MENINGITIS

-inflammation of the leptomeninges, the CT layer in close proximity to the surface of

the brain
-Can be Bacterial, Aseptic (Viral), and Chronic (Tuberculous, Fungal, Parasitic)
-in the Phil, remains to be among the top 10 killers of children < 4 years old

S & Sxs

Neonates

Nonspecific

Fever/hypothermia, sleepy
Fever, anorexia, confusion,
/lethargic, disinterest in
irritability, photophobia, nausea,
feeding/poor feeding,cyanosis, vomiting, headache, seizure
grunting, apneic sepisodes,
vomiting

Meningeal
inflammation

+/- neck rigidity

Increased
intracranial
pressure

Bulging fontanel, diastasis of Headache, bulging fontanel,

sutures, convulsions,
diastasis of sutures in infants,
opisthotonus
papilledema, mental confusion,
altered state of consciousness

Focal neurologic
signs

Hemiparesis, ptosis, facial

nerve palsy

Predisposing Factors

Older children

Neck rigidity, Kernig and

Brudzinski signs

Hemiparesis, ptosis, deafness,

facial nerve palsy, optic neuritis

1 .Prematurity, prolonged difficult delivery & maternal infection neonates

2. Age- greatest between birth & 5 yrs of age, peak at 1 st month of life
3. Congenital immunodeficiencies
4. Acquired immunodeficiencies
- opportunistic & encapsulated bacteria
5. Poor sanitation, lack of access to preventive care & overcrowding
6. Exposure of cranial vault or spine
(eg. Congenital, post-traumatic, surgical)

Diagnosis
1. Examination of the CSF
- single most impt. diagnostic test in patients w/ suspected CNS infection
- lumbar puncture (LP) therefore is a mandatory step especially if bacterial
meningitis is suspected
CSF findings

Opening Cell count

pressure

Glucose (mg/100 Protein

ml)
(mg/100 ml)

(mm H20)
Normal Values

90- 180

Bacterial

200 - 300 100 5,000;

Meningiti
s

0 5 lymphocytes

Neutrophils
usually > 80%

50 75 (at least
50% of
simultaneous
serum glucose)

15 - 40

Reduced, < 40

100 1,000

Tuberculous
Meningitis

CSF
findings

180 - 300 Usually < 500

lymphocytes

Reduced, < 40

Opening Cell count

pressure

100 200, but

up to 1,000 if
CSF block is
present

Glucose
(mg/100 ml)

Protein
(mg/100
ml)

Cryptococc 180 - 300 10 200 lymphocytes

al
Meningitis

Reduced, < 40

50 - 200

Viral
Meningitis

Normal;
occasionally
slightly reduced
in mumps
meningitis and
LCM

50 - 100

Normal

50 -100

(mm
H20)

90 - 200

10 300 lymphocytes; maybe

>1,000 in echoviral & mumps
meningitis & in lymphocytic
choriomeningitis; early echoviral
meningitis may show up to 80%
neutrophilic predominance

Viral
180 - 300 0 500 lymphocytes
encephaliti
s

2. Brain Imaging
Indications:
- prolonged depressed consciousness
- persistent full fontanel

prolonged fever
focal neurologic deficits
seizures
failure to display clinical improvement
sudden unexplained clinical deterioration

When facilities permit, cranial Ct scan or MRI should be considered

at diagnosis in critically ill patients and should be obtained in
patients at risk for a subsequent unfavorable clinical course.
A NORMAL NEUROIMAGING DOES NOT RULE OUT CNS INFECTION
1. Viral Meningitis
ETIOLOGY
1. Enteroviruses (coxsackievirus A & B, echovirus
& poliovirus)
- most common
2. Mumps virus- decreased with vaccination
3. HSV, Rubella, CMV, Rabies, Arbovirus
- minor causes
CLINICAL MANIFESTATIONS
a. Prodrome: sore throat, fever, anorexia, malaise & myalgia
b. Acute: lethargy, vomiting, headache, stiff neck
(+) nuchal rigidity & meningeal signs
2. Bacterial Meningitis
- Acute, life- threatening
- Mortality rate: 10-15% (depending on cause)
- Etiology:
- encapsulated
- high affinity for specific receptors
a. choroid plexus
b. meninges
- >80% of cases beyond the neonatal period are caused by the
following:

Streptococcus pneumoniae (18 of more than 80 serotypes)

Neisseria meningitidis (serotypes A, B, C & Y)
Haemophilus influenzae (type b)
20% are caused by various pathogens & opportunistic bacteria
(Listeria monocytogenes, G(-) enteric rods, S. aureus, Strep
pyogenes, S. epidermidis, M. tuberculosis)

Pathogenesis

Bacterial access to the meninges or subarachnoid

a. Bacteremic spread
b. Direct invasion
- from contiguous focus (sinusitis, mastoiditis,
osteomyelitis, otitis media)

skull & vertebral

- loss of integrity of CSF space

a. congenital(dermoid sinus,meningomyelocele)
b. traumatic (fractures)
c. surgical

Inflammation

Release of bacterial products

Release of inflammatory mediators
1. vasodilation
2. permeability
3. recruitment of neutrophils & other WBCs

Tissue injury
- edema

- ICP
- blood flow
- suppuration

Streptococcus pneumoniae
-

leading cause of pneumonia in children and adults

Paired G+ cocci (ovoid)
- hemolyticFacultative aerobe
Bile soluble
Optochin sensitive
VIRULENCE FACTORS
1. polysaccharide capsule
2. IgA protease
RISK FACTORS
1. impaired immune response
2. viral- induced tissue alteration
3. loss of splenic function
EPIDEMIOLOGY
- strictly human pathogen
- droplet inhalation
DIAGNOSIS
1. rapid diagnostic tests eg. Latex agglutination
2. culture & isolation
Confirmation:
a. Optochin sensitive
b. bile soluble
c. (+) Quellung reaction

TREATMENT
Penicillin resistance
3rd gen Cephalosporin (ceftriaxone)- DOC
Vancomycin- highly resistant strains
PREVENTION

- vaccination