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Meningitis

Meningitis

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Publicado porRenante Maramot

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Published by: Renante Maramot on Dec 31, 2011
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05/18/2012

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MENINGITIS

Meningitis is inflammation of the protective membranes covering the brain and spinal cord, known collectively as the meninges. The inflammation may be caused by infection with viruses, bacteria, or other microorganisms, and less commonly by certain drugs. Meningitis can be lifethreatening because of the inflammation's proximity to the brain and spinal cord; therefore the condition is classified as a medical emergency. The most common symptoms of meningitis are headache and neck stiffness associated with fever, confusion or altered consciousness, vomiting, and an inability to tolerate light (photophobia) or loud noises (phonophobia). Sometimes, especially in small children, only nonspecific symptoms may be present, such as irritability and drowsiness. If a rash is present, it may indicate a particular cause of meningitis; for instance,meningitis caused by meningococcal bacteria may be accompanied by a characteristic rash. A lumbar puncture may be used to diagnose or exclude meningitis. This involves inserting a needle into the spinal canal to extract a sample ofcerebrospinal fluid (CSF), the fluid that envelops the brain and spinal cord. The CSF is then examined in a medical laboratory. The usual treatment for meningitis is the prompt application of antibiotics and sometimes antiviral drugs. In some situations, corticosteroid drugs can also be used to prevent complications from overactive inflammation. Meningitis can lead to serious long-term consequences such as deafness,epilepsy, hydrocephalus and cognitive deficits, especially if not treated quickly. Some forms of meningitis (such as those associated with meningococci, Haemophilus influenzae type B, pneumococci or mumps virus infections) may be prevented by immunization. MENINGITIS

Classification and external resources

A parasitic cause is often assumed when there is a predominance of eosinophils (a type of white blood cell) in the CSF. The most common parasites implicated are Angiostrongylus

cantonensis, Gnathostoma spinigerum, Schistosoma, as
Causes Meningitis is usually caused by infection from viruses or microorga nisms. Most cases are due to infection with viruses with bacteria, fungi, and parasites being the next most common causes. It may also result from various non-infectious causes. Bacterial The types of bacteria that cause bacterial meningitis vary by age group. In premature babies and newborns up to three months old, common causes are group B streptococci (subtypes III which normally inhabit the vagina and are mainly a cause during the first week of life) and those that normally inhabit the digestive tract such as Escherichia coli (carrying K1 antigen).Listeria monocytogenes (serotype IVb) may affect the newborn and occurs in epidemics. Aseptic The term aseptic meningitis refers loosely to all cases of meningitis in which no bacterial infection can be demonstrated. This is usually due to viruses, but it may be due to bacterial infection that has already been partially treated, with disappearance of the bacteria from the meninges, or by infection in a space adjacent to the meninges Viral Viruses that can cause meningitis include enteroviruses, herpes simplex virus type 2 (and less commonly type 1), varicella zoster virus (known for causing chickenpox and shingles),mu mps virus, HIV, and LCMV. Parasitic well as the conditions cysticercosis, toxocariasis, baylisascariasis, paragonimiasis, and a number of rarer infections and noninfective conditions.

Signs and symptoms Clinical features In adults, a severe headache is the most common symptom of meningitis – occurring in almost 90% of cases of bacterial meningitis, followed by nuchal rigidity (inability to flex the neck forward passively due to increased neck muscle tone and stiffness). The classic triad of diagnostic signs consists of nuchal rigidity, sudden high fever, and altered mental status; however, all three features are present in only 44– 46% of all cases of bacterial meningitis. If none of the three signs is present, meningitis is extremely unlikely. Other signs commonly associated with meningitis include photophobia (intolerance to bright light) and phonophobia (intolerance to loud noises). Small children often do not exhibit the aforementioned symptoms, and may only be irritable and look unwell. In infants up to 6 months of age, bulging of the fontanelle (the soft spot on top of a baby's head) may be present. Other features that might distinguish meningitis from less severe illnesses in young children are leg pain, cold

Often. as it may lead to brain herniation. and sometimes indicate severe illness or worse prognosis. Neutrophil granulocytes tend to have migrated to the cerebrospinal fluid and the base of the brain. In severe forms of meningitis. lumbar puncture is contraindicated if there is a mass in the brain (tumor or abscess) or the intracranial pressure (ICP) is elevated. guidelines recommend that benzylpenicillin be administered before transfer to hospital. spinal tap). the excessive activation of blood clotting. Early complications disease. This applies in 45% of all adult cases. white and red blood cells and/or bacteria. or evidence on examination of a raised ICP). CT or MRI scans are performed at a later stage to assess for complications of meningitis. the inappropriate excretion of the antidiuretic hormone (SIADH). the "opening pressure" of the CSF is measured using a manometer. as well as admission to an intensive care unit if deemed necessary. However. Intravenous fluids should be administered if hypotension (low blood pressure) or shock are present. and inserting a needle into the dural elevated. Very low blood pressure may occur early. The initial appearance of the fluid may prove an indication of the nature of the infection: cloudy CSF indicates higher levels of protein. The pressure is normally between 6 and 18 cm water (cmH2O). professional guidelines suggest that antibiotics should be administered first to prevent delay in treatment. regular medical review is recommended to identify these complications early. high or abnormally low temperature and rapid breathing. applying local anesthetic. These may require specific treatment. in bacterial meningitis the pressure is typically . or if LP proves difficult. hyponatremia is common in bacterial meningitis. for example. The infection may trigger sepsis. a CT orMRI scan is recommended prior to the lumbar puncture. as well as blood cultures. usually lying on the side. In meningococcal In someone suspected of having meningitis.fast heart rate. Gram stain of meningococci from a culture showing Gram negative (pink) bacteria. especially if this may be longer than 30 minutes.extremities. When this has been achieved. Bacterial meningitis sac (a sac around the spinal cord) to collect cerebrospinal fluid (CSF). or overly aggressive intravenous fluid administration. delay in treatment has been associated with a poorer outcome. < 300/mm³ mononuclear and PMNs. People with meningitis may develop additional problems in the early stages of their illness. The findings from a post mortem are usually a widespread inflammation of the pia materand arachnoid layers of the meninges covering the brain and spinal cord. If a CT or MRI is required before LP. < 300/mm³ < 300/mm³ usually mononuclear high normal or high normal Tuberculo us Fungal Malignant low high low low high high A severe case of meningococcal meningitis in which the petechial rash progressed to gangrene and required amputation of all limbs. If meningococcal disease is suspected in primary care. Diagnosis Blood tests and imaging CSF findings in different forms of meningitis Type of meningitis Acute bacterial Acute viral Glucos e low Protein Cells PMNs. Creactive protein. monitoring of blood electrolytes may be important. Given that meningitis can cause a number of early severe complications.complete blood count). along with cranial nerves and the spinal cord. may be surrounded with pus—as may the meningeal vessels. especially but not exclusively in meningococcal illness. Lumbar puncture A lumbar puncture is done by positioning the patient. a known immune system problem. Disseminated intravascular coagulation.g. If someone is at risk for either a mass or raised ICP (recent head injury. due to a combination of factors including dehydration. localizing neurological signs. this may lead to insufficient blood supply to other organs. often > 300/mm³ mononuclear. often in pairs Postmortem Meningitis can be diagnosed after death has occurred. a systemic inflammatory response syndrome of falling blood pressure. may cause both the obstruction of blood flow to organs and a paradoxical increase of bleeding risk. and therefore may suggest bacterial meningitis. Thus treatment with widespectrum antibiotics should not be delayed while confirmatory tests are being conducted. Treatment Initial treatment Meningitis is potentially lifethreatening and has a high mortality rate if untreated.gangrene of limbs can occur. The most important test in identifying or ruling out meningitis is analysis of the cerebrospinal fluid through lumbar puncture (LP. and an abnormal skin color. blood tests are performed for markers of inflammation (e.

where resistance to cefalosporins is increasingly found in streptococci. Viral meningitis typically requires supportive therapy only. bedrest. Mild cases of viral meningitis can be treated at home with conservative measures such as fluid. Structural formula of ceftriaxone. whether the patient has undergone neurosurgery and whether or not a cerebral shunt is present. it may be possible to change the antibiotics to those likely to deal with the presumed group of pathogens. Prevention Bacterial and viral meningitis are contagious. as well as those who are immunocompromised. whether the infection was preceded by head injury. For instance. Given that most of the benefit of the treatment is confined to those with pneumococcal . one of the third-generation cefalosporin antibiotics recommended for the initial treatment of bacterial meningitis. Herpes simplex virus and varicella zoster virus may respond to treatment with antiviral drugs such as aciclovir.Antibiotics meningitis. Steroids neurological damage in adolescents and adults from high income countries which have low rates of HIV. Both can be transmitted through droplets of respiratory secretions during close contact such as kissing. and continued for four days. most viruses responsible for causing meningitis are not amenable to specific treatment. in young children and those over 50 years of age. and the broad type of bacterial cause is known. Viral meningitis tends to run a more benign course than bacterial meningitis. Empirical therapy may be chosen on the basis of the age of the patient. For some causes of meningitis. but cannot be spread by only breathing the air where a person with meningitis has been. Once the Gram stain results become available. in the United Kingdom empirical treatment consists of a thirdgeneration cefalosporin such as cefotaxime or ceftriaxone. and analgesics. Viral meningitis is typically caused by Enteroviruses. For instance. The choice of initial treatment depends largely on the kind of bacteria that cause meningitis in a particular place. but there are no clinical trials that have specifically addressed whether this treatment is effective. Neither are as contagious as the common cold or flu. The likely mechanism is suppression of overactive inflammation. prophylaxis can be provided in the long term with vaccine. Professional guidelines therefore recommend the commencement of dexamethasone or a similar corticosteroid just before the first dose of antibiotics is given. addition of ampicillin is recommended to cover Listeria monocytogenes. sneezing or coughing on someone. In the USA. and is most commonly spread through fecal contamination. or in the short term with antibiotics. even before the results of the lumbar puncture and CSF analysis are known. Empiric antibiotics (treatment without exact diagnosis) must be started immediately. some guidelines suggest that dexamethasone be discontinued if another cause for meningitis is identified. addition of vancomycin to the initial treatment is recommended.

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