Meningitits - Learning Package Flashcards by Becca M

What is meningism?

Meningism = symptom complex characterised by headache, photophobia and vomiting with muscle spasms leading to neck rigidity

Caused by meningitis or sub-arachnoid haemorrhage or infection

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What is meningitis?

Meningitis, due to infection or meninges, leads to inflammation and signs of meningeal irritation

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Describe the pathophysiology of meningitis due to anatomy?

Anatomy:

Under surface of brain rests within cranial fossae, which abuts on structures from which infection may spread
- Such as from frontal and ethmoid sinuses to produce abscess/empyema in frontal lobe
- Middle ear extend to temporal lobe
- Fractures of skull or neurosurgery may be complicated by opportunistic bacterial meningitis

Blood brain barrier has implications for transport of antibiotics from blood to brain

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Describe the pathogenesis of meningitis?

Inflammation of meninges
1 Attachment to mucosal epithelial cells
2 Transgression of the mucosal barrier
3 Survival in blood stream
4 Entry into CSF
5 Production of overt infection in the meninges with or without brain infection (encephalitis)

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How is meningitis classified?

Classified by cause as bacterial, viral or fungal:

Bacterial
- Neisseria meningitides (meningococcus)
- Streptococcus pneumoniae (pneumococcus)
- In neonates
  - E-coli
  - Group B streptococci
Viral
- Enteroviruses
  - Echoviruses
  - Parechoviruses
  - Coxsackie A and B
  - Poliovirus
  - Mumps
  - Herpes simplex virus

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What are some common organisms for bacterial meningitis?

Neisseria meningitides (meningococcus)
Streptococcus pneumoniae (pneumococcus)
In neonates
- E-coli
- Group B streptococci

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What are some common organisms for viral meningitis?

Enteroviruses
- Echoviruses
- Parechoviruses
- Coxsackie A and B
- Poliovirus
- Mumps
- Herpes simplex virus

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What are some non-infective causes of meningitis?

Tumour cells in CSF can produce an aseptic meningitis
Reactions to certain drugs or chemicals
By some diseases of unknown aetiology such as sarcoidosis or SLE
Subarachnoid haemorrhage
Migraine

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What are some common conditions that present with meningism?

Influenza
Tonsillitis
Pneumonia
Sinusitis
UTI
Any severe bacteraemic illness
Non-infective causes
- Subarachnoid haemorrhage
- Migraine

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What are the different forms of meningitis presentation?

Acute
- Symptoms and signs for less than 24 hours, quickly progresses
- Commonest cause meningococcal infection
Subacute
- Signs and symptoms for 1-7 days
- Number of aetiologies possible, almost all viral and 75% bacterial meningitides present subacutely

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Describe the general presentation of meningitis?

“Meningeal symptoms”
- Vomiting
- Headache
- Stiff neck
- Lethargy
- Clouding of consciousness
- Photophobia
Signs
- Neurological signs usually absent although cranial nerve palsies (VI, VII or VIII usually) may occur
- Pyrexia
- Reduced consciousness
- Skin and conjunctival petechiae
- Rashes
- Hypotension due to septic shock
- Kernig’s sign

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What are “meningeal symptoms”?

Meningeal symptoms”
- Vomiting
- Headache
- Stiff neck
- Lethargy
- Clouding of consciousness
- Photophobia

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What are some risk factors for meningitis?

Risk factors include recent skull trauma, alcoholism and diabetes mellitus

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What investigations should be done for meningitis?

Blood culture
FBC
U&E
LFT
Lumbar puncture
- Definitive diagnosis by allowing examination of CSF
CSF microbiology
- Gram stain
- Differential cell count
- Antigen detection test
- Bacterial culture
- Mycobacterial or fungul culture
- PCR for viruses
- PCR for bacteria
CSF biochemistry
- Glucose
- Protein
CT scan
- If focal neurological signs or papilloedema to exclude space occupying lesion

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CSF findings, appearance for:

Normal
Bacterial meningitis
Viral meningitis
TB meningitis

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CSF findings, cells for:

Normal
Bacterial meningitis
Viral meningitis
TB meningitis

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CSF findings, predominant cell type for:

Normal
Bacterial meningitis
Viral meningitis
TB meningitis

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CSF findings, glucose for:

Normal
Bacterial meningitis
Viral meningitis
TB meningitis

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CSF findings, protein for:

Normal
Bacterial meningitis
Viral meningitis
TB meningitis

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Describe the aetiology of bacterial meningitis?

Usually streptococcus pneumoniae, Neisseria meningitides or haemophilus influenza

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What are the principles of bacterial meningitis treatment?

Early recognition
Rapid detection of pathogen
Rapid initiation of appropriate bactericidal antimicrobial therapy
Early recognition and treatment of sequelae of septicaemia
- Eg DIC with shock, hypoxia, acidosis and adrenal insufficiency
Antibiotic prophylaxis of close contacts

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Describe the general pharmaceutical management of bacterial meningitis?

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Antibiotic therapy
- Benzylpenicillin reaches CSF in sufficient quantities only if meninges are inflamed and given 4 hourly high doses
- Ceftriaxone penetrates poorly into normal CSF, but effective concentrations obtained in bacterial meningitis
Steroids (dexamethasone)
- Prevention of long term neurological sequelae

What organism causes meningococcal meningitis?

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Neisseria meningitides

Describe the aetiology of meningococcal meningitis?

(age)

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Most common in children and young adults
Groups A, B and C

Describe the presentation of meningococcal meningitis?

* Meningitis +/- septicaemia (commonest) * Fulminant meningococcal septicaemia characterised by suddenness of symptoms causing deterioration in consciousness, fever, septicaemia shock with renal failure and disseminated intravascular coagulation (DIC)

Describe the treatment of meningococcal meningitis?

* Early recognition * Antibiotics given by GP before hospitalisation * Parenteral penicillin (3-4MU) * On arrival to hospital if acutely unwell administer high dose ceftriaxone prior to LP * Treatment modified after culture * Benzylpenicillin or ceftriaxone * At time of discharge rifampicin or ciprofloxacin * Notification and prophylaxis * Reported to local consultant in health protection * Close family given chemoprophylaxis with rifampicin or ciprofloxacin

Describe the prognosis of meningococcal meningitis?

* Bad prognostic markers includes * Delay in instigation of antibiotic therapy * Extremes of age * Shock with absence of signs of meningitis * Presence of DIC, metabolic acidosis and absence of polymorph leucocytosis

What organism is responsible for pneumoccal meningitis?

* Streptococcus pneumonia

Describe the aetiology of pneumococcal meningitis? (age)

* Most frequent case of bacterial meningitis in adults

Describe the clinical presentation of pneumococcal meningitis?

* Onset acute * More likely to have altered consciousness or focal neurological signs that haemophilus or meningococcal meningitis

Describe the treatment of pneumococcal meningitis?

* Early administration of high dose ceftriaxone

What are some possible complications of pneumococcal meningitis?

* Death (30-50%) * Loss of hearing * Cranial nerve deficits * Hemiparesis * Hydrocephalus * Seizures

How can pneumoccal meningitis be prevented?

* Pneumococcal vaccine * For those over 65 in Scotland

How can meningococcal meningitis be prevented?

* Group C vaccination part of immunisation schedule in UK * A and B exists but not part of

What are some less common bacterial meningitis?

* Haemophilus influenza (type B) meningitis * Listeria monocytogenes meningitis * Tuberculous meningitis * Leptospirosis and lyme disease

What organisms usually cause viral meningitis?

* Enteroviruses, especially echovirus and coxsackie, are most common in UK

Describe the clinical presentation of viral meningitis?

* Non-specific prodromal illness followed by rapid onset of headache, photophobia, low grade fever and a stiff neck * Patients usually lucid and alert * If encephalitis also present * Lethargy, confusion, seizures and focal neurological signs * With enteroviral meningitis * Rash

What investigations are done for viral meningitis?

* **PCR of CSF for enteroviruses, herpes simplex, mumps and other viruses** * Enteroviruses can be detected in throat swabs and from faeces * Testing for HIV

Describe the treatment for viral meningitis?

* Enteroviruses and parechoviruses * Symptomatic and usually recovery within 72 hours * If chronic infection occurs (eg in immunocompromised) * IV immunoglobulin * Herpes simplex virus * Aciclovir, initially IV

Describe the prognosis of viral meningitis?

* Most people make complete recovery

How is viral meningitis prevented?

* MMR immunisation in immunisation schedule * Good hand hygiene

Describe the aetiology of fungal meningitis?

* The yeast Cryptococcus neoformans (most common cause) of patients with HIV infection, or rarely in patients with diabetes, lymphoma or taking immunosuppressive drugs

What is the most common form of fungal meningitis?

Cryptococcal meningitis

Describe the clinical presentation of cryptococcal menignitis?

* Subacute onset of symptoms with low grade fever, headache, nausea, lethargy, confusion and abdominal pain * Meningism less common

Describe the treatment for cryptococcal meningitis?

* Parenteral amphotericin, sometimes in combination with flucytosine

How is cryptococcal meningitis prevented?

* Long term chemoprophylaxis with fluconazole for patients with HIV prevention

What are the 2 fundamental ways that neonatal meningitis differs from adults?

* Symptoms and signs usually non-specific or not well localised * Bacteria commonly involved are group B streptococci, E-coli and L. Monocytogenes as well as enteroviruses and parachoviruses

What are risk factors for neonatal meningitis?

* Low birth weight * Prolonged rupture of membranes * Maternal diabetes mellitus

Descibe the epidemiology of neonatal meningitis? (incidence, time of year)

* Incidence 1/2500 births * Seasonal as with adults

Describe the clinical presentation of neonatal meningitis?

* 2 syndromes occur in neonatal meningitis * Early onset * Marked respiratory distress, bacteraemia and high mortality * Organism usually acquired at birth from mothers GI tract * Late onset * More than 1 week after birth * Infection is typified by bacteraemia and meningitis but pulmonary involvement rare * Organism spread by cross infection with other mothers, babies or healthcare workers

Describe the diagnosis of neonatal meningitis?

* Bacterial * Neonatal CSF and blood cultures * Maternal blood cultures * Viral * Neonatal CSF, EDTA blood, faeces and nasopharyngeal secretions

Describe the treatment of neonatal meningitis?

* Parenteral ampicillin (group B strep and Listeria) and gentamicin or cefotaxime (to cover gram negative bacilli) until causative organism identified * IVIG for enteroviruses or parechoviruses

Describe the prognosis of neonatal meningitis?

* High mortality up to 50% * Neurological sequelae about 33%

How is neonatal meningitis prevented?

* Chemoprophylaxis to prevent neonatal group B strep infection to high risk mothers duriung labour * Usually amoxicillin or co-amoxiclav * Source isolation of neonates with enterovirus or parechovirus, and strict attention to hand hygiene

Meningitits - Learning Package Flashcards

(54 cards)