Meningitis

Question 1

What is meningitis

Answer 1

Inflammation of the meninges of the brain

Question 2

Causes of meningitis

Answer 2

Viral meningitis
Bacrerial meningitis

Question 3

4 main causes of bacterial meningitis

Answer 3

Streptococcus pneumniae
Neissiera meningitidis
Haemophilus influenzae
Listeria

Question 4

Causes of meninigitis to look out for in neonates, elderly, immunosupressed

Answer 4

Listeria (unpasteurised dairy)
TB esp w HIV

Question 5

Meningitis presenting smyptoms

Answer 5

Headache
Fever
Neck stiffness
Altered mental status
>2+ in 95% conditions but often dont have all

Question 6

What clinical signs can suggest meningitis

Answer 6

Neck stiffness - kerniges, brudzinkis
Rash - non blanching purpuric = meningococcal sepsis

Question 7

What is kerniges test

Answer 7

Flex hip and extend knee
Positive = pain in back and legs

Question 8

What is brudzinkis sign

Answer 8

Passively flex head - positive = flexion at hipe to lift lefs

Question 9

Warning signs of poor prognosis in meningitis

Answer 9

DIC: Rapidly progresive rash
Sev sepsis/shock: Poor peripheral perfusion, cap refill time >4 secs, oliguria and systolic BO <90 (hypotension late sign)
RR<8 or >30
HR <40 or >140
Acidosis <7.3 or BE less than -5
WBC <4
NEURO:
GCS<9 or fluctuating consciousness
Focal neurology
Persistent sizures
Bradycardia and hypertension
Papilloedema

Question 10

What do poor prognositc features predict the presence of in meningitis

Answer 10

Disseminated intravascular coagulation
Severe sepsis/septic shock
Raised ICP

Question 11

Investigations for meningitis

Answer 11

Bloods
LP - PCR, gram stain and culture
Brain imaging before LP with criteria

Question 12

Bloods in meningitis

Answer 12

FBC, U_Es, LFTs, coagulation, CRP, lactate, blood cultures
16SPCR - S.pneumonia and N.meninigitidis

Question 13

What does meningitis look like on LP

Answer 13

High opening pressure
Cloudy
100-50,0000 WCC
Neutrophils
Low glucose
Protein high >1

Question 14

What might mean a non classical LP in meninigitis

Answer 14

If need imaging before and LP significantly delayed, prior antibiotic treaetment

Question 15

When need to do brain imaging before LP

Answer 15

(signs of raised ICP)
New onset or recent seizures
Papilloedmea
Focal neurological deficit
Reduced or deteriorating conscious level (GCS<9)

Question 16

General principles of meningitis managmenet

Answer 16

A-E assess
Sepsis 6
Antibiotic therapy
IV steroids

Question 17

When treat outpatients with meningitis

Answer 17

When meningococcal rash, septic shock/severe OR over an hor before can get to hospital and sus bacterial meningitis - IM benzylpenicillin or ceftriazone

Question 18

Antibiotic therapy given in hospital for meningitis

Answer 18

Antibiotics within 1 hour if sus (just after take tests)
Cefotazime/ceftriazone

Question 19

What antibiotic use if penicillin allergic in meningitis

Answer 19

Chloramphenicol

Question 20

Why use Cefotazime/ceftriazone in meningitis

Answer 20

Cross BBB, high conc in CSF
3rd generation cephalosporin

Question 21

How can steroids benefit patients with meningitis

Answer 21

Modest reduction in mortality in oneumococcal meningitis
Reduction in hearing loss risk

Question 22

When give steroids in meningitis

Answer 22

Start dexamethasone before antibiotics
If cant then in first 12 hours beneficial
Continue if + pneumococcal or Hib
DO NOT GIVE in meningococcal disease unless shock not responding to vasoactive agents - hten low dose

Question 23

Prognosis of meningococcal infection

Answer 23

Mortality - children 4-8%, adults 7%
Significant morbiditiy - 10%

Question 24

Prognosis of pneumococcal meningitis

Answer 24

8% child mortality, 20-40% adukt
30-50% of survivors morbidity significant

Question 25

Most common morbidities left with after meningitis

Answer 25

Deafness Cognitive impiarment Focal neurological deficits Epilepsy

Question 26

Which infection is post exposure prophylaxis used in meningitis

Answer 26

ONLY meningococcal infection

Question 27

What is the aim of PE prophylaxis meningitis

Answer 27

Eradicate nasal carriage of N.meningitidis

Question 28

Who is PE prophylaxis for M meninitis offered to

Answer 28

Close contacts - house, halls High risk exposure - AW secretions intubation etc

Question 29

Recommended PE prophylaxis for meningococcal meningitiis

Answer 29

Ciprofloxacin oral single dose Rifampacin 2 days IM ceftriaxone single dose

Question 30

What vaccinations available against bacterial meningitis

Answer 30

Haemopholus influenzae B meningitis ACWY Men B Strep pneumoniae

Question 31

What viruses can cause viral meningitis

Answer 31

Enteroviruses > HSV1+2 >VZV

Question 32

How differentiate viral vs bacterial meningitis

Answer 32

Difficult clinically Need PCR - myphocytosis w normal proteina nd glucose, viral PCR

Question 33

Treatment for viral meningitis

Answer 33

Self limitng and managed supportively (no benefit of antivirals)

Question 34

Prognosis of viral meningitis

Answer 34

Significant long term morbidity Slow recovery Headaches, fatigue, slowed thinking, mood disturbance

Question 35

Risk factors for a fatal outcome in meningococcal disease.

Answer 35

apidly progressing rash Coma Hypotension and shock Lactate >4 mmol/L Low/normal peripheral white blood cell count Low acute phase reactants Low platelets Coagulopathy Absence of meningitis

Question 36

What tests do after LP viral memninigtis

Answer 36

PCR for enteroviruses, HSV 1+2, VZV on CSF smaple

Question 37

What test should all patients with meningitis be offered

Answer 37

HIV

Question 38

When do CT beore LP

Answer 38

Whem risk of gross cerebral pathology eg sapce occupying lesion, infart, haemorrhage eg post seizure

Question 39

When get cultures back in bacterial meningitis, when continue vs stop steroids

Answer 39

Continue if pneumococcal or Hib Otherwise stop

Question 40

What give if concerned about ICP in meningtiis

Answer 40

mannitol or hypertonic sodium chloride NOT glycerol

Question 41

What explore after meningitis infection immunity

Answer 41

Babies - inspect for sinus tract Test for HIV Immunity history Pneumococcal meningitis in paeds REFER to immunology for primary immunodeficiecny investigation