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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
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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
the inappropriate excretion of the antidiuretic hormone (SIADH). Gram stain of meningococci from a culture showing Gram negative (pink) bacteria. the "opening pressure" of the CSF is measured using a manometer. Neutrophil granulocytes tend to have migrated to the cerebrospinal fluid and the base of the brain. Lumbar puncture A lumbar puncture is done by positioning the patient. Treatment Initial treatment Meningitis is potentially lifethreatening and has a high mortality rate if untreated. due to a combination of factors including dehydration.fast heart rate. especially but not exclusively in meningococcal illness.gangrene of limbs can occur. often > 300/mm³ mononuclear. The initial appearance of the fluid may prove an indication of the nature of the infection: cloudy CSF indicates higher levels of protein. hyponatremia is common in bacterial meningitis. However. delay in treatment has been associated with a poorer outcome. This applies in 45% of all adult cases. In severe forms of meningitis. < 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. high or abnormally low temperature and rapid breathing. often in pairs Postmortem Meningitis can be diagnosed after death has occurred. white and red blood cells and/or bacteria. If a CT or MRI is required before LP. usually lying on the side. The most important test in identifying or ruling out meningitis is analysis of the cerebrospinal fluid through lumbar puncture (LP. If someone is at risk for either a mass or raised ICP (recent head injury. the excessive activation of blood clotting. When this has been achieved. as it may lead to brain herniation. localizing neurological signs. applying local anesthetic.g. The infection may trigger sepsis. 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. or evidence on examination of a raised ICP). and an abnormal skin color. Disseminated intravascular coagulation. and therefore may suggest bacterial meningitis.complete blood count). or if LP proves difficult. These may require specific treatment. Creactive protein. professional guidelines suggest that antibiotics should be administered first to prevent delay in treatment. Intravenous fluids should be administered if hypotension (low blood pressure) or shock are present. If meningococcal disease is suspected in primary care. may be surrounded with pus—as may the meningeal vessels. and sometimes indicate severe illness or worse prognosis. Often. 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. in bacterial meningitis the pressure is typically . monitoring of blood electrolytes may be important. may cause both the obstruction of blood flow to organs and a paradoxical increase of bleeding risk. Given that meningitis can cause a number of early severe complications. blood tests are performed for markers of inflammation (e. In meningococcal In someone suspected of having meningitis. CT or MRI scans are performed at a later stage to assess for complications of meningitis. for example. Very low blood pressure may occur early.extremities. as well as admission to an intensive care unit if deemed necessary. Early complications disease. as well as blood cultures. along with cranial nerves and the spinal cord. this may lead to insufficient blood supply to other organs. or overly aggressive intravenous fluid administration. a known immune system problem. Bacterial meningitis sac (a sac around the spinal cord) to collect cerebrospinal fluid (CSF). a CT orMRI scan is recommended prior to the lumbar puncture. The pressure is normally between 6 and 18 cm water (cmH2O). especially if this may be longer than 30 minutes. 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. Thus treatment with widespectrum antibiotics should not be delayed while confirmatory tests are being conducted. spinal tap). < 300/mm³ mononuclear and PMNs. a systemic inflammatory response syndrome of falling blood pressure. People with meningitis may develop additional problems in the early stages of their illness. and inserting a needle into the dural elevated. regular medical review is recommended to identify these complications early.
The likely mechanism is suppression of overactive inflammation. and continued for four days. For some causes of meningitis. Given that most of the benefit of the treatment is confined to those with pneumococcal . but cannot be spread by only breathing the air where a person with meningitis has been. Viral meningitis typically requires supportive therapy only. addition of ampicillin is recommended to cover Listeria monocytogenes. as well as those who are immunocompromised. and is most commonly spread through fecal contamination. Empirical therapy may be chosen on the basis of the age of the patient.Antibiotics meningitis. whether the patient has undergone neurosurgery and whether or not a cerebral shunt is present. Herpes simplex virus and varicella zoster virus may respond to treatment with antiviral drugs such as aciclovir. most viruses responsible for causing meningitis are not amenable to specific treatment. Viral meningitis is typically caused by Enteroviruses. some guidelines suggest that dexamethasone be discontinued if another cause for meningitis is identified. in the United Kingdom empirical treatment consists of a thirdgeneration cefalosporin such as cefotaxime or ceftriaxone. where resistance to cefalosporins is increasingly found in streptococci. bedrest. but there are no clinical trials that have specifically addressed whether this treatment is effective. The choice of initial treatment depends largely on the kind of bacteria that cause meningitis in a particular place. and analgesics. Once the Gram stain results become available. Empiric antibiotics (treatment without exact diagnosis) must be started immediately. Neither are as contagious as the common cold or flu. addition of vancomycin to the initial treatment is recommended. whether the infection was preceded by head injury. Steroids neurological damage in adolescents and adults from high income countries which have low rates of HIV. For instance. prophylaxis can be provided in the long term with vaccine. in young children and those over 50 years of age. or in the short term with antibiotics. even before the results of the lumbar puncture and CSF analysis are known. Viral meningitis tends to run a more benign course than bacterial meningitis. and the broad type of bacterial cause is known. In the USA. Structural formula of ceftriaxone. Professional guidelines therefore recommend the commencement of dexamethasone or a similar corticosteroid just before the first dose of antibiotics is given. Prevention Bacterial and viral meningitis are contagious. it may be possible to change the antibiotics to those likely to deal with the presumed group of pathogens. Mild cases of viral meningitis can be treated at home with conservative measures such as fluid. For instance. one of the third-generation cefalosporin antibiotics recommended for the initial treatment of bacterial meningitis. sneezing or coughing on someone. Both can be transmitted through droplets of respiratory secretions during close contact such as kissing.
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