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

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

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

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