Meningitis

Gary R. Skankey, MD, FACP

Causes of Meningitis

Bacteria

Community-acquired - S. pneumoniae, N. meningitidis, gp B streptococcus Post-op or hospital acquired MRSA, Ps. Aeruginosa In the very young and very old Listeria monocytogenes
Enterovirus, coxsackie virus, echovirus, HSV-2, etc

Viruses

Fungi

Coccidioides, cryptococcus

TB

Clincal Presentation

Acute meningitis
Abrupt or rapid onset flu-like prodrome myalgias Fever Headache Nucal stiffness Altered sensorium (meningo-encephalitis) Rash

Clinical Presentation

Chronic meningitis
Insidious, gradual onset Weeks of headache Low grade fever Sweats, chills Weight loss

Acute Meningitis

Physical Exam

Koenig-Brudzinskis sign uncommon Nucal rigidity common Photophobia common Rash - uncommon

Lab

CT head r/o cerebritis, brain abscess, brain edema Lumbar puncture

Pleocytosis High protein Low glucose (CSF:serum glucose < 50%) Bacterial antigens more sensitive in children Gram stain and culture

Treatment

Ceftriaxone 2 gm IV Q 12, or Cefotaxime 2 gm IV Q 4, plus Vancomycin 1.5 gm IV Q 12 In the very young or very old add Ampicillin 2 gm IV Q 4 If pcn allergic, ask for details:
Rash : use cephalosporin Anaphylactic : use Aztreonam 2 gm IV Q 8

IN The ER

1st step Give antibiotics ASAP 2nd step draw labs 3rd step CT head 4th step - LP

Prevention

Vaccines

Pneumovax Meningicoccal vaccine Both should be administered to any asplenic patient

Rifampin 600 mg PO BID x 4 doses Only for intimate contacts: spouse, boyfriend/girlfriend, household contacts Not needed for: classmates, co-workers, HCWs (ER personnel, EMTs, etc)

Exposure to meningococcus

Viral Meningitis

75% caused by enteroviruses

Enterovirus Coxsackie virus Echo virus

HSV2 (HSV1 causes encephalitis) HIV Lymphocytic choriomeningitis virus Mumps Varicella Zoster

Other viruses

Viral Meningitis

Cannot distinguish initially from bacterial meningitis Severe HA, photophobia, nucal rigidity, fever May be preceded by a few weeks by viral gastroenteritis

Ask pt is he/she had the stomach flu some time in the past couple weeks Pt never obtunded, no Hx of seizure

Almost never involves brain (meningoencephalitis)

Disease is self-limited, resolves after 7 to 10 days without treatment No serious sequelae

CSF

Low numbers of WBCs : 10 to 500

PMNs predominate early, Monos or Lymphocytes later

CSF to serum glucose ratio usually = 50% Protein may be high Gram stain, culture and bacterial antigens negative Enteroviral PCR positive about 70% of time

Approach to Viral Meningitis

Treat like bacterial meningitis until the 72 hr culture comes back negative, or Enteroviral PCR comes back positive Consider acyclovir if CSF HSV PCR positive

HSV meningitis is self-limited

Chronic Meningitis

Causes

Cryptococcus Coccidioides immitis Mycobacterium tuberculosis Other fungal histoplasmasma, blastomyces, sporotrix Other bacteria brucella, francisella, nocardia, borellia Non-infectious Wegeners, sarcoid, malignanacy

Presentation

Insidious onset Low grade fever if any Persistant, worsening headache Photophobia and nucal rigidty usually absent Symptoms have usually lasted several weeks by the time diagnosis is made

Diagnosis

History
Exposure to bird droppings (crypto) Travel to Arizona, Central Valley California, Desert Southwest (cocci) Contacts with TB pts

CSF
Modest pleocytosis Glucose may be normal, but protein usually high (very high if coccidioma causes CSF obstruction)

Diagnosis

TB
CSF AFB smear usually negative AFB culture takes 6 weeks Positive PPD or quantiFERON may suggest diagnosis CSF PCR not standardized yet, but may be helpful;

Cryptococcus
India ink Cryptococcal Ag in CSF

Diagnosis

Coccidioidomycosis
Difficult diagnosis to make CSF fungal smear and cultures usually negative Titers have high false negativity rate even from CSF Cocci CF titer from serum may give clue. Any pt with history of pulmonary cocci who develops HA with pleocytosis should be treated for cocci meningitis

Treatment

TB

Treat like pulmonary TB: INH, Rif, Eth, PZA for two months, then INH, Rif to comlete 12 months Steroids improves mortality, reduces adverse events (infarcts)
Amphotericin plus flucytosine for 6 weeks followed by fluconazole to complete 6 months

Crytpococcus

High toxicity rate (renal failure, pancytopenia)

High dose fluconazole (400 to 800 mg QD) if cant tolerate ampho + 5FC Serial LPs to reduce CSF pressure and assure clearing of infection In AIDS pts continue Fluconazole until CD4 >100

Treatment

Coccidioidomycosis

Intrathecal amphotericin now rarely used

Chemical arachnoiditis

High dose fluconazole (800 to 1200 mg QD) Serial LPs to assure improvement of infection Incurable symptoms may resolve, but patient can never stop fluconazole

Taper down to no lower than 400 to 600 mg QD

Recurrent meningitis

Mollarets meningitis Most common cause is HSV2 Many other poorly defined causes as well
Leaking arachnoid cyst Cryptogenic

May respond to acyclovir

Conclusion

Acute bacterial meningitis is most commonly caused by viruses, then bacteria Chronic meningitis can be caused by fungi and TB Recurrent meningitis Mallorets Call ID when pt has meningitis