Meningitis Flashcards by Sumaya L

What is meningitis?

Inflammation of the meninges, typically secondary to an existing infection or defect increasing risk of infection

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What are some defects that increase the risk of meningitis?

Cribiform plate defect
Otitis media
Sinusitis
Mastoiditis
Basal skull fracture
Pneumonia
Spina bifida

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What are the main causative organisms of meningitis?

Group B streptococcus
Streptococcus pneumonia
Neisseria meningitidis
Gram negative bacilli
Haemophilus influenza

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What are some triggers for meningitis?

Autoimmune disease
Adverse reaction to medication
Infection (most commonly from Neisseria meningitidis or herpes simplex)

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Where is CSF produced and how does it flow?

CSF is produced by lateral ventricles, flows to the third and fourth ventricles, enters the subarachnoid space, and then the venous sinus for return to the heart.

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What is aseptic meningitis?

Meningitis caused by viral, fungi, or parasitic agents, with routine bacterial cultures of CSF being negative.

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What are the common causes of meningitis in infants less than 3 months?

Group B strep
E. coli
Listeria monocytogenes

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What are the common causes of meningitis in children 3 months to 6 years?

Neisseria meningitidis
Streptococcus pneumonia
Haemophilus influenzae

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What are the common causes of meningitis in 13-17 year olds?

Neisseria meningitidis
Streptococcus pneumonia
Haemophilus influenzae

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What are the common causes of meningitis in adults and those over 50?

Streptococcus pneumonia
Neisseria meningitidis
Haemophilus influenzae
Listeria monocytogenes

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What are the signs of bacterial infection in CSF?

Over 100 WBCs with 90% polymorphonuclear cells

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What indicates viral infection in CSF?

10-1000 WBC count with predominant lymphocytes

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What indicates fungal infection in CSF?

High WBC count with lymphocyte predominance

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What is the mode of transmission for meningitis?

Mode of transmission of meningitis can be via direct spread from defect or haematogenous spread through the blood brain barrier. Vulnerable areas include the choroid plexus.

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What is the composition of the meniges?

Meringues is composed of dura, arachnoid and PPIs material. The leptomenigies is the arachnoid and pia amateur together.between the arachnoid and pia material is the subarachnoid space containing CSF.

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What are the symptoms of viral meningitis?

Self-limiting with symptoms improving over 7-14 days, complications are rare in immunocompetent patients.

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What are the risk factors for viral meningitis?

patients at the extremes of age (< 5 years and the elderly)
* immunocompromised, e.g. patients with renal failure, with diabetes
* intravenous drug users

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What is the management of viral meningitis?

whilst awaiting the results of the lumbar puncture, treatment should be supportive and if there is any question of bacterial meningitis or of encephalitis, the patient should be commenced on broad-spectrum antibiotics with CNS penetration e.g. ceftriaxone and aciclovir intravenously. This is particularly the case if the patient has risk factors e.g. elderly, immunocompromised

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What is prognosis of viral meningitis?

viral meningitis is self-limiting, with symptoms improving over the course of 7 - 14 days and complications are rare in immunocompetent patients. Aciclovir may be used if the patient is suspected of having meningitis secondary to HSV.

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What are the classic symptoms of meningitis?

Headache
Fever
Neck rigidity
Photophobia
Phonophobia
Nausea
Vomiting

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What causes CSF with high WBC count of polymorphonuclear?

Bacterial ifnection

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What causes CSF with predominant lymphocytes?

viral infection

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Which meningitis presents within hours to day

Bacterial meningitis and HSV meningoencpehalitis

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Which menigitidis presents over days to week?

viral meningitis and Lyme disease menigitidis

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What meningitis presents months after onset?

tuberuclosis Coccidodes Syphilis meningitis

What is Kernig's sign?

Patient lies flat on back and straightening of knee from knee flexion causes back pain.

What is Brudzinski's sign?

Automatic hip or knee flexion when the patient lying flat has their neck flexed.

What does petechia indicate?

neisseria menigitidis

What is Lyme meningitis associated with?

Erythema chronicum migrants (Bulls-eye rash) and bilateral facial nerve palsy

What is parotitis assoicated with?

mumps meningitis

What is the diagnosis method for meningitis ?

Diagnosis is lumbar puncture between L3-L4 at subarachnoid space to measure pressure and analysed for WBC, protein and glucose level. PCR can be done for the causative agent.

When is lumbar puncture contraindicated?

increased intrcranial pressure due to risk of uncontrolled bleeding

What is the most common viral cause of meningitis?

* Enteroviruses (e.g., coxsackie) * Herpes simplex * HIV

How does tuberculous meningitis occur?

caused by the seeding of the meninges with the bacilli of MTB and is characterized by inflammation of the membranes (meninges) around the brain or spinal cord. collections form called rich foci which rupture into the subarachnoid space resulting in the meningitis symptoms. These can can encase cranial nerves and cause nerve palsies. They can entrap blood vessels, causing vasculitis, and block cerebral spinal fluid (CSF) flow, leading to hydrocephalus.

What is the preferred imaging method for assessing tuberculosis meningitis (TBM)?

MRI is preferred over CT for higher quality assessment.

What are the three phases of tuberculosis meningitis?

* Early prodromal phase * Meningitic phase * Paralytic phase

What is the prodromal phase of tuberculosis?

The early prodromal phase is characterized by the insidious onset of low-grade fever, malaise, headache, and personality change—usually lasting for 1 to 3 weeks.

What happens following meningitis phase of tuberculosis?

confusion gives way to stupor, seizures, coma, and often hemiparesis in the paralytic phase. Death frequently ensues within 5 to 8 weeks of the onset of untreated illness . Patients may sometimes also present with an encephalitic course characterized by convulsions, stupor, and coma without overt signs of meningitis.

What does CSF show for tuberculosis?

reveals low glucose, elevated protein, and modestly elevated white blood cell count with a lymphocytic predominance. The CSF analysis most closely resembles the CSF analysis of viral meningitis

What is the treatment of tuberculosis?

Anti-tuberculosis treatment must start promptly to reduce morbidity and mortality in patients with TBM. First-line anti-tuberculosis treatments have excellent CSF penetration. Treatment for TBM consists of 2 months of an intensive phase of daily isoniazid (INH), rifampin (RIF), pyrazinamide (PZA), and either streptomycin or ethambutol (EMB).

What is the treatment of tuberculosis meningitis in kids?

In children, EMB is replaced by either an aminoglycoside or ethionamide because of difficulty monitoring for ethambutol-associated optic neuritis

What are complications of tuberculosis meningitis?

* Hydrocephalus * Hyponatremia due to SIADH * Vasculitis and stroke * Seizures * Loss of vision

What is the management approach for suspected bacterial meningitis?

Urgent transfer to hospital, broad-spectrum antibiotics, and supportive treatment.

When should senior review for menigitidis be done?

rapidly progressive rash * poor peripheral perfusion * respiratory rate < 8 or > 30 / min or pulse rate < 40 or > 140 / min * pH < 7.3 or WBC< 4 *109/L or lactate > 4 mmol/L * GCS < 12 or a drop of 2 points * poor response to fluid resuscitation

When should lumbar puncture be delayed?

signs of severe sepsis or a rapidly evolving rash * severe respiratory/cardiac compromise * significant bleeding risk * signs of raised intracranial pressure * focal neurological signs * papilloedema * continuous or uncontrolled seizures * GCS ≤ 9

What is the general management for meningitis?

IV access Lumbar puncture IV antibiotics IV dexamethasone

Which antibiotic is ideal for 3 months to 60 years old with meningitis?

ceftriazone

Which antibiotic is ideal for over 60 years old with meningitis?

Ceftriaxone and amoxicillin -> due to risk of listeria

When should steroids be adminsitered?

preferably starting before or with first dose of antibacterial, but no later than 12 hours after starting antibacterial;

When should steroids be avoided?

avoid dexamethasone in septic shock, meningococcal septicaemia, or if immunocompromised, or in meningitis following surgery'

What should be done for patients with high intracranial pressure?

*get critical care input * secure airway + high-flow oxygen IV access → take bloods and blood cultures * IV dexamethasone * IV antibiotics as above * arrange neuroimaging

How should patients with rapidly evolving rash be managed?

get critical care input * secure airway + high-flow oxygen * IV access → take bloods and blood cultures * IV fluid resuscitation * IV antibiotics as above

What should CSF be tested for?

glucose, protein, microscopy and culture * lactate * meningococcal and pneumococcal PCR * enteroviral, herpes simplex and varicella-zoster PCR * consider investigations for TB meningitis

What is indicated by a high opening pressure in CSF?

Bacterial meningitis

What does a normal glucose level in CSF indicate?

Viral meningitis

What is the role of dexamethasone in managing meningitis?

To prevent injury to leptomeninges from inflammation caused by bacterial destruction.

What are the neurological sequelae of meningitis?

* Sensorineural hearing loss * Seizures * Focal neurological deficit * Infective complications (e.g., sepsis) * Pressure-related complications (e.g., brain herniation)

What does a Gram-positive stain indicate in meningitis?

Streptococcus pneumonia or Listeria monocytogenes.

What does a Gram-negative stain indicate in meningitis?

Neisseria meningitidis.

What causes moderate tos light increase in CSF?

Fungal and tuberculosis infection

What causes protein level elevation?

bacterial and tuberculosis infection due to disruption of blood rain barrier casing serum protein to leak in CSF

What causes glucose levels to decrease?

Glucose levels decrease in bacterial, fungal and tuberculosis infections for meningitis. Mumps and herpes encephalitis are infective causes of low glucose. -> bacteria interfere with normal glucose transport. -> virus level glucose will be normal

How is cryptococcal meningitis diagnosed?

with India ink stain because it is a broad budding yeast with thick fungal capsule that prevents it taking up stainBrain CT/MRI will reveal lesions like soap bubbles. Latex agglutination is best.

How should meningitis be treated if under 3 months cause?

IV cefotaxmine or ceftriazone

How should meningitis be treated if over 3 months?

If meningitis cause is over 3 months, treat with IV cefotaxmine OR ceftriazone

What is the most common causative agent of tick-borne meningitis?

Borrelia burgdorferi, associated with Lyme disease.

What is the significance of petechiae in meningitis?

Indicates Neisseria meningitidis.

What is the recommended prophylactic treatment for contacts of meningitis?

Ciprofloxacin is preferred over rifampicin. With 2g

How should hydrocephalus be managed?

with intraventricular shunt and can occur due to thickened meninges obstructing CSF flow or adherence of inflamed lining of aqueduct of Sylvia’s or fourth ventiruclar outflow.

What are the signs of meningoencephalitis?

Neurological symptoms like seizures and altered mental status.

What is the contraindication for lumbar puncture?

Increased intracranial pressure due to risk of fatal cerebral herniation.

What does cloudy appearance in CSF indicate?

Bacterial or tuberculous meningitis.

What are less common viral causes of meningitis?

* Mumps * Varicella zoster * Lymphocytic choriomeningitis

What is the treatment for tuberculosis meningitis?

2 months of intensive phase with isoniazid, rifampin, pyrazinamide, and either streptomycin or ethambutol.

What is preferred for antibiotic prophylaxis of contacts in meningitis?

Ciprofloxacin ## Footnote Rifampicin is an alternative but not preferred.

List the neurological sequelae of meningitis.

* sensorineural hearing loss (most common) * seizures * focal neurological deficit * infective complications * pressure complications

What are the infective complications of meningitis?

* sepsis * intracerebral abscess

What are the pressure complications of meningitis?

* brain herniation * hydrocephalus

What syndrome are patients with meningococcal meningitis at risk of?

Waterhouse-Friderichsen syndrome

What is Waterhouse-Friderichsen syndrome?

Adrenal insufficiency secondary to adrenal haemorrhage ## Footnote This syndrome is a critical complication of meningococcal meningitis.

Which serotypes of meningococcus have children in the UK been routinely immunised against?

Serotypes A & C

What is the most common cause of bacterial meningitis in the UK after routine vaccination against serotypes A & C?

Meningococcal B

What is the name of the vaccine developed against meningococcal B?

Bexsero

What was the initial decision of the Joint Committee on Vaccination and Immunisation (JCVI) regarding Bexsero?

Rejected after cost-benefit analysis

What change occurred regarding the use of Bexsero by the JCVI?

Decision reversed; added to routine NHS immunisation

How many doses of Bexsero are now given and at what ages?

* 2 months * 4 months * 12-13 months

Who else can receive Bexsero on the NHS?

Patients at high risk of meningococcal disease

List some conditions that make patients high risk for meningococcal disease.

* asplenia * splenic dysfunction * complement disorder

How to manage meningitis in infants?

IV cefotaxime for broad spectrum coverage IV amoxicillin to cover for listeria monocytogenes, a common pathogen affecting infants with menigitidis

What does IV cefotaxime cover?

Common athogens like E.colia nd group B strep

What does amoxicillin cover?

Listeria monocytogenes

What is the gram positive non baccilus?

Listeria monocytogenes

What is the gram positive diplococcs?

Stewprrococcus pneumoina

What is the gram negative coccobacillus?

Haemophilius influenzae

What is the gram negative bacillus causing meningitis?

E.Coli

What is the gram negative diplococcus causing meningitis?

Neisseria meningitidis

How to manage menigitidis with risk of listeria monocytogenes?

Combination of IV ceftriaxone and amoxicillin

What is an indicator of menigitis caused by Neisseria meningitidis?

Non-blanching rash

What causes lymphocyte predominance with normal LP in immunocompromised patient?

Cryptococcal neoformans, which will cause a rash and cranial nerve VI palsy

What is the most common complication of meningitis?

Sensorineural hearing loss

What is reccomended after bacterial menigitis in children?

Audiometry due to sensorineural hesrijg loss

What should be screened for adults with meningococcal disease?

HIV immunoassay

What investigation must be done in bacterial meningitis?

Meningitis Flashcards

(105 cards)