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MENINGITIS OUTCOME VARIABLE Acute Benign Form of Viral TO Rapidly Fatal Bacterial Meningitis WITH Local Progressive mental deterioration and death Meningitis – inflammation of the meninges Encephalitis – infection of the brain parenchyma Meningoencephalitis – inflammation of brain + meninges Aseptic meningitis – inflammation of meninges with sterile CSF Introduction Meningitis: inflammation of the pia mater and the arachnoid mater, with suppuration of the cerebrospinal fluid Symptoms of meningitis Fever Altered consciousness, irritability, photophobia Vomiting, poor appetite Seizures 20 - 30% Bulging fontanel 30% Stiff neck or nuchal rigidity Meningismus (stiff neck + Brudzinski + Kernig signs) Contraindications: – ICP reported to increase risk of herniation –Cellulitis at area of tap –Bleeding disorder WHAT DETERMINE THE OUTCOME? 1. Etiological organism 2. Speed and appropriation of the therapy. MORTALITY Bacterial Meningitis : 40 % CAUSES OF MENINGITIS INFECTIOUS Viral NON-INFECTIOUS Aseptic Meningitis Bacteria Malignancy Mycobacterial Sarcoid Brucella behcet disease Fungal SLE Viral Meningitis Generally benign, rarely fatal Enterovirus: around 80% of cases Other viruses: mumps, Epstein-Barr virus, Rare but serious forms: Herpes group viruses No specific preventive or curative treatment for most except Herpes viruses Clears up on its own with no treatment in 3 to 8 days Bacterial meningitis Organisms Neonates – Most caused by Group B Streptococci – E coli, enterococci, Klebsiella, Enterobacter, Samonella, Serratia, Listeria Older infants and children – Neisseria meningitidis, S. pneumoniae, tuberculosis, H. influenzae Causes of bacterial meningitis Strep pneumonia………….37 Neisseria meningitides…..13 Listeria monocytogenes….10 Other strept.species……….7 Gram negative……………….4 Haemophillus influenza……4 No pathogens………………37 Review of 493 cases of adult meningits (Durand NEJM 1993 ) APPROACH TO PATIENT WITH POSSIBLE MENINGITIS I) Maintain diagnostic VIGILANCE a.) Suspect the diseases b.) Look for classical features 1) Headache 2) meningeal irritation….HOW? 3) Obtundation c.) Confirm or exclude the diagnosis II) INITIATE RAPID TRATMENT a. b. c. I.V. Large and sufficient dose Effective choice INITIAL MANAGEMENT APPROACH Recognition of the meningitis syndrome. Rapid diagnostic evaluation. Emergent antimicrobial & adjunctive therapy. III. CONSIDER CHANGING EPIDEMIOLOGY A.) Global emergence and Prevalence of Penicillin- Resistant Strain of Strep. pneumonia. B.) Dramatic Reduction in invasive H. influenza disease secondary to use of conjugate Haemophillus Type B- vaccine. C.) Group B – Streptococci Now > 50 also. Neonate IV. COMPLEXITIESOF EMPIRIC MANAGEMENT I F Focal Sign Pappiledema OR Focal Neurological deficit (often >VI N) ? Brain abscess Chr. Meningitis DON’T Delay Administration of Antibiotics Bacterial Meningitis Treatment Neonatal (<3 mo) Ampicillin (covers Listeria) + Cefotaxime – High CSF levels – Less toxicity than aminoglycosides – No drug levels to follow Management Algorithm for Adults Suspicion of bacterial meningitis YES new onset seizure, papilledema, altered level of consciousness, or focal neurological deficit or delay in performance of diagnostic L.P NO YES Blood c/s & Lumbar puncture Dexamethasone + empirical Abx CSF is abnormal B/C stat Dexamethasone + empirical Abx -ve CT-scan of the head YES +ve CSF gram stain NO Dexamethasone + empirical Abx Perform L.P YES Dexamethasone + targeted Abx CASE I A 12 year old Nigerian boy who has arrived to Riyadh 2 days prior to presentation - C/O severe headache & Photophobia? How do you approach & manage him? Presence of fever & neck stiffness. Neurological deficit & Fundus. Skin RASH CSF examination: Opening pressure: 260 mm H20 & cloudy WBC: 1500/ ml. 96% segmented Glucose: 24mg / dl Protein: 200 mg. MOST – 1. – 2. – 3. – 4. LIKELY DIAGNOSIS: Neisseria m. Strep. Pneumonia H. influenza Listeria monocytogen EPIDEMIOLOGICAL FEATURES OF MENINGOCOCCAL MENINGITIS 1. Affect children + young adult 2 – 20 years 2. Epidemic usually sero group A & C 3. Nasopharyngeal Acquisition 4. Predisposing in those with Terminal Complement deficiencies ( Cs ----- C9 ) 5. SKIN RASH a. Fulminate meningococcemia with purpura b. Meningitis with RASH (Petechiae) c. Meningitis without RASH. 6. Mortality 3 - 10 %. 7. D. O. Choice Penicillin I.V. CASE 2 A 26 YEAR OLD Saudi female who has been C / O unwell & fever & cough and headache for the last 3 days. Examination revealed ill – looking women with sign of consolidation R Lung base. DIAGNOSIS: Bacteria Pneumonia. Organism? Six (6) hours after admission, her headache became worse and she became obstunded. DIAGNOSIS: ? MENINGITIS CSF: WBC: 3000 99% DML Sugar: Zero Protein: 260 mg/dl. Gram Stain: Gram + DIAGNOSIS: Bacterial…..? Epidemiological Features of Pneumococcal meningitis The most common. Cause The most killing. 20 - 30 % DEATH May be associated with other Focus: a. Pneumonia 25% b.Otitis Media 30% c. Sinusitis 15 % d. Head Trauma & CSF Leak 10%. E. splenectoy and SS disease.. Global emergence of Penicillin – Resistant. Case presentation 30 years old sudanese male who was to the ER in confusional state for few hours befor presentation ..history revealed presence of two attacks of seizures in the same day with high fever… EXAMINATION: Looks unwell Neck Stiffness Funds Possible diagnosis: 1. Meningitis 2. Brain abscess 3. Subarachnoid. Hemorrhage… Temp. 39°C absent Bilateral papilledema MENINGITIS 1. 2. 3. Viral Meningitis Bacterial Meningitis Brucella & Tuberculosis PREVENTION : CHEMOPROPHYLAXIS Neiseria meningitidis Eradication of nasopharyngeal carriage ..(post exposure ) for : 1)house hold contact 2)Treating doctor who has examined patient very closely What drugs are recommonded: Rifampicin 600 X 2 d Ciprofloxacin 500X1 Ceftriaxon 125mg I.M X1 VACCINE TO 1. Hib Type B vaccine 1.Protection 2. Eliminate 2. Meningococcal vaccine: A, C, Y, W135 - Up to 3 years adult Does not affect N. ph. Carriage …Does not provide herd immunity. Viral meningitis Treatment Supportive No antibiotics Analgesia Fever control Often feel better after LP No isolation - Standard precautions Caes 56 years saudi women presented to the infectious disease clinic c/o low grade fever and night sweating for the last 6 wks…on detailed inquires she admitted to have headache for 4 wks improving on analgesics.. EXAMINATION: T: 38.2..Fully conscious Neck stiffnes..bilateral papillodema LABORATORY RESULTS.. CSF:…xanthocromic wbc 340 L: 85 % protein 1.5g sugar 25 mg WHAT IS YOUR ANYLASIS OF THIS CSF……….. 1) 2) 3) 4) 5) Partially treated bacterial meningitis Aseptic meningitis Bruclla meningitis Tubercoulus meningitis OTHERS…….. TREATMENT: A. Principles of Therapy: 1. Multiple drugs. ( INH& Rif.) 2. Educate the patient Long therapy 6/12 3. Tell about Potential side effects a. Orange sweat & tears with Rifampicin. b. Hepatitis with INH. 4. Follow patient closely. B. Commonly Used Drugs: 1. INH (Isonized) a. Bactericidal inhibit DNA synthesis b. Excellent tissue and CNS penetration. c. Acetylated with liver Renal. d. Toxicity : Hepatitis / P. Neuropathy. 2. Rifampicin a. b. c. d. Bactericidal inhibit RNA synthesis Excellent tissue & CNS penetration Hepatic excretion Toxicity : Hepatitis / RASH / Drugs interaction Malaria&Travel Medicine MALARIA Febrile illness caused by Plasmodium. 200 – 300,000,000 cases. 700,000---2.7,000,000 death/year more in rural area.. more during rainy season Human ---- ----- Another Mosquito Transmission BITE OF FEMALE ANOPHELES BETWEEN DUSK AND DAWN BLOOD TRANSFUSION CONTAMINATED NEEDLES CONGENITAL. ETIOLOGY Four species. Death is mostly due to ..? SYPMTOMS --- Non-specific Headache & fatigue & muscle pain Fever DX: Viral infection..? Clinical Features: Symptoms: 7 – 10 days Paroxysms. Cold Hot Malaria Chills & Rigor & cold skin Fever, warm skin 3-6 hours deverevescence Marked sweating Between Paroxyms Well DX ? SIGNS Spleen Enlargement Jaundice Fever Anemia Clinical example: An 18 years old Saudi pregnant young women originally from Jazan came C/O Fever and headache. Exam: Pale, jaundiced, Temp. - 39°C Spleen enlarged NEXT? CBC: WBC - 8000 Hb - 9.0 Platelets: 90 CXR: MCU : 98 Normal DIAGNOSIS 1. Index of suspicion Travel hist. Incubation Period 2 WKS Prophylaxis - Longer 2. ? Malaria 3. Blood smear :Thin & thick 4. Special Drug COMPLICATION: 1. Cerebral Malaria encephalopathy Seizure Death 20% 2. Black. Water Fever non immune High degree of F.M. Hemolysis Malaria & Pregnancy: 1. 2. Risk of low birth & abortion. Risk of glucose , pulm. oedema TREATMENT 1. 2. 3. History Smear Species 4. Severity 5. Drugs: CBC Hib Coagulation TREATMENT 1. Uncontrolled airway 2. I.V . infusion Blood glucose test, parasitemia, Hct. Antimalaria. a. Chloroquine p.o. b. Mefloquine C. Quinine AND DOXYCYCLINE D. ARTEMISININS E . ATOVAQUONE PLUS PROGUANEL 4. 5. Fluid balance P. Edema Dehydration & Shock 6. Convulsion Diazepam 7. Blood C/ S……8) LP DRUG TOXICITY MEFLOQUINE : neuropsychiatric symptoms : mood changes .encephalopathy…transient QUININE : Bitter taste , GIT upset , cinchonism ( nausea, vomiting , tinnitus , high tone deafness ) Doxycycline ..GIT upset, vaginal candidiasis..( use antifungal ) PREVENTION Avoid mosquito Wear long sleeved clothing Sleep in well – screened rooms Use mosquito netting Use insect repellents (e.g. DEET) Chemoprophylaxis.. 1) CHLOROQUINE ONE TABLET EVERY WK.. DAILY WILL LEED TO RETINOPATHY Consider resistant plasmodium Chloroquine-sensitive areas Drug of choice Chloroquine 500 mg (300 mg base) : once/wk Atovaquone/ proguanil (Malarone) : 1 tab/d ( 250 mg atovaquone /100 mg proguanil) Mefloquine 250 mg once/wk Doxycycline 100 mg daily Alternatives Primaquine 30 mg base daily Chloroquine plus proguanil 500 mg (300 mg base) once / wk + 200 mg