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Meningitis
Acute infection of meningitis, important medical problem Causes: Infective:
Bacterial Viral: Enterovirus; mumps Fungal: cryptococcus; candida Protozoa: amoeba; toxoplasma; cysticercus
Non infective:
Malignant disease: breast CA; leukemia; lymphoma; Bronchial CA Inflammatory: Behcets disease; SLE; sarcoidosis
Causative organisms
Age of onset Common Less common
Neonate
Gram ve bacil Gr. B Strep. H. Influenza N meningitidis St. Pneumoniae N meningitidis St. Pneumoniae
Listeria
Pre school
Etiology
Strep Pneumoniae:
most common in > 20yrs Predisposing condn. - pneumonia, sinusitis, otitis media, - alcoholism, diabetes, - splenectomy, - hypogamma.,complement defn. Mortality: 20%
Listeria monocytogens:
< 1 month & >60 yrs; pregnancy, immunocompromised (all ages) Ingestion contaminated food : milk products, meat products
Pathophysiology
Colonize nasopharynx Intravascular space Choroid plexus Absence effective host defense mech Avoids phagocytosis
CSF
Proliferation of bact.
Pathophysiology
Most neuro. Manifest & complications: immune response to invading pathogen and not direct bact. Induced injury Injury can progress even after CSF sterilized Lyse bacteriarelease of cell wall components (LPS, teicholic & peptidoglycan) in SA space cytokines (IL 1 & TNF)
WCC & CSF protein Production of excitatory amino acids, reactive O2, nitrogen species permeability of BB barrier: vasogenic oedema; protein in SA space
Increase ICP
Clinical manifestations
Onset: rapid (few hours) or subacute (worsens over days) Classic clinical triad : Fever, headache, nuchual rigidity (Kernigs sign; Brudzinski sign) level of consciousness 75% (lethargy to coma) Nausea and vomiting Photophobia Seizure (20-40%)
Focal: focal ischemia or infarction; cv thrombosis; focal edema Generalized: hyponatremia; cerebral anoxia; toxic effect of Penn.
Rash: meningococcemia
Clinical manifestations
ICP 90% Signs:
level of consiousness
Papilloedema Dilated and partly reacting pupils VI th nerve palsy Decerebrate posture Cushingss reflex: pulse rate, HTN, irreg. resp
Diagnosis
Suspected blood culture empirical Antibiotics Diagnosis by CSF examination LP safely done in:
Immunocompetent person normal level of consiousness No Papilloedema No focal neurological signs
Cond.
Normal
Cell
Lymph
Count
0-4
Glucos
>60% bl
Protein mg/dL
0 to 45
Gram
_
Viral
Lymph
10-2000
Bact.
Polym.
10005000
N/
TB
Lymp/ mixed
Lymph
50-5000
N/
Often-
Fungal
50-500
+/-
Malig
Lymph
0-100
Diagnosis
CSF in pyogenic meningitis
PMN leucocytes (>100/microL) 90% glucose (< 40 mg/dL) 60% protein ( > 45 mg/dL) 90% pressure (> 180 mm H2O) 90% Gram stain: 60% Culture: >80%
Differential Diagnosis
Viral meningo encephalitis: HS virus
CSF: normal glucose and lymphocytosis MRI : high intensity signal lesions EEG
Rickettsial disease
fever, headache, myalgia and nausea and vomiting Rash in 96 hrs
Treatment
Start Antimicrobial: Goal, < 60 mins arrival to ER Empirical before CSF results
Patients with typical meningococcal rash - Benzylpenicillin 4 megaunits 6 hrly Adults : 18 -50 without typical meningococcal rash - 3rd gen. Cephalosporin ( ceftriaxone 2 g 12 hrly) Penn resistant pneumocci suspected - 3rd gen. Cephalosporin + Vancomycin 1 g 12 hrly Listeria suspected ( < 3/12 and > 55 yrs) - 3rd gen. Cephalosporin + Ampicillin 2 g, 4 hrly H/O anaphylaxix to B lactam - Chloramphenicol 25mg/kg, 6 hr + Vancomycin 1 g 12 hrly
Adjunctive Treatment
Dexamethasone:
20 minutes before antibiotic therapy.(Before the macrophages and microglia are activated by endotoxin) No benefit if started > 6 hrs after Ab therapy Dose: 10 mg, 6 hrly for 4 days
Benefits
synthesis of IL1 and TNF CSF outflow resistance stabilizing the BB barrier
Reduce the number of unfavorable outcomes - unfavourable outcome 15% vs 25% - death: 7% vs 15%
Adjunctive Treatment
Treatment of raised ICP
Elevation of patients head 30-45 degrees Intubation and hyperventilation (PaCo2 25-30 mmhg) Mannitol
Prognosis
. Poor prognostic markers
decrease level of cons. seizure in 24 hrs Sign of increase ICP Young age & >50 yrs Co morbid condn. Delay in starting treatment decrease CSF glucose (<40 mg) & increased protein (>3 g/l)
Drug:
Rifampicin : 10 mg/kg, 12 hrly for 2 days Ciprofloxacin: 500 mg single dose
Sequele
intellectual fxn memory impairment seizure Extremes of age Difficulty in gait
Viral meningitis
Most common cause Usually benign and self limiting illness requiring no therapy Common organisms: echo & mumps C/F:
Children or young adults affected Headache, irritability, fever and meningnism Focal neurological signs: rare
Brain abscess
Pathogenesis & Etiology
Penetrating injury, direct spread from paranasal sinus or middle ear Hematogenous spread: septicaemia Initial infection suppuration loculation of pus surrounding wall of gliosis
Etiology
Streptococci Anaerobes Staphylococci
Brain abscess
Investigations
LP hazardous CT: single or multiple low density areas with ring enhancement and surrounding oedema DD: cerebral toxoplasmosis and tuberculoma
Management
Medical treatment: small abscess (<2-3 cm) or non encapsulated Antibiotics - community acq: 3rd gen cephalosporin + metronidazole - penetrating injury: Ceftazidime+ vancomycin - duration: 6- 8 weeks Neuro Surgical intervention: diagnostic and therapeutic Prophylactic Anticonvulsants Mortality: 10-20%.