Meningitis

ETIOLOGY
• Meningitis: inflammation of the leptomeninges caused by bacteria, viruses or rarely
fungi.
• aseptic meningitis= viral meningitis, but a similar picture seen with:
1. infectious organisms (Lyme disease- borrelia bugdorferi, TB,Syphilis)
2. parameningeal infections (brain abscess, epidural abscess, venous sinus empyema)
3. chemical exposure (NSAIDs, IV Ig)
4. autoimmune disorders
• The organisms commonly causing bacterial meningitis before the availability of current
conjugate vaccines were Hib, S. pneumoniae, and N. meningitidis.
• The bacteria causing neonatal meningitis are the Age Most Common Less Common
same as the bacteria that cause neonatal sepsis. Neonatal Group B streptococci Staphylococcus aureus
• Staphylococcal meningitis occurs in patients who
Escherichia coli Coagulase-negative staph.
have had neurosurgery or penetrating head trauma
Klebsiella Enterococcus faecalis
• Viral meningitis:
 caused most commonly by entero-viruses ( Enterobacter Citrobacter diversus
usually last 2-4 days, may improve after lumbar Salmonella
puncture): Listeria monocytogenes
1. coxsackieviruses Pseudomonas aeruginosa
2. echoviruses Haemophilus influenzae
3. polioviruses ( if unvaccinated) types
 Other viruses: HSV, EBV, CMV, lymphocytic a, b, c, d, e, f, and
nontypable
choriomeningitis virus, and HIV.
>1 mo Streptococcus H. influenzae type b ( in
 Enteroviruses and arboviruses are the principal pneumoniae ( with areas without vaccine)
causes of meningoencephalitis. highest rate of
 Mumps virus is a common cause of viral commplicatons)
meningitis in unvaccinated children. Neisseria meningitidis Group A streptococci
Gram-negative bacilli
EPIDEMIOLOGY L. monocytogenes
• bacterial meningitis is highest among children <1
year of age.
• Risk factors:
1. Genetic factors
2. acquired or congenital immunodeficiencies
3. hemoglobinopathies ex. sickle cell disease, functional or anatomic asplenia.
4. Crowding.
5. CSF leak resulting from congenital anomaly or after a basilar skull fracture especially
caused by S. pneumoniae.
6. Low birth weight, PROM, chorioamionitis.
Note:
Most common 3 symptoms:
CLINICAL MANIFESTATIONS 1. vomiting.
• Preceding upper respiratory tract symptoms are common. 2. lethargy
• Rapid onset is typical of S. pneumoniae and N. meningitidis. 3. fever
• Indications of meningeal inflammation include ( symptoms) :  headache: if old age.
1. headache
2. irritability
3. nausea & vomiting
4. nuchal rigidity
5. lethargy
6. photophobia
7. Fever (95%)( in bacterial = high fever / in lyme dz = low grade fever)
 Signs:
1. Young infants: irritability, restlessness, depressed mental status, and poor
feeding as signs of meningeal inflammation.
2. Children >I year of age: Kernig sign (flexion of the hip 90 degrees with subsequent
pain with extension of the leg), and Brudzinski sign (involuntary flexion of the knees
 and hips after passive flexion of the neck while supinesigns of meningeal irritation
are positive.
3. others: Focal neurologic signs, seizures, arthralgia, myalgia, petechial or purpuric
lesions(with rapid onset in N. Meningitis), erythema migrans (lyme disease),sepsis,
shock, and coma.
4. increased intracranial pressure complaints are:
1. headache
2. diplopia
Note:
3. vomiting  N. meningitides: C5-9 terminal
4. bulging fontanel in infants
complement
5. Ptosis,  H. influenzae: humeral immunity
6. sixth nerve palsy deficiency.
7. anisocoria,
8. bradycardia with HTN
9. apnea
10. Papilledema (uncommon)

LABORATORY AND IMAGING STUDIES

 If bacterial meningitis is suspected, a lumbar puncture should be performed ( diagnostic)
 A lumbar puncture should be avoided in the presence of :
1. cardiovascular instability
2. Signs of  ICP other than bulging fontanel  risk of herniation.
3. skin infection over skin site of LP
 Thrombocytopenia is a relative contraindication for LP.
 Bacterial meningitis is characterized by:
1. neutrophilic pleocytosis
2. moderately to markedly elevated protein
3. low glucose.
 Viral meningitis is characterized by:
1. mild to moderate lymphocytic pleocytosis
2. normal or slightly elevated protein
3. normal glucose
 CSF should be cultured for bacteria and, fungi, viruses, and mycobacteria.
 PCR : diagnose enteroviruses and HSV(more sensitive & rapid than viral culture)
 CBC:Leukocytosis is common.
 Blood cultures are positive in 90% of cases.
 electroencephalogram (EEG) may confirm an encephalitis component.
CSF Findings in Various CNS Disorders:

DIFFERENTIAL DIAGNOSIS
 Many disorders show signs of meningeal irritation &  ICP including :
1. encephalitis
2. hemorrhage
3. rheumatic diseases
4. malignancies
5. malignant HTN
6. hypoxia/anoxia
7. drug intoxication
 Seizures are associated with meningitis, encephalitis, and intracranial abscess or brain
edema, cerebral infarction or hemorrhage, or vasculitis.

WBC Protein Glucose

Condition Pressure (/μL) (mg/dL) (mg/dL) Comments
Normal 50-180 <4; 60-70% 20-45 >50 or 75% blood
mm H2O lymphocytes, 30- glucose
40% monocytes,
1-3% neutrophils
Acute bacterial elevated 100-60,000+; a 100-500 Depressed Organism may be seen on
meningitis few thousand; compared with Gram stain and recovered by
PMNs blood glucose; culture
predominate usually <40
Partially treated Normal or 1-10,000; PMNs >100 Depressed or Organisms may be seen;
bacterial meningitis elevated ,mononuclear normal pretreatment may render CSF
cells predominate sterile in pneumococcal and
if pretreated for meningococcal disease, but
extended period antigen may be detected
Tuberculous elevated; low 10-500; PMNs 100-500; may <50 usual; Acid-fast organisms may be
meningitis if CSF block early be higher in decreases with seen on smear; organism can
in advanced ,lymphocytes and presence of time if treatment be recovered in culture or by
stages monocytes CSF block not provided PCR; PPD, chest x-ray positive
predominate later
Fungal elevated 25-500; PMNs 20-500 <50; decreases Budding yeast may be seen;
early; with time if organism recovered in culture;
mononuclear cells treatment not India ink preparation or antigen
predominate later provided positive in cryptococcal disease
Viral meningitis or Normal or PMNs early; 20-100 Generally normal; Enteroviruses may be
meningoencephalitis slightly mononuclear cells may be depressed recovered from CSF by
elevated predominate later; to 40 in some viral appropriate viral cultures or
rarely more than diseases (15-20% PCR; HSV by PCR
1000 cells. of mumps)
Abscess Normal or 0-100 PMNs 20-200 Normal Profile may be completely
elevated unless rupture normal
into CSF
Clinical notes by Dr. IMad:
 Every 500 RBC:  1 WBC, 0.5 protein.
 So if CSF contain 100.000 RBC with protein 140  100.000∕500× 0.5 = 100  100-140
=40 ( normal CSF protein)
 CSF culture and gram stain are not change if traumatic LP was happened
 Neonates have as many as 30 leukocytes/mm 3 (usually <10), but older children <5
leukocytes/mm3 in the CSF/both  a predominance of lymphocytes or monocytes.
 Plz memorize partial treated bacterial meningitis.

TREATMENT
 Treatment of bacterial meningitis focuses on sterilization of the CSF by antibiotics (
effective + cross BBB) and maintenance of adequate cerebral and systemic perfusion.
 If suspected bacterial meningitis give: 3ed generation cephalosporins ( cefotaxime or
ceftriaxon) in meningitis dose – the highest dose. As no H.Inf or N.M were reported to be
resistant.
 If suspect S. pneumoniae: cefotaxime (or ceftriaxone) plus vancomycin (relatively
resistant to penicillin or cephalosporins – in some places up to 60%)
 N. meningitidis and H. influenzae types a -f: Cefotaxime or ceftriaxone only.
 Infants <2 months of age: add ampicillin to cover the possibility of Listeria
monocytogenes.
 In H. influenza : antibiotic  bacteria lyses  release toxic metabolites  affect hearing (
so give steroids before antibiotic to prevent inflammation – proven to H. inf but can be
given in case of N.M or Strep.
 Duration of treatment:
1. 10 -14 days for S. pneumoniae
Note:
2. 7 -10 days for H. influenzae
Best empirical therapy:
3ed generation cephalosporins + vancomycin
3. 5 -7 days for N. meningitides (Gram -) (Gram +)
 Initial Antimicrobial Therapy by Age for Presumed
Bacterial Meningitis
Alternative
Age Recommended Treatment Treatments
Newborns Cefotaxime or ceftriaxone plus ampicillin Gentamicin plus ampicillin
(0-28 days) with or without gentamicin
Ceftazidime plus ampicillin
Infants and toddlers Ceftriaxone or cefotaxime plus Cefotaxime or ceftriaxone plus
(1 mo-4 yr) vancomycin rifampin
 Children and adolescents Ceftriaxone or cefotaxime plus Ampicillin plus chloramphenicol?
(5-13 yr) & adults vancomycin Don’t use…

COMPLICATIONS
 Include:
1. SIADH: necessitates balancing the need for fluid administration for hypotension and
hypoperfusion.
2. seizures
3. strike
4. cerebral and cerebellar herniation
5. transverse myelitis
6. ataxia
7. thrombosis of dural venous sinuses
 CT or MRI detects subdural effusions with S. pneumoniae &Hib meningitis. Most are
asymptomatic &do not need drainage unless associated with  ICP or focal neurologic
signs.
 Persistent fever (n= 5-7 days, if >10 days as in 10% of pts) think of:
1. infective or immune complex-mediated pericardial or joint effusions
2. thrombophlebitis
3. drug fever
4. nosocomial infection
5. intracranial viral infection
6. secondary bacterial infection
 A repeat lumbar puncture is not indicated for fever in the absence of other signs of
persistent CNS infection.

PROGNOSIS
 the mortality rate for bacterial meningitis in children is significant:
 25% for S. pneumoniae,
 15% for N. meningitidis,
 8% for Hib.
 35%, particularly after pneumococcal infectiondeafness, seizures, learning disabilities,
blindness, paresis, ataxia, or hydrocephalus.
 All patients with meningitis should have hearing evaluation.
 Poor prognosis is associated with:
1. young age < 6 months
2. delayed antibiotic treatment
3. seizures ( only after 4th day)
4. coma at presentation
5. shock
6. low or absent CSF WBC count with visible bacteria on Gram stain of the CSF
7. immunocompromised status.
 Rarely, relapse occurs 3 to 14 days after treatment from parameningeal foci or resistant
organisms.
 Recurrence indicate an immunologic or anatomic defect.

PREVENTION
 Routine immunizations against Hib and S. pneumoniae are recommended for children
beginning at 2 months of age.
 Vaccines against N. meningitidis are recommended for young adolescents and college
freshmen as well as military personnel and travelers to highly endemic areas.
 Close contacts: who stay with the index case more than 24 hrs/ week.