Bacterial Meningitis - A Medical Emergency

1. Bacterial Meningitis -A Medical Emergency Swartz MN N Engl J Med 2004;351:1826-1828

2. Mortality Rates Associated with Community-Acquired Bacterial Meningitis over the Past 90 Years Swartz MN N Engl J Med 2004;351:1826-1828

3. Bacterial Meningitis -A Medical Emergency • Fever and neurologic symptoms • Bacterial meningitis • Aseptic meningitis

4. Bacterial meningitis Aseptic meningitis Encephalitis Brain abscess Epidural Abscess Subdural empyema Sinus septic thrombosis Collagen diseases Neurologic SymptomsWith Fever

5. Typical CSF Changes etiology protein glucose leukocytes bacterial meningitis100-500 100-10000, P viral meningitis50-200 N <1000, MN TB meningitis100-500 10-500, MN fungal meningitis25-500 25-500, MN brain abscess 75-500 N 0-200, MN

6. Neonates Gram (-) rods Strep group B Listeria monocytogenes Haemophilus influenzae b > 3 months Haemophilus influenzae b Strep pneumoniae N. meningitidis Bacterial MeningitisEtiology

7. Bacterial MeningitisClinical Presentation • "Looks Bad” • Fever • Headache, nausea, vomiting • Irritability, restlessness • Sleepy • Confusion, mental signs • Back pain • Bulging fontanel / nuchal rigidity

8. Bacterial MeningitisDiagnosis • LP – mandatory (protein, glucose, cells, culture, Gram stain, antigen detection by latex, ELISA, CIE) • Blood culture – always • CT? (search for focus)

9. Bacterial MeningitisTreatment • Antibiotic regimen • Steroids • Fluid restriction? • Anticonvulsant medications? • Monitoring

10. CSF Penetrationof Antibiotics adequate good with minimal with nil inflammation inflammation chloramphenicol ampicillin gentamicin clindamycin sulfa cefotaxime tobramycin benza pen TMP/SMX amikacin erythromycin ampho B metronidazole vancomycin ketoconazole polymyxin rifampin

11. Bacterial MeningitisTreatment • Antibiotic regimen • Steroids • Fluid restriction? • Anticonvulsant medications? • Monitoring

12. Bacterial MeningitisSequelae 1. Mortality: 1-5% 6. Motor abnormalities 2. Hearing loss: 10-40% 7. Seizures: 2-8% 3. Language disorders 15% 8. Hydrocephalus 4. Impaired vision: 2-4% 9. Cranial N palsy 5. Mental retardation: 10% 10. Ataxia… (Sell et al)

13. Bacterial Meningitisfactors affecting prognosis • Age • Specific cause • Underlying disorders • Delay in therapy • Focal neurologic findings • Bacterial load (animals)

14. Bacterial – partially treated, mycobacteria, T. pallidum, borrelia, leptospira Viral Rickettsia Fungal Protozoa Parameningeal foci (abscess, mastoiditis, sinus septic thrombosis) Aseptic Meningitis

15. Viral Meningitis - USA • Enteroviruses - 85% • Arboviruses - 5% • Mumps - 2% • Herpes simplex 2-5% • Others: adeno, VZV, CMV, measles, rubella, influenza, parainfluenza, RSV

16. Herpes simplex Encephalitis Presentation (Kohl, Ped C N Am 1998) • Fever 90-100% • Altered consciousness 80-100% • Headache 76-80% • Seizures 40-85% • Hemiparesis 33-40% • Cranial N palsy 30-35% • Behavioral changes 47-85%

17. Herpes simplex Encephalitis Laboratory findings (Kohl, Ped C N Am 1998) • Abnormal CSF 90-97% • CSF pleocytosis 50-1000, lymph • CSF RBCs 75-85% • CSF protein increased • CSF glucose normal • Culture negative • PCR (type 1, 2) positive

18. Herpes simplex Encephalitis – Outcome Acyclovir Vidarabine placebo • Mortality (1m) 16% 36% 70% • Severe sequelae 34 72% • Moderate sequelae 10 15% • Minor or no impairment 46% 13%

19. Recurrent Meningitis • Communication of SAS with: Skin - dermal sinus, meningomyelocele Paranasal sinuses, middle ear, nasopharynx – due to fractures, cong malformations • Parameningeal focus – epidural, brain, mastoid • Immune deficiency • Unknown

20. Thank You for the attention Shai Ashkenazi