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MENINGITIS OUTCOME  VARIABLE Acute Benign Form of Viral TO

MENINGITIS OUTCOME  VARIABLE Acute Benign Form of Viral TO Rapidly Fatal Bacterial Meningitis WITH Local Progressive mental deterioration and death. Meningitis – inflammation of the meninges Encephalitis – infection of the brain parenchyma

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MENINGITIS OUTCOME  VARIABLE Acute Benign Form of Viral TO

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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

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

  7. CAUSES OF MENINGITIS

  8. 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

  9. Bacterial meningitis - Organisms • Neonates • Most caused by Group B Streptococci • E coli, enterococci, Klebsiella, Enterobacter, Samonella, Serratia, Listeria • Older infants and children • Neisseria meningitidis, S. pneumoniae, tuberculosis, H. influenzae

  10. 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 )

  11. APPROACH TO PATIENTWITH POSSIBLE MENINGITIS • I) Maintain diagnostic VIGILANCE a.) Suspect the diseasesb.) Look for classical features 1) Headache 2) meningeal irritation….HOW? 3) Obtundation c.) Confirm or exclude the diagnosis

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

  13. INITIAL MANAGEMENTAPPROACH • Recognition of the meningitis syndrome. • Rapid diagnostic evaluation. • Emergent antimicrobial & adjunctive therapy.

  14. 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.

  15. 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

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

  17. Management Algorithm for Adults Suspicion of bacterial meningitis YES new onset seizure, papilledema, altered level ofconsciousness, or focal neurological deficit or delay in performance of diagnostic L.P NO YES Blood c/s & Lumbar puncture B/C stat Dexamethasone + empirical Abx Dexamethasone + empirical Abx CSF is abnormal -ve CT-scan of the head YES +ve CSF gram stain Perform L.P NO YES Dexamethasone + empirical Abx Dexamethasone + targeted Abx

  18. 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.

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

  20. 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

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

  22. 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.

  23. 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?

  24. 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…..?

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

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

  27. 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…

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

  29. MENINGITIS • 1. Viral Meningitis • 2. Bacterial Meningitis • 3. Brucella & Tuberculosis

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

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

  32. 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.

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

  34. 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

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

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

  37. 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.

  38. 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.

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

  40. Malaria&Travel Medicine

  41. 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

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

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

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

  45. Between Paroxyms  Well DX ? SIGNS • Spleen Enlargement • Jaundice • Fever • Anemia

  46. 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

  47. 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

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

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

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