MENINGITIS

Meningitis is an inflammatory
process of the meninges and CSF
Demography of Meningococcal Meningitis

♦ Meningitis belt ♦ epidemic zones ♦ sporadic

cases
 Causes/Major Pathogens
Type Pathogen (most Common)
Bacterial Strep pneumoniae, E-coli, Neisseria
meningitis
Viral infection Coxsackie Virus, Echovirus,
Enterovirus, Arbovirus, HIV, HSV-2
TB meningitis M. Tuberculosis
Protozoal Toxoplasma Gondii
Infection
Fungal infection (toxoplasmosis)
Cryptococcus neoformans
(cryptococcal meningitis)
Other: Progressive multifocal
leukoencephalopathy (PML)
Primary CNS lymphoma, HIV-
associated dementia (HAD),
Painful sensory and motor
peripheral neuropathies,
Neurosyphilis
 PATHO PHYSIOLOGY
Microorganisms
Direct to
Via Blood
CSF
Subarachnoid
Immune Response
Space
from
Astrocytes+Micro
glia,
Cytokin Release
Inc. BBB Inc. no. of WBC in Vasculitis of cerebral
permeabilty CSF vessels
Fluid leakage from Inflammation of Dec. cerebral
vessels Meninges blood flow
Vasogenic Interstitial edema Ischemia, cytotoxic
edema (Inc. ECF) edema

Cerebral
Edema

Dec. Cerebral blood flow, Ischemia, apoptosis (Brain Death)

 MAJOR FORMS OF MENINGITIS

Bacterial Viral
More serious, less Less serious, more
common
Immunization available common
No immunization
for some available
Treatable with Treatment includes
antibiotics waiting it out
More common in winter More common in
summer/ early fall
 Classification

• Acute pyogenic (bacterial) meningitis

• Acute aseptic (viral) meningitis
• Chronic bacterial infection (tuberculosis).
• Acute focal suppurative infection (brain
abscess, subdural and extradural empyema)
1) Acute Pyogenic Bacterial
Meningitis
 2) Acute Aseptic (Viral )
Meningitis
• Can follow any viral
infection
• Less danger
• Viral meningitis is
usually self-limiting and
treated
• Fever ± delirium, lethargy, disorientation,
symptomatically.
malaise, headache most common
• Stiff neck, photophobia, cranial nerve deficits
less common
• No focal neurological deficits
• Gastrointestinal symptoms: diarrhea, colitis,
esophageal ulceration appear in 12-15% of
3) Chronic bacterial infection
(tuberculosis/
TB Meningitis)
 Complications

• Antibiotic treatment------ full recovery

• Delayed or untreated cases--- can be fatal
• Healing by fibrosis cause obliteration of
subarachenoid space--- HYDROCEPHALUS
• Brain abscess
• Septic shock and skin rashes, why ?
 1) Brain
abscess
• Causes :
1. complication of bacterial
meningitis
2. bacterial endocarditis
3. pulmonary sepsis :
pneumonia……etc
4. other sepsis

Brain abscess cause a space

occupying lesion in the brain
 2) Skin
• rashes
Is due to small skin bleed
• All parts of the body are affected
• The rashes do not fade under pressure
• Pathogenesis:
a. Septicemia
b. wide spread endothelial damage
c. activation of coagulation
d. thrombosis and platelets aggregation
e. reduction of platelets (consumption )
f. BLEEDING 1.skin rashes
2.adrenal hemorrhage
Adrenal hemorrhage is called Waterhouse-
Friderichsen Syndrome. It cause acute
adrenal insufficiency and is usually fatal
 Work up for Meningitis
Physical Exam
• Brudzinski’s & Kernig’s sign
• Nuchal rigidity
• Papilledema
Lumbar puncture to obtain CSF
Chemistry (glucose & protein)
Cytology (WBC# & %PMN’s)
Gram stain or rapid identification test (< 24hrs)
• CIE (Counterimmunoelectrophoresis), coagglutination, or latex
agglutination
• Limulus lysate for gram negative endotoxin
• PCR (N.meningitidis, S. pneumoniae, H. influenzae, S. agalactiae,
L. monocytogenes & enteroviruses)
• Lactate (>4.2 mmol/L considered positive for bacterial meningitis)
• Procalcitonin (> 5 micrograms/L suggestive of bacterial meningitis)
• C-reactive proteins (CRP) (Elevated in bacterial meningitis)
• Culture for pathogens (> 24hrs)
Blood, Urine, & Sputum Cultures
Kernig's sign
The thigh is flexed on the
abdomen, with the knee flexed;
attempts to passively extend the
knee elicit pain when meningeal
irritation is present.

Brudzinski's sign:
passive flexion of the neck
results in spontaneous flexion of
the hips and knees.
Nuchal rigidity:
Inability to flex the neck forward
passively due to increased neck
muscle tone. It occurs in 70% of
adult cases of bacterial meningitis
Jolt accentuation maneuver:
•The patient is told to rapidly rotate his or her head
horizontally; if this does not make the headache
worse, meningitis is unlikely.
•It helps determine whether meningitis is present in
patients reporting fever and headache.

Kernig’s and Brudzinski’s signs have high

specificity but low sensitivity(44%) for the
diagnosis of meningitis. Jolt accentuation of
headache was determined to have a 97%
sensitivity and 60% specificity.
It has been suggested that absence of the jolt
sign essentially excludes meningitis.
 CSF Detail Report
Changes in Pyogenic
Normal Viral Tuberculosis
CSF (Bacterial)
Turbid/purule Turbid/visco
Appearance Crystal-clear Clear/Turbid
nt us
WBC < 5 mm3 25-500 mm3 > 1000 mm3 < 500 mm3
Mononuclear 100-300
< 5 mm3 10-100 mm3 <50 mm3
cells mm3
Polymorph 200-300/
Nil Nil 0-200/ mm3
cells mm3
Protein 0.2- 0.4 g/L 0.4-0.8 g/L 0.5-2.0 g/L 1-5g/L
Glucose 40-80 mg/dl 30-70 mg/dl <40 mg/dl 20-40 mg/dl

Harrison's Principles of Internal Medicine,

17`Edition, 2008
 Empirical Therapy For ABM
Age Common Pathogen Anti microbial
<1 Streptococcus agalactiae, Escherichia Ampicillin plus
month coli, Listeria monocytogenes, Klebsiella cefotaxime or
species ampicillin plus an
1-23 Streptococcus pneumoniae, Neisseria aminoglycoside
Vancomycin plus a
month meningitidis, S. agalactiae, Haemophilus third-generation
influenzae, E. coli cephalosporina,b
2-50 yrs N. meningitidis, S. pneumoniae Vancomycin plus a
third-generation
cephalosporina,b
> 50 yrs S. pneumoniae, N. meningitidis, L. Vancomycin plus
monocytogenes, aerobic gram-negative ampicillin plus a
bacilli third-generation
cephalosporina,b
ftriaxone or cefotaxime
me experts would add rifampin if dexamethasone is also given.
•Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004 Nov 1;39(9):1267-84. [120 references] Pub Med

Recommendations for Appropriate use of Antimicrobials at Hospitals

in Pakistan
Departments of Infectious Disease and Infection Control
 Total Daily Dose and Dosing Interval
Antimicrobia Child (>1 month) Adult
l Agent
Ampicillin 200 (mg/kg)/d, 12 g/d, q4h
q4h
Cefotaxime 200 (mg/kg)/d, 12 g/d, q4h
q6h
Ceftriaxone 100 (mg/kg)/d, 4 g/d, q12h
q12h
Ceftazidime 150 (mg/kg)/d, 6 g/d, q8h
Gentamicin q8h
7.5 (mg/kg)/d, 7.5 (mg/kg)/d, q8h
q8h b
Metronidazo 30 (mg/kg)/d, q6h 1500–2000 mg/d,
le
Penicillin q6h
G 400,000 (U/kg)/d, 20–24 million U/d,
q4h
Vancomycin 60 (mg/kg)/d, q6h q4h
2 g/d, q12hb
a
All antibiotics are administered intravenously; doses indicated assume normal renal and hepatic function.
b
Doses should be adjusted based on serum peak and trough levels: gentamicin therapeutic level: peak: 5–8
g/mL; trough: <2 g/mL; vancomycin therapeutic level: peak: 25–40 g/mL; trough: 5–15 g/mL.

Harrison's Principles of Internal Medicine,

 Duration OF Therapy For ABM
Microorganism Duration of therapy, days

Neisseria meningitidis 7

Haemophilus influenzae 7

Streptococcus pneumoniae 10-14

Streptococcus agalactiae 14-21

Aerobic gram-negative bacillia 21

Listeria monocytogenes >21

Duration of Antimicrobial Therapy for Bacterial Meningitis Based on Isolated Pathogen (A-III)
a
Duration in the neonate is 2 weeks beyond the first sterile CSF culture or >3 weeks, whichever is longer.
•Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL, Scheld WM, Whitley RJ. Practice guidelines for
the management of bacterial meningitis. Clin Infect Dis 2004 Nov 1;39(9):1267-84. [120 references]
PubMed
 Adjunct Steroid Therapy for Infants,
Children and Adults
• Dexamethasone should be initiated 10-20 min prior
to, or at least concomitant with, the first
antimicrobial dose, at 0.15 mg/kg every 6 h for 2-4
days.
• Adjunctive dexamethasone should not be given to
the patients who have already received
antimicrobial therapy, because administration of
dexamethasone in this circumstance is unlikely to
improve patient outcome
At present, there are insufficient data to make a recommendation on
the use of adjunctive dexamethasone in neonates with bacterial
meningitis
•Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL, Scheld WM, Whitley RJ. Practice guidelines for the management of
bacterial meningitis. Clin Infect Dis 2004 Nov 1;39(9):1267-84. [120 references] Pub Med
 Management and Treatment Of TBM
Daily administration of
Rifampicin 600 mg (450 mg for weight <55 KG)
Isoniazid 300 mg
Pyrizinamide 1.5 g for <55 Kg & 2 gm for above 55 Kg.
(Initial 2 Months)
All in combination 30 min before breakfast.
Treatment require
For PTB is six months
For bone TB is nine months &
For TB meningitis is 1 year.
The addition of a fourth drug STREPTOMYCIN is left to the
choice of the local physicians and their experience, with little
evidence to support the use of one over the other
Tarakad S Ramachandran, MBBS, FRCP(C), FACP, Chief, Department of Neurology, Crouse Irving
Memorial Hospital; Professor, Department of Neurology, State University of New York Upstate Medical
University
Contributor Information and Disclosures
Updated: Mar 9, 2007 from E medicine web Md
 Vaccines For Meningitis
Routine immunization can go a long way toward
preventing meningitis.
The vaccines against Hib, measles, mumps, polio,
meningococcus, and pneumococcus can protect
against meningitis caused by these microorganisms.
Bacteria Polysaccharide Conjugate Vaccine
H. influenzae Vaccine
PRP PRP-OMP (PedvaxHIB,
S. Pneumoniae PPV23 Comvax)
PCV7 (Prevnar)
N. Meningitidis Quadrivalent Quadrivalent
A/C/Y/W135 A/C/Y/W135 (Menactra)
(Menomune) Monovalent C
(Meningitec)

WHO Fact sheet

N°141
Revised May 2003
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