaginal Doxycycline ..GIT upset, vaginal candidiasis..( use antifungal ) candidiasis..( use antifungal )
PREVENTIONPREVENTION
Avoid mosquitoAvoid mosquito Wear long sleeved clothingWear long sleeved clothing Sleep in well – screened roomsSleep in well – screened rooms Use mosquito nettingUse mosquito netting Use insect repellents (e.g. Use insect repellents (e.g.
DEET)DEET) Chemoprophylaxis..Chemoprophylaxis..
1) CHLOROQUINE1) CHLOROQUINE ONE TABLET EVERY WK..ONE TABLET EVERY WK.. DAILY WILL LEED TO DAILY WILL LEED TO
RETINOPATHYRETINOPATHY Consider resistant plasmodiumConsider resistant plasmodium
Chloroquine-sensitive areas Chloroquine-sensitive areas Drug of choice Drug of choice Chloroquine 500 mg (300 mg base)Chloroquine 500 mg (300 mg base) : :
once/wk once/wk Atovaquone/ proguanil (Malarone) : 1 tab/d Atovaquone/ proguanil (Malarone) : 1 tab/d ( 250 mg atovaquone( 250 mg atovaquone //100 mg proguanil)100 mg proguanil) Mefloquine 250 mg once/wk Mefloquine 250 mg once/wk
Doxycycline 100 mg dailyDoxycycline 100 mg daily Alternatives Alternatives Primaquine 30 mg base dailyPrimaquine 30 mg base daily Chloroquine plus proguanil 500 mg (300 Chloroquine plus proguanil 500 mg (300
mg base) oncemg base) once // wk + 200 mg wk + 200 mg