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

Malaria&Travel Malaria&Travel MedicineMedicine

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

4.4. Severity Severity CBC CBC HibHib Coagulation Coagulation

5.5. Drugs:Drugs:

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