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MENINGITIS OUTCOME VARIABLE Acute Benign Form of Viral TO Rapidly Fatal Bacterial Meningitis WITH Local Progressive

. Meningitis inflammation of the meningesEncephalitis infection of the brain parenchymaMeningoencephalitis inflammation of brain meningesAseptic meningitis inflammation of meninges with sterile CSF. . IntroductionMeningitis: inflammation of the pia mater and the arachnoid mater, with

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MENINGITIS OUTCOME VARIABLE Acute Benign Form of Viral TO Rapidly Fatal Bacterial Meningitis WITH Local Progressive

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    1. MENINGITIS OUTCOME ? VARIABLE Acute Benign Form of Viral TO Rapidly Fatal Bacterial Meningitis WITH Local Progressive mental deterioration and death

    2. Meningitis – inflammation of the meninges Encephalitis – infection of the brain parenchyma Meningoencephalitis – inflammation of brain + meninges Aseptic meningitis – inflammation of meninges with sterile CSF

    3. Introduction Meningitis: inflammation of the pia mater and the arachnoid mater, with suppuration of the cerebrospinal fluid

    4. Symptoms of meningitis Fever Altered consciousness, irritability, photophobia Vomiting, poor appetite Seizures 20 - 30% Bulging fontanel 30% Stiff neck or nuchal rigidity Meningismus (stiff neck + Brudzinski + Kernig signs)

    5. Contraindications: ? ICP reported to increase risk of herniation Cellulitis at area of tap Bleeding disorder

    7. WHAT DETERMINE THE OUTCOME? 1. Etiological organism 2. Speed and appropriation of the therapy. MORTALITY Bacterial Meningitis : 40 %

    8. CAUSES OF MENINGITIS

    9. 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

    11. Causes of bacterial meningitis Strep pneumonia………….37 Neisseria meningitides…..13 Listeria monocytogenes….10 Other strept.species……….7 Gram negative……………….4 Haemophillus influenza……4 No pathogens………………37 Review of 493 cases of adult meningits (Durand NEJM 1993 )

    12. APPROACH TO PATIENT WITH POSSIBLE MENINGITIS I) Maintain diagnostic VIGILANCE a.) Suspect the diseases b.) Look for classical features 1) Headache 2) meningeal irritation….HOW? 3) Obtundation c.) Confirm or exclude the diagnosis

    13. II) INITIATE RAPID TRATMENT a. I.V. b. Large and sufficient dose c. Effective choice

    14. INITIAL MANAGEMENT APPROACH Recognition of the meningitis syndrome. Rapid diagnostic evaluation. Emergent antimicrobial & adjunctive therapy.

    15. III. CONSIDER CHANGING EPIDEMIOLOGY A.) Global emergence and Prevalence of Penicillin- Resistant Strain of Strep. pneumonia. B.) Dramatic Reduction in invasive H. influenza disease secondary to use of conjugate Haemophillus Type B- vaccine. C.) Group B – Streptococci ? Neonate Now ? > 50 also.

    16. IV. COMPLEXITIES OF EMPIRIC MANAGEMENT I F Focal Sign Pappiledema OR Focal Neurological deficit (often >VI N) ? Brain abscess Chr. Meningitis DON’T Delay Administration of Antibiotics

    17. Bacterial Meningitis - Treatment Neonatal (<3 mo) Ampicillin (covers Listeria) + Cefotaxime High CSF levels Less toxicity than aminoglycosides No drug levels to follow

    19. CASE I A 12 year old Nigerian boy who has arrived to Riyadh 2 days prior to presentation - C/O severe headache & Photophobia? How do you approach & manage him? Presence of fever & neck stiffness.

    20. Neurological deficit & Fundus. Skin ? RASH CSF examination: Opening pressure: 260 mm H20 & cloudy WBC: 1500/ ml. 96% segmented Glucose: 24mg / dl Protein: 200 mg.

    21. MOST LIKELY DIAGNOSIS: 1. Neisseria m. 2. Strep. Pneumonia 3. H. influenza 4. Listeria monocytogen EPIDEMIOLOGICAL FEATURES OF MENINGOCOCCAL MENINGITIS 1. Affect children + young adult 2 – 20 years

    22. 2. Epidemic usually sero group A & C 3. Nasopharyngeal Acquisition 4. Predisposing in those with Terminal Complement deficiencies ( Cs ----- C9 ) 5. SKIN RASH ?

    23. a. Fulminate meningococcemia with purpura b. Meningitis with RASH (Petechiae) c. Meningitis without RASH. 6. Mortality 3 - 10 %. 7. D. O. Choice ? Penicillin I.V.

    24. CASE 2 A 26 YEAR OLD Saudi female who has been C / O unwell & fever & cough and headache for the last 3 days. Examination revealed ill – looking women with sign of consolidation R Lung base. DIAGNOSIS: Bacteria Pneumonia. Organism?

    25. Six (6) hours after admission, her headache became worse and she became obstunded. DIAGNOSIS: ? MENINGITIS CSF: WBC: 3000 99% DML Sugar: Zero Protein: 260 mg/dl. Gram Stain: Gram + DIAGNOSIS: Bacterial…..?

    26. Epidemiological Features of Pneumococcal meningitis The most common. Cause The most killing. 20 - 30 % DEATH May be associated with other Focus: a. Pneumonia 25%

    27. b.Otitis Media 30% c. Sinusitis 15 % d. Head Trauma & CSF Leak 10%. E. splenectoy and SS disease.. Global emergence of Penicillin – Resistant.

    28. Case presentation 30 years old sudanese male who was to the ER in confusional state for few hours befor presentation ..history revealed presence of two attacks of seizures in the same day with high fever…

    29. EXAMINATION: Looks unwell - Temp. 39°C Neck Stiffness - absent Funds - Bilateral papilledema Possible diagnosis: 1. Meningitis 2. Brain abscess 3. Subarachnoid. Hemorrhage…

    30. MENINGITIS 1. Viral Meningitis 2. Bacterial Meningitis 3. Brucella & Tuberculosis

    31. PREVENTION : CHEMOPROPHYLAXIS Neiseria meningitidis Eradication of nasopharyngeal carriage ..(post exposure ) for : 1)house hold contact 2)Treating doctor who has examined patient very closely

    32. What drugs are recommonded: Rifampicin 600 X 2 d Ciprofloxacin 500X1 Ceftriaxon 125mg I.M X1

    33. VACCINE TO 1. Hib Type B vaccine ? 1.Protection 2. Eliminate 2. Meningococcal vaccine: A, C, Y, W135 - Up to 3 years adult - Does not affect N. ph. Carriage ? …Does not provide herd immunity.

    34. Supportive No antibiotics Analgesia Fever control Often feel better after LP No isolation - Standard precautions Viral meningitis - Treatment

    35. Caes 56 years saudi women presented to the infectious disease clinic c/o low grade fever and night sweating for the last 6 wks…on detailed inquires she admitted to have headache for 4 wks improving on analgesics.. EXAMINATION: T: 38.2..Fully conscious Neck stiffnes..bilateral papillodema

    36. LABORATORY RESULTS.. CSF:…xanthocromic wbc 340 L: 85 % protein 1.5g sugar 25 mg WHAT IS YOUR ANYLASIS OF THIS CSF………..

    37. 1) Partially treated bacterial meningitis 2) Aseptic meningitis 3) Bruclla meningitis 4) Tubercoulus meningitis 5) OTHERS……..

    38. TREATMENT: A. Principles of Therapy: 1. Multiple drugs. ( INH& Rif.) 2. Educate the patient ? Long therapy ? 6/12 3. Tell about Potential side effects ? a. Orange sweat & tears with Rifampicin. b. Hepatitis with INH.

    39. 4. Follow patient closely. B. Commonly Used Drugs: 1. INH (Isonized) a. Bactericidal ? inhibit DNA synthesis b. Excellent tissue and CNS penetration. c. Acetylated with liver ? Renal. d. Toxicity : Hepatitis / P.

    40. Neuropathy. 2. Rifampicin a. Bactericidal ? inhibit RNA synthesis b. Excellent tissue & CNS penetration c. Hepatic excretion d. Toxicity : Hepatitis / RASH / Drugs interaction

    41. Malaria&Travel Medicine

    42. MALARIA Febrile illness caused by Plasmodium. 200 – 300,000,000 cases. 700,000---2.7,000,000 death/year more in rural area.. more during rainy season Human ---- -----? Another Mosquito

    43. Transmission BITE OF FEMALE ANOPHELES BETWEEN DUSK AND DAWN BLOOD TRANSFUSION CONTAMINATED NEEDLES CONGENITAL.

    44. ETIOLOGY Four species. Death is mostly due to ..? SYPMTOMS ---? Non-specific Headache & fatigue & muscle pain Fever DX: ? Viral infection..?

    45. Clinical Features: Symptoms: 7 – 10 days ? Malaria Paroxysms. Cold ? Chills & Rigor & cold skin Hot ? Fever, warm skin 3-6 hours deverevescence ? Marked sweating

    46. Between Paroxyms ? Well DX ? SIGNS Spleen Enlargement Jaundice Fever Anemia

    47. Clinical example: An 18 years old Saudi pregnant young women originally from Jazan came C/O Fever and headache. Exam: Pale, jaundiced, Temp. - 39°C Spleen enlarged NEXT? CBC: WBC - 8000 Hb - 9.0

    48. Platelets: 90 MCU : 98 CXR: Normal DIAGNOSIS 1. Index of suspicion Travel hist. Incubation Period 2 WKS Prophylaxis -? Longer 2. ? Malaria 3. Blood smear :Thin & thick 4. Special Drug

    49. COMPLICATION: 1. Cerebral Malaria ? encephalopathy ? Seizure ? Death 20% 2. Black. Water Fever ? non immune ? High degree of F.M. ? Hemolysis

    50. Malaria & Pregnancy: 1. Risk of low birth & abortion. 2. Risk of glucose , pulm. oedema TREATMENT 1. History 2. Smear 3. Species

    53. 4. Severity CBC Hib Coagulation 5. Drugs:

    54. TREATMENT 1. Uncontrolled airway 2. I.V . infusion Blood glucose test, parasitemia, Hct. 4. Antimalaria. a. Chloroquine p.o. b. Mefloquine C . Quinine AND DOXYCYCLINE D. ARTEMISININS E . ATOVAQUONE PLUS PROGUANEL 5. Fluid balance ? P. Edema ? Dehydration & Shock 6. Convulsion ? Diazepam 7. Blood C/ S……8) LP

    55. DRUG TOXICITY MEFLOQUINE : neuropsychiatric symptoms : mood changes .encephalopathy…transient QUININE : Bitter taste , GIT upset , cinchonism ( nausea, vomiting , tinnitus , high tone deafness ) Doxycycline ..GIT upset, vaginal candidiasis..( use antifungal )

    56. PREVENTION Avoid mosquito Wear long sleeved clothing Sleep in well – screened rooms Use mosquito netting Use insect repellents (e.g. DEET) Chemoprophylaxis..

    57. 1) CHLOROQUINE ONE TABLET EVERY WK.. DAILY WILL LEED TO RETINOPATHY Consider resistant plasmodium

    58.

    60. Chloroquine-sensitive areas Drug of choice Chloroquine 500 mg (300 mg base) : once/wk Atovaquone/ proguanil (Malarone) : 1 tab/d ( 250 mg atovaquone /100 mg proguanil) Mefloquine 250 mg once/wk Doxycycline 100 mg daily Alternatives Primaquine 30 mg base daily Chloroquine plus proguanil 500 mg (300 mg base) once / wk + 200 mg

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