KENYA MEDICAL TRAINING

COLLEGE-EMBU
 & SURGERY
CLINICAL MEDICINE
MEDICINE III
COUSRE CODE: MED312
MR. MUTHIKE R
BSc. CMCH
 
NERVOUS SYSTEM
DISORDERS
 MENINGITIS

 Definition- inflammation of the meninges, especially the
arachnoid and the pia mater ( known as leptomeninges),
often secondary to infection
 Edema and infiltrates lead to fever, focal neurological
deficits, decreased level of consciousness and seizures
 Infectious causes can be bacterial, viral, fungal or parasitic
 While the etiology is usually infectious, ultimately it is the
inflammatory changes in the CNS that cause morbidity
and mortality.
 ETIOLOGY

 Bacterial causes which varies by age groups include;
- <3 months- group B Streptococcus, E. coli, Listeria monocytogenes
- Children 3 months- 18 years- Streptococcus pneumoniae (pneumococcus),Neisseria
meningitidis (meningococcus)Haemophilus influenzae type B (less common now with the
advent of the HiB vaccination)
- Adults- 18-50 years- Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus
influenzae type B
- Elderly -> 50years- Streptococcus pneumoniae, Neisseria meningitidis, Listeria
monocytogenes
 Viruses - Enteroviruses- poliovirus, echovirus,coxsackievirus A & B, enterovirus 68-71,HSV -
HSV-1 and HSV-2, Varicella- zooster virus, CMV, paramyxovirus- mumps virus, measles
 Fungi- cryptococcus neoformans,Blastomyces dermatitidis
 Parasites- Acanthamoeba spp, schistosoma spp
 Aseptic meningitis- occurs if no organism can be isolated with routine culture and sensitivity
assay of CSF. The etiology is likely viral and less commonly due to tuberculous meningitis,
lyme disease, parasitic infection and malignancy
 PATHOGENESIS OF
MENINGITIS

 Risk factors for pathogen entry include;
-immunocompromised state (HIV positve, cancer,
chemotherapy patient),
-bacteremia,
-viremia,
-endorcarditis,
-asplenia (the absence of spleen),
- site infection (pneumonia, sinusitis, otitis media)
-Cranial injury
PATHOGENESIS OF
MENINGITIS

 CLINICAL FEATURES


Features befitting bacterial meningitis
- About 44% of adults with bacterial meningitis exhibit the classic triad of
 Fever
 Headache
 Neck stiffness
- These symptoms can develop over several hours or over 1-2 days
- Other symptoms include;
 Nausea and vomiting
 Photophobia
 Sleepiness
 Confusion
 Irritability
 Coma
 Seizures/convulsion
- Patients with viral meningitis may present with fatigue, myalgia or anorexia
 ON PHYSICAL
EXAM
- Fever >38°c
- Brudzinski’s and kerning sign positive
- Nuchal rigidity
- Decreased Glasgow Coma Scale (GCS)
- Focal neurological deficits- cranial nerve palsies, hemiparesis, hypertonia, nystagmus
 CLINICAL FEATURES
CONT’D

 In pediatric population, additional symptoms and signs
include;
 Bulging fontanelles
 Jaundice
 Reduced feeds
 Irritability
 Lethargy
 Fever, shock and cerebral edema
 DIAGNOSIS

1. Lumbar puncture for CSF analysis is the cornerstone of diagnosis.
- Note the opening pressure, send the sample for microbiology(gram
stain and culture of the CSF), cell count, chemistry(glucose and protein).
NB: lowering of CSF could precipitate brain herniation. Herniation can
also occur due to acute bacterial meningitis and other CNS infections due
to severe cerebral edema or acute hydrocephalus. This present with
altered level of consciousness, abnormalities in pupil reflexes,
decerebrate or decorticate posturing.
In such cases a screening CT SCAN head may be performed before LP to
determine the risk of herniation
2. Blood cultures to complement the CSF cultures
 DIAGNOSIS CONT’D

3. Blood studies
- Complete blood count and differential which demonstrate leukocytosis
 Serum electrolytes, to determine dehydration or syndrome of
inappropriate secretion of antidiuretic hormone (SIADH)
 Serum glucose (which is compared with the CSF glucose)
 Blood urea nitrogen (BUN) or creatinine and liver profile, to assess
organ function and adjust antibiotic dosing
 HIV testing
4. Neuroimaging – CT SCAN of the head and brain MRI
- Employed to find complications of meningitis and to determine
parameningeal cause of abnormal CSF
 DIAGNOSIS CONT’D

 Indications for screening head CT SCAN before LP in adult
patients
-Immunocompromised state
-History of CNS disease such as mass lesion, stroke or focal
infection
-Seizure within 1 week of presentation
-Papilloedema
-Abnormal level of consciousness
-Focal neurological deficit (dilated nonreactive pupil, gaze
palsy)
 MANAGEMENT

 In acute meningitis, regardless of presentation, a lumbar puncture and
CSF examination are indicated to identify the causative organism and in
bacterial meningitis , for antibiotic sensitivities.
 Do CT SCAN head before LP if indicated
 Radiologic imaging should not delay initiation of empiric antimicrobial
treatment and should be initiated before CT scan if indicated
 If patient is in shock or hypotensive, infuse crystalloid until euvolemia is
achieved
 If patient has seizures, treat according to the usual protocol
 If the patient is hypoxemic, give oxygen
 Watch for signs of hydrocephalus and raised ICP
 Manage fever and pain
 MANAGEMENT
CONT’D

 The mainstay of treatment for bacterial meningitis is antibiotics;
 choice of antibiotic depends on the organism isolated from blood and
CNS cultures.
 Any delay in treatment results in increased morbidity and mortality, so
antibiotics are often started empirically and antibiotic regimen is then
adjusted once the causative organism is known
 Start IV ceftriaxone 2g BD PLUS Vancomycin 15mg/kg TDS
 Corticosteroids such as dexamethasone can be used adjunctively to
reduce inflammation in the brain
 In viral meningitis, the treatment is supportive.
 In patients with suspected Herpes Simplex Virus (HSV) infection, empiric
antiviral therapy is started to prevent complications of HSV encephalitis.
 MANAGEMENT
CONT’D

 Fungal meningitis - Cryptococcal (amphotericin B, flucytosine,
fluconazole)
 Tuberculous meningitis (isoniazid, rifampin, pyrazinamide, ethambutol,
streptomycin) for 12months
COMPLICATION OF MENINGITIS
 Immediate complications
- Septic shock, including disseminated intravascular coagulation (DIC)
- Coma with loss of protective airway reflexes
- Seizures, which occur in 30-40% of children and 20-30% of adults
- Cerebral oedema
- Septic arthritis
- Pericardial effusion
 COMPLICATION OF
MENINGITIS

 Delayed complications include the following:
- Decreased hearing or deafness
- Other cranial nerve dysfunctions
- Multiple seizures
- Focal paralysis
- Subdural effusions
- Hydrocephalus
- Intellectual deficits
- Ataxia
- Blindness
 Brain parenchymal damage due to bacterial meningitis leads to the following complications;
- Sensory and motor deficits
- Cerebral palsy
- Learning disabilities
- Mental retardation
- seizures
 

END- THANK YOU