Acute Meningitis: DR K. Saroj Novel Jr-1 General Medicine Moderator:Dr - Sushanth MD Assistant Professor

ACUTE MENINGITIS
DR K. SAROJ NOVEL
JR-1 GENERAL MEDICINE
MODERATOR:DR.SUSHANTH MD
ASSISTANT PROFESSOR
DEFINITION
• Meningitis is an inflammatory disease of the protective

layers, the tissues surrounding the brain and spinal cord.
CNS INFECTIONS ARE SERIOUS
• Among adults
• Of those with bacterial meningitis upto 25% die
• Of those with tuberculous meningitis upto 35% die
• Of those with encephalitis about 40% die
• Of those who survive, half will have neurological sequelae
• Key goal of management is
• Early recognition
• Prompt treatment
TYPES OF MENINGITIS BASED ON
DURATION
ACUTE :
It is a life threatening inflammation which develops over the course of few hours
to days.
SUBACUTE:
Develops over days to a few weeks; mainly bacterial.
CHRONIC:
Persists for at least 1 month without spontaneous resolution; mainly fungal,
tubercular infections, autoimmune and neoplastic.
BACTERIAL MENINGITIS
• Bacterial meningitis is an acute purulent infection within the

subarachnoid space (SAS).
• It is associated with a CNS inflammatory reaction that may
result in decreased consciousness ,seizures ,raised ICP and
stroke
• The meninges ,SAS and brain parenchyma are all frequently
involved in the inflammatory reaction – Meningoencephalitis.
ETIOLOGY
• Streptococcus pneumonia(50%)
• Neisseria meningitidis (25%)
• Group B streptococci(15%)
• Listeria monocytogenes(10%)
• Hemophilus influenza type –B ( <10% )
Organism Site of entry Age range Predisposing
conditions
Neisseria meningitidis Nasopharynx All ages Usually none, rarely

complement deficiency
Streptococcus pneumoniae Nasopharynx, direct All ages All conditions that
extension across skull predispose to pneumococcal
fracture, or from contiguous bacteremia, fracture of
or distant foci of infection cribriform plate, cochlear
implants, cerebrospinal
fluid otorrhea from basilar
skull fracture, defects of the
ear ossicle (Mondini defect)
Listeria monocytogenes Gastrointestinal tract, Older adults and neonates Defects in cell-mediated
placenta immunity (eg,
glucocorticoids,
transplantation [especially
renal transplantation]),
pregnancy, liver disease,
alcoholism, malignancy
Coagulasenegative staphylococci Foreign body All ages Surgery and foreign
body, especially
ventricular drains
Staphylococcus aureus Bacteremia, foreign All ages Endocarditis, surgery and
body, skin foreign body, especially
ventricular drains;
cellulitis, decubitus ulcer
Gram-negative bacilli Various Older adults and Advanced medical
neonates illness, neurosurgery,
ventricular drains,
disseminated
strongyloidiasis
Haemophilus influenzae Nasopharynx, contiguous Adults; infants and Diminished humoral
spread from local children if not vaccinated immunity
infection
PATHOPHYSIOLO
GY
INVESTIGATIONS
CT/MRI:
Typically shows thin and linear leptomeningeal enhancement.
CSF EXAMINATION:
SEROLOGICAL/IMMUNOLOGICAL TESTS
The latex particle agglutination test, for the detection of bacteria antigen in csf.
DETECT THE SOURCE OF INFECTION:
Chest x ray – pneumonia
Skull x ray – fracture
PNS x ray – sinusitis
Petrous view - mastoididtis
BLOOD CULTURES
• CSF bacterial cultures arepositive in >70% of patients, and CSF Gram’s stain
demonstratesorganisms in >60%..
INDICATIONS FOR CT SCAN BEFORE
LP
• Head CT should be performed before LP in adults with suspected
bacterial meningitis who have one or more of the following risk factors
• Immunocompromised state (eg, HIV infection, immunosuppressive
therapy, solid organ or hematopoietic cell transplantation)
• History of central nervous system (CNS) disease (mass lesion, stroke,
or focal infection)
• New onset seizure (within one week of presentation)
• Papilledema
• Abnormal level of consciousness
• Focal neurologic deficit
• Patients without these indications should not undergo a CT scan as it is
of no clinical benefit and delays therapy
TREATMENT
INCREASED INTRACRANIAL
PRESSURE
Emergency treatment of increased ICP includes
elevation of the patient’s
head to 30–45°, intubation, and hyperventilation
(Paco2 25–30 mmHg),
and mannitol. Patients with increased ICP should
be managed in an
intensive care unit; accurate ICP measurements are
best obtained with
an ICP monitoring device.
ADJUNCTIVE TREATMENT
• Dexamethasone10mg IV (within 20 minutes of antibiotic) and repeat q6h

x 4 days
• Inhibits TNF alpha production
• Stabilizes BBB Adjunctive therapy
• Benefits when given before antibiotic therapy. No benefit if given 6hrs

after
• Supportive
• Fluids, Hydration, Analgesics, rest, Seizure control
VIRAL MENINGITIS-ETIOLOGY
CLINICAL FEATURES
• Fever
• Headache – frontal and retro orbital pain
• Signs of meningeal irritation
• Photophobia
• Nuchal rigidity ( mild )
• CONSTITUTIONAL : malaise ,myalgias, anorexia , nausea
&vomiting ,abdominal pain ,diarrhea
• Patients often have mild lethargy or drowsiness; however, profound alterations
in consciousness, such as stupor, coma, or marked confusion, do not occur in
viral meningitis and suggest the presence of encephalitis or other alternative
diagnoses
LAB DIAGNOSIS
CSF ANALYSIS:-
• Mildly elevated opening CSF pressure (100- 350 mmHg )
• Elevated protein concentration (20-80 mg/dl )
• Normal glucose concentration
• Gram stain – Negative
• Lymphocytic pleocytosis
• Total cell count ( 25-500 cells /µdl )
EXCEPTIONS :
• Cell counts in thousands – LCMV and Mumps
• PMN predominance in the first 48 hrs – Echovirus 9, West nile virus , Eastern equine encephalitis
virus ,Mumps
• Low Glucose – LCMV and Mumps
• PMN pleocytosis with low glucose - CMV
• PCR AMPLIFICATION OF VIRAL NUCLEIC ACID:
• Single most important method for diagnosing CNS viral infection
• HSV CSF PCR is also an important diagnostic test in patients with recurrent episodes of “aseptic” meningitis,
many of whom have amplifiable HSV DNA in CSF despite negative viral cultures
• CSF PCR is also used routinely to diagnose CNS viral infections caused by CMV, Epstein-Barr virus (EBV), VZV,
and human herpesvirus 6 (HHV-6).
• PCR is also useful in the diagnosis of CNS infection caused by Mycoplasma pneumoniae, which can mimic viral
meningitis and encephalitis
• PCR throat and stool specimens – Enteroviral infections
• VIRAL CULTURES:
• CSF cultures are positive in 30-70% of patients.
• Sensitivity and Specificity of CSF viral cultures are generally poor compared to bacterial meningitis
• SPECIMEN - VIRUS:
• Feces – Enterovirus , Adenovirus
• Blood – Arbovirus ,Some Enteroviruses , LCMV
• Throat – Enterovirus , Mumps , Adenovirus
• SEROLOGY:
• Serologic studies are important for the diagnosis of arboviruses such as WNV; however,
these tests are less useful for viruses such as HSV, VZV, CMV, and EBV that have a high
seroprevalence in the general population
• CSF oligoclonal gamma globulin bands occur in association with a number of viral
infections.
• The associated antibodies are often directed against viral proteins.
• OTHER LABORATORY STUDIES :-
• Complete blood count , LFT , RFT , ESR , CRP, Serum Electrolytes , Aldolase,
Amylase ,lipase,
• Creatine kinase
• Neuroimaging studies (MRI preferable to CT) are not absolutely necessary in patients with
uncomplicated viral meningitis but should be performed in patients with altered
consciousness, seizures, focal neurologic signs or symptoms , atypical CSF profiles, or
underlying immunocompromising treatments or conditions
TREATMENT
• Usually symptomatic – Anti pyretics , Analgesics , Anti emetics

• Fluid and Electrolyte balance
• Oral or intravenous acyclovir may be of benefit in patients with meningitis caused
by HSV-1 or -2 and in cases of severe EBV or VZV infection.
• Seriously ill patients should probably receive intravenous acyclovir (15–30 mg/kg
per day in three divided doses), which can be followed by an oral drug such as
acyclovir (800 mg five times daily), famciclovir (500 mg tid), or valacyclovir (1000
mg tid) for a total course of 7–14 days.
• Patients who are less ill can be treated with oral drugs alone.
• Patients with HIV meningitis should receive highly active antiretroviral therapy
• Vaccination is an effective method of preventing the development of meningitis and
other neurologic complications associated with poliovirus, mumps, measles, rubella,
and varicella infection.
• REFERENCES :-
• HARRISONS PRINCIPLES OF INTETRNAL MEDICINE -21ST

EDITION
• BRADLEYS TEXTBOOK OF NEUROLOGY – 8 TH EDITION

THANK YOU

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ACUTE MENINGITIS

• Meningitis is an inflammatory disease of the protective

• Bacterial meningitis is an acute purulent infection within the

Neisseria meningitidis Nasopharynx All ages Usually none, rarely

• Dexamethasone10mg IV (within 20 minutes of antibiotic) and repeat q6h

• Benefits when given before antibiotic therapy. No benefit if given 6hrs

• Usually symptomatic – Anti pyretics , Analgesics , Anti emetics

• HARRISONS PRINCIPLES OF INTETRNAL MEDICINE -21ST

• BRADLEYS TEXTBOOK OF NEUROLOGY – 8 TH EDITION

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