Meningitis.

1. Meningitis. Dr; Abdulrahman Al shaikh

2. definition • Inflammatory disease of leptomeninges, the tissue surrounding the brain and spinal cord. • The meninges consist of three parts : the pia, arachnoid ; and dura maters. • It involves the arachnoid mater and the cerebrospinal fluid in the subarachnoid space as well as in the cerebral ventricles.

3. Types • Acute either pyogenic or viral. • Chronic due to tuberculosis or fungal.

4. Pyogenic meningitis.

5. ETIOLOGICAL AGENT "Normal" Adults (6-21 yrs)     Neisseria meningitidis    Streptococcus pneumoniae Children (3 months - 6 years)     Haemophilus influenzae    Neisseria meningitidis    Streptococcus pneumoniae    Staphylococcus aureus    Mycobacterium tuberculosis Infants (½ - 3 months)     Streptococcus, Group B     Listeria monocytogenes    Escherichia coli :

6. Neonates     Escherichia coli    Streptococcus, Group B     Staphylococcus aureus    Listeria monocytogenes    Streptococcus, Group A Diabetics, alcoholics, elderly, debilitated, diseased (untreated)     Listeria monocytogenes    Streptococcus pneumoniae    Treponema pallidum

8. Clinical feature. • Fever and headache in majority. • Headache severe and generalized. • Most have fever but small percentage have hypothermia. • CNS symptoms: photophobia, and cloudy sensorium. Changes in mentation and level of consciousness, seizures, and focal neurological signs tend to appear later in the course of the disease.

9. Nuchal rigidity. • The patients might not complain of neck stiffness but easy to find it by passive or active flexion of the neck will usually result in inability to touch the chin to the chest. • Brudzinski sign refers to spontaneous flexion of the hips during attempted passive flexion of the neck. • The kernig signs refers to the inability to allow full extension of the knee when the hip is flexed 90 degree.

10. Other finding. • Skin manifestation in form of petechiae and palpable purpura.( N. meningitides ). • If sequelae of infection in other part of the body, there may the feature of that infection. ( sinusitis and otitis).

11. Laboratory features. • Increased WBC. • Low platelets if there is intravascular coagulation. • Electrolytes abnormalities mainly low sodium. ( SIADH ). • Blood culture at least one half have positive before antibiotics.

12. CSF. • Can be diagnostic should be done in all only if there is contraindication. • Can distinguish viral from bacterial. • Gram stain should be done if suspected bacterial.

14. Complication. • Cerebrovascular involvement. • Cerebral odema. • Hydrocephalus. • Septic shock. • Disseminated intravascular coagulation. • Acute respiratory distress syndrome.

15. Treatment. • Empiric ceftriaxone has a potent activity for causative organism except Listeria . • Ampicilin should be added if Listeria infection possible. • Dexamethazone reduced the complication.

16. H- influenza. • Ceftriaxone 2 gm twice a day. • Cefotaxime 2gm 6 hourly. • Rifampicin 6oo mg daily for 4 days to clear the colonization. • Should be treated 5 – 7 days.

17. Neisseria meningitis. • Penicillin, but there resistant cases. • Third generation cephalosporin. • Treatment for 5 days at least. • Rifampicin if penicillin used in treatment. • Rifampicin or ciprobay for contact.

19. PREVENTION: Neisseria meningitidis - each dose of the multivalent vaccine provides A, C, Y and W-135 capsular polysaccharides. Effective in children over 3 months of age. Streptococcus pneumoniae - each dose of the multivalent vaccine provides 23 types of capsular         polysaccharide covering the majority of strains causing meningitis. Recommended for children         over 2 years of age. months of age. Haemophilus influenzae – each dose of the monovalent vaccine provides the capsular polysaccride from serotype b. organisms. Recommended for children over 18 months of age.

20. Viral meningitis

21. ETIOLOGICAL AGENTS:      Mumps virus       Polio virus       Coxsackie B virus        Echovirus       Arboviruses        Human Herpesvirus 1 (Herpes simplex 1 virus)         Lymphocytic choriomeningitis viruses-Arenavirus          Encephalomyocarditis viruses       Louping ill virus          Pseudolymphocytic meningitis virus           Hepatitis viruses           Adenovirus            Rhinovirus            Coxsackie A virus

22. CHRONIC MENINGITIS NAMES OF DISEASE:         Fungal meningitis                                           Cryptococcosis                                  Torulosis                                               Tubercular meningitis                                               Amoebic meningitis                                               Syphilitic meningitis

23. ETIOLOGICAL AGENTS: Cryptococcus neoformans (Serotypes A,B,C,D)      Treponema pallidum                                             ) All slow      Mycobacterium tuberculosis                                 ) growers in       Naegleria fowleri                                                  ) the CNS       Human immunodeficiency virus                           )       Coccidioides immitis                                            )

24. Fungal meningitis-predisposing factors.   1.     Glucosteroid therapy     2.     Malignancy (particularly of the lymphoreticular system)     3.     Collagen - vascular disease.     4.     Sarcoidosis - a disorder involving many organs where there is formation of epithelioid cell             tubercles.     5.     Diabetes mellitus     6.     Pregnancy     7.     Alcoholism     8.     Genetic impairment of host defense mechanisms - 50%. T-cell diseases (Di George Syndrome, Nezelof's syndrome)     9.     AIDS

25. Clinical feature: fungal. • 1.     Headache - frontal, temporal or retro-orbital. Most common feature and it becomes progressively more frequent and severe. •  2.     Mental aberrations (from simple irritability to psychosis) •  3.     Motor abnormalities (altered reflexes to paralyses) •  4.     Cranial nerve dysfunctions (aphasia, visual disturbances, hearing loss) •  5.     Cerebellar signs (dyssynergia, dysmetria, dysrhythmia, intentional tremor, slurring of speech) •  6.     Evidence of increased intracranial pressure •  7.     Fever in about 1/3 of patients

26. CSF: in fungal • 1.     Increased CSF pressure •  2.     Protein is elevated •  3.     Leukocytosis (40-400/mm3 - mostly mononuclear cells) •  4.     Glucose is decreased (45% of blood glucose) •  5.     C. neoformans present in India ink preparations •  6.     Serological tests for cryptococcal antigen

27. TREATMENT: 1.     Amphotericin B injected I.V. and into the subarachnoid space. NOTE: This is poorly  absorbed into CSF. Treat for 6 weeks. Toxic. 2.     Flucytosine (5-fluorocytosine)-penetrates into all body fluids, including CSF. Less toxic but higher doses required. 3.     Miconazole-an imidazole derivative     4.     Amphotericin B methyl ester    

28. Tuberculous meningitis. • Clinical feature. • Diagnosis. • Treatment.

29. Clinical feature: TB. • Atypical presentations : Rapid progressive as pyogenic or slow dementia. • Stage 1: lucid with no focal neurological signs. • Stage 11 are confused or focal signs such as hemiparesis or cranial nerve palsies. • Stage 111 advanced illness with delirium , stupor, coma and dense hemiplegia.

30. Diagnosis. • High degree of suspicion. • CSF – high protein, low sugar and a mononuclear pleocytosis. • Early in the illness the cellular reaction is atypical with low cell or polymorphonuclear leukocyte. • AFB smear in 37%. • Polymerase chain reaction = 70%. • CT Scan of the brain with contrast or MRI.

31. Treatment. • INH, Rifampicin and pyrazinamid for 2 months then discontinue PYZ. • In endemic areas where resistance to INH is high the streptomycin or ethambutol added. • The duration for 12 months but if PYZ not tolerated the duration extended to 18 months and in case multiple drugs resistance for 18-24 months. • Steroid improve morbidity and mortality, prednisone 60 mg to be tapered over 4 weeks. • Surgery in case of hydrocephalus or increase intracranial pressure.( deterioration in conscious level and stupor).