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Good Morning!. July 25, 2013. Semantic Qualifiers. Lumbar Puncture. Lumbar Puncture. Lumbar Puncture. Lumbar Puncture. Lumbar Puncture. Orders: “Please send CSF for following tests: Tube 1: Gram stain and Culture Tube 2: Glucose and Protein Tube 3: Cell count and differential

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  1. Good Morning! July 25, 2013

  2. Semantic Qualifiers

  3. Lumbar Puncture

  4. Lumbar Puncture

  5. Lumbar Puncture

  6. Lumbar Puncture

  7. Lumbar Puncture • Orders: • “Please send CSF for following tests: • Tube 1: Gram stain and Culture • Tube 2: Glucose and Protein • Tube 3: Cell count and differential • Tube 4: HOLD any extra CSF for further testing, +/- HSV PCR, +/-West Nile Virus, +/-Enterovirus”

  8. Illness Script on Meningitis • Predisposing Conditions • Age, gender, preceding events (trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc) • Pathophysiological Insult • What is physically happening in the body, organisms involved, etc. • Clinical Manifestations • Signs and symptoms • Labs and imaging

  9. Predisposing Conditions • Most common in children < 5yo, especially in children < 1yo • Bacterial Meningitis • Your patient has a history of multiple infections and now has Neisseria meningitis. What disorder or defect should you test for in this patient? • Terminal complement deficiency…C5-9** • Influenza A can also predispose to meningococcal disease

  10. Predisposing Conditions • Bacterial Meningitis • You are taking care of a HgbSS patient with suspected bacterial meningitis based on CSF chemistries. What 3 organisms is this patient at risk for and why? • N. meningitidis, S. pneumoniae, Hib** • Functional asplenia in a sickle cell patient leads to decreased host defenses against encapsulated organisms • Other predisposing factors • Neurosurgery or head trauma within past month • CSF leak • Presence of a neurosurgical device (VP shunt, etc.)

  11. Aseptic Meningitis • Definition: Syndrome of meningeal inflammation in which common bacterial pathogens have not been identified • Caused by a variety of infectious and noninfectious agents • A definitive agent is found in 1 out of 4 patients

  12. Predisposing Conditions • Aseptic meningitis • Depends on the cause of the aseptic meningitis. • For infectious causes… • Travel to endemic regions • Seasonality • During which time of the year will you most likely see patients present with enterovirus meningitis? • Summer months, swimming pools (fecal-oral)** • Exposure • What are the two most common viruses to cause meningitis in the neonate due to maternal exposure? • HSV and enterovirus**

  13. Pathophysiology** • Bacterial meningitis • Neonates: • You are taking care of a VERY ill-appearing baby who you suspect is septic. An LP is also suspicious for meningitis. Mom reports having some AGE symptoms just before delivery and recently received some cheese as a gift from her friends who visited France. • Listeria • What are the 3 most common causes of bacterial meningitis in the neonate? • GBS, E. coli, Listeria • What is the gold standard antibiotic used for intrapartum prophylaxis of GBS and how many doses should be given? • Penicillin, 2 doses OR 1 dose AT LEAST 4 hours before delivery

  14. Pathophysiology** • Bacterial meningitis • Older children: • What are the two MOST COMMON bacterial pathogens that cause meningitis in children > 1 month? • Streptococcus pneumoniae • Neisseria meningitidis • Which bacteria should you also consider in a patient adopted from a foreign country or a patient whose mom has withheld vaccinations due to her fear of autism? • Hib • Up to a 99% decrease in the incidence of this infection since the advent of vaccination.

  15. Pathophysiology**

  16. Pathophysiology** • Aseptic meningitis: list 3 viral, 3 bacterial, and 3 fungal causes

  17. Pathophysiology** • What are some non-infectious causes of aseptic meningitis?

  18. Clinical Manifestations** • Older Children? • Malaise • Myalgia • HA • Photophobia • Neck stiffness • Anorexia • Nausea • Infants? • Fever • Lethargy • Irritability • Especially with exam • Prefer to be motionless • AMS • Vomiting • Seizures

  19. Kernig sign • Thigh is bent at the hip and knee at 90 degree angles, and subsequent extension in the knee is painful Brudzinski sign • Involuntary lifting of the legs in meningeal irritation when lifting a patient's head **ABSENCE DOES NOT EXCLUDE MENINGITIS**

  20. Clinical Manifestations** • What is this physical exam finding and what organism do you suspect? Other than an LP, what diagnostic test can you do in an unstable patient to detect the organism? • Purpurafulminans • N. meningitidis** • Skin biopsy

  21. Clinical Manifestations** • Neurologic findings • AMS • Papilledema • Cranial nerve palsies (Lyme disease)** • Focal deficits • Etc. • Clinical manifestations of aseptic meningitis can be identical to those of bacterial meningitis. • Typically the timing is a little more subacute • Findings may not be as severe

  22. Diagnosis: CSF analysis**

  23. Imaging? ** • CT of the head is necessary before LP in patients with signs or symptoms of increased ICP and should be considered for… • Altered mental status (GCS <12 or drop in GCS of ≥2) • Immunodeficiency • Papilledema • Focal neurologic deficit [excluding isolated CN VI or VII palsy] • CSF shunt • Hydrocephalus • CNS trauma • History of neurosurgery or a space-occupying lesions • Signs or symptoms of parameningeal infection or tumor

  24. Management** • Bacterial meningitis • Neonate: Ampicillin, Gentamicin/Claforen, consider Acyclovir!! Supportive Care!! • > 2 months: Vancomycin and Ceftriaxone/Claforen • *Tailor antibiotic therapy once culture results obtained! • Dexamethasone 0.6mg/kg/day divided q6 • Give just before or with the 1stAbx dose • Treat increased ICP if present

  25. Management** • Aseptic meningitis • Supportive care • Acyclovir if HSV meningitis suspected • Empiric therapy if suspect/cannot rule out bacterial meningitis until cultures are negative

  26. Complications • Shock • Seizures • Increased ICP • Subdural effusions vs. empyema** • Focal neurologic deficits • Cerebral edema • SIADH**…close monitoring of I/Os and electrolytes is very important, especially for bacterial meningitis cases!

  27. Prognosis • Mortality - 5-10% for bacterial meningitis • Intellectual deficits** • Hydrocephalus • Spasticity • Blindness • Hearing loss** • VERY important to get a follow-up hearing evaluation…remember meningitis can cause as well as the antibiotics we use to treat it!!

  28. Thanks Noon Conference Today Intern Clinical Reasoning with Dr. English Interns only!

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