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Harrisons 20th A > Acute Meningitis > Flashcards

Acute Meningitis Flashcards

1
Q

Acute purple to infection within the subarachnoid space

A

Bacterial meningitis

Associated with CNS inflammatory reaction that may result in decreased consciousness, seizures raised intra cranial pressure and stroke

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2
Q

Organisms responsible for CNS community acquired

A

1, streptococccus pneumonia (50%)

  1. neisseria meningitidis (-25%)
  2. Group b streptococci (15%)
  3. Listeria monocytogenes (10%)
  4. Haemophilia influenzas (10%)
    - common ever 8-12 years
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3
Q

Most common cause of meningitis in adults more than 20 years old

A

S. Pneumonia

Risk factors: acute or chronic sinusitis, otitis media, alcoholism,diabetes,splenectomy, hypogammaglobulinemia, complement deficiency and head trauma

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4
Q

N. Menigitidis

A

Creased due to immmunization with quadrivalent serogroup A,C,W135 an Y) meningococcal glycoconjugate

Serogropu B- responsible for 1/3 of cases of meningococcal disease.

Vaccinate 16-23 years old with MenB

Clue to diagnosis: purification,petecheal rashes

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5
Q

Previously responsible for meningitis in neonates:

A

Group B streptococcus or streptococcus agalactiae

Increasing in frequency with individuals aged >50 years

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6
Q

Increasingly important with neonatal meningitis 9<1month) pregnant women and individuals more than 60 years old

A

L. Monocytogenes

Acquired by ingesting food contaminated with listeria. Coleslaw, milk,soft cheeses and several ready to eat foods

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7
Q

Scomplication of the use of subcutaneous ommaya reservoirs and administration of intrathecal chemotherapy

A

S. Aureus

And coagulate negative staphylococci

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8
Q

Essential prerequisite for bacterial phagocytosis

A

Complement proteins and immunoglobulin

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9
Q

Critical event in the pathogenesis of bacterial menigitis

A

Inflammatory reaction induced by the invading bacteria.

Many of the neurologic manifestations and complications of bacterial meningitis result the immune response to the invading pathogen rather than from direct bacterial- induced tissue injury

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10
Q

Bacterial cell wall component of the gram negative

A

Lipopolysaccharide (LPS)

Teichoic acid and peptidoglycan of s. Pneumoniae

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11
Q

Chemokine s that act synergistically to increase the permeability of the blood-brain barrier, reduction of vasogenic edema and the leakage of serum proteins into the SAS

A

TNF alpha and IL 1B

Subarachnoid exudate of proteinacious material and leukocytes obstructs the flow of CSF trough the ventricular system and diminishes the resorptive capacity of the arachnoid granulations.

Leading to communicating hydrocephalus and concomitant interstitial edema

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12
Q

What combination changes in brain arenchyma leads to coma

A
  1. Interstitial
  2. Vasogenic
  3. cytotoxic edema leads to increase ICP
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13
Q

Triad of meningitis

A

Fever
He ache
And unchallenged rigidity

Decrease level of sensorium by >75% and can vary from lethargy to coma

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14
Q

Pathognomonic sign of meningieal irritation

A

Nuchal rigidity

Kernig: elicited with the patenting in the supine position thigh I sflexed over the abdomen with knee flexed, attempts to passively extend the knee elicit pain when meningeal irritation is present.

Brudzinkski: signs is elicited with the patient in supine position and is positive when passive flexion of the neck results in sponteneous flexion and hips and knee

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15
Q

Absent kernig and brudzinksi

A
  1. Very young
  2. Very old
    Immunocompromised individual
  3. Very depressed mental status
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16
Q

Seizure:
Focal:1. Arterial is he is
2.cortical venous thrombosis
3.focal edema

A

Generalised seizure activity and status epilepticus

  1. Hyponatremia
  2. cerebral anoxia
  3. less commonly
  4. toxic effects of antimicrobial meningitis
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17
Q

Raised ICP

A

Obtundation
Coma in disease
CSF opening pressure .180mmH20 and 20% have opening pressure >400 mmH20

  1. Decrease level of consciousness
    2.papilledema
    Dilated poorly reactive pupils
  2. Sixth nerve palsies
    4.decerebrate posturing
  3. Cushing reflex: bradycardia,hypertension,irregular respiration’s
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18
Q

Classic CSF abnormalities

A
  1. PMN leukocytosis (>100 cells/uL in 90%)
  2. decreased glucose contraction (<2.2mmol/L /<40mg/dL)
  3. increased protein concentration (>0.45g/L (>45mg/dL in 90%)
  4. increased opening pressure (>180mmH20 in 90%)
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19
Q

Diffrenec between viral meningitis and bacterial meningitis

A

CSF profile of Viral meningitis: lymphocytic pleocytosis with normal glucose concentration concentration

CSF profile to bacterial meningitis:
PMN pleocytosis
Hypoglycorrhachia

HSV PCR 96% sensitivity: 72 hours of symptoms and within first week of antiviral therapy

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20
Q

Rickettsial disease: resemble bacterial meningitis

A

High fever prostration, myalgia, headache, nause and vomiting

Petcheal rash—> purification—.skin necrosis and gangrene

Dx: immunofluorescent staining of skin biopsy specimen

21
Q

Ehrlichiosis

A 
Transmitted by a tick bite
Gram negative coccobacilli
Two species
1. Anaplasma phagocytophylum
   -human granulomatous ehrlichiosis
 (Anaplasmosis)
  1. ehrlichichia chaffeensis
    • human monocytic ehrlichiosis
22
Q

Focal suppurative CS infections

A
  1. Subdural
  2. epidural empyema
  3. Brain abscess

Other
1. Subarachnoid haemorrhage (SAH)

23
Q

Sub acute meningitis

A

Mycobacterium tuberculosis

Crypto coccus neoformans

Histoplasma capsulatum

Coccidiosis Emmitt is

24
Q

Treatment for acute bacterial meningitis

60mins: patients arrival in the emergency room

A

S. Pneumonia
Tx: dexamethasone
Third or 4th generation cephalosporin

(Ceftriaxone,cefotaxime, cefepime) and vancomycin and acyclovir

Doxycycline: tick season

Cefepime more on enterobacteriasea and pseudomonas aurogenosa

Ampicillin for : L. Monocytogenes individuals <3months and age >55 years old

Metronidazole: cover gram-negative anaerobes in patients with otitis sinusitis or mastoiditis

Vancomycin and ceftazidime or meropenem forllowing surgical procure, staphylococci and gram negative-organism

25
Q

Meningococcal meningitis

A

pen G. Remains the antibiotic of choice for meningococcal meningitis

Resistance to pen G.

  • cefotaxime or ceftraixone
  • 7 days course of intravenous antibiotic therapy for uncomplicated meningococcal meningitis

For close contact: chemoprpphylaxis
2 day regimen
1. Rifampin (600mg every 12 hours for 2 days in adults 10mg/kg q12hours for 2 days in children >1 year)

Rifampin not recommended for pregnant

Adult use: azithromycin 500mg or intra muscular ceftraixone 250mg

26
Q

Pneumococcal meningitis: treatment

A

Cephalosporin (ceftriaxone, cefotaxime or cefepime) and vancomycin

Susceptible to penicillin: MIC <0.06
Resistant when MIC >12

Sensitive to s. Pneumonia. MIC <0.5
(Cefotaxime, ceftriaxone,cefepime)

MIC 1ug/L intermediate resistance treatment vancomycin

MIC >2ug/ml resistant

2 weeks course of IV antibiotic

Should have repeat LP after 24-36 hours

27
Q

L. Monocytogenes

A

Ampicillin for at least 3 weeks

Gentamicin is added in critically ill patients 92mg/kg loading dose then 7.5 mg/kg per day given every 8 hours

Combination of trimethoprim (10-20/kg loading dose) and sulfamethozole (50-100mg/kg/per day) given 6 hours may provide an alternative in penicillin -allergic patients

28
Q

Staphylococcal meningitis

A

S. Aureus and coagulase negative staphylococci is related with nafcillin

Vancomycin is a drug of choice for MRSA and patient allergic to penicillin

29
Q

Gram negative bacillary meningitis

A

3rd generation cephalospohorin- cefotaxime,ceftraixone,ceftazidime

P. Aureginosa: ceftazidime or meropenem

3 week course of IV antibiotic

30
Q

Adjunctive therapy
Inhibit the synthesis of ILB and TNF a at the level of mRNA, decreasing CSF outflow resistance and estabilizing blood brain barrier

A

Dexamthasone given 20 min before antibiotic therapy inhibits production of TNF alpha by macrophage ABG microglia

Decrease meningeal irritation an neurologic sequel are such as sensorineural hearing loss

The 1omg q 6 x 4 days

Vancomycin dose: 45-60mg/kg per day

Increase hypocampal injury and reduced learning capacity

31
Q

Increase ICF treatment

A

Elevate patients head 30-45
Incubate and hyperventilate (paco2 25-30mmHg
Mannitol

32
Q

Mortality rate

A

H. Influenza, N. Meningitidis, group B streptococci 3-7%

L. Monocytogenes 15%

S. Pneumoniae 20%

33
Q

Risk of death from bacterial meningitis

A
  1. Decrease level of sensorium
  2. Onset of seizure within 24 hours
  3. signs of increased ICP
  4. young age (infancy) and age >50
  5. The presence of Conor I conditions including shock and need for mechanical ventilation
  6. Delay in initiation of treatment
34
Q

Viral meningitis

A

Pleocytosis- normal or slightly elevated protein concentration (0.2-0.8gdL (20-80mg/dL)

Normal or slightly elevated opening pressure: 100-350mmH20)

PMN pleocytosis with low glocuse: CMV infection in immunocompromised host

35
Q

As a rule: a lymphocytic pleocytosis wit low glocuse concentration should suggest fungal or tuberculous meningitis, listeria meningoencephalitis or non infectious disorder

A

PCR amplification of viral nuclei acid: single most important method for diagnosing CNS viral infections

36
Q

Most common cause of viral meningitis

A

Enter obvious
-more than 85% of cases

EV17
- common in summer or fall

-lymphocytic pleocytosis (100-1000cells/uL), normal glucose and elevated protein concentration

  • CSF reverse transcriptase PCR is diagnostic procedure of choice and is both sensitive and specific
  • highest sensitivity within 48 hours
37
Q

Arbovirus: common in summer

A

HSV meningitis: common viral in adults

HSV2: uncomplicated meningitis
HSV1: responsible to HSV encephalitis

Aseptic meningitis/ mollarets meningitis : due to HSV

38
Q

EVb infections

A

Presence of atypical lymphocytes in the CSF or peripheral blood is suggestive of EBV
-almost never cultured

Dx: CSF serology: presence of viral IgM viral capsid antibodies (VCAs)

39
Q

HIV meningitis

A

Cranial nerve palsies:

CN V, VII,VIII

40
Q

Mumps
-late winter or early spring
More to male

A

Presence of parotitis, orchitis, oophoritis, pancreatitis or elevations of serum lipase and amylase

Mumps infection confers life long immunity

CS pleocytosis exceed 1000 cells/uL 25%
Lymphocytes 75%
CSF neutrophil is occurs more than 25%

Hypoglycorrhachia 10-30%: clue for diagnosis

41
Q

LCMV infection: aseptic meningitis late fall or winter

House mice : mus muscular

A

Associated with rash, pulmonary infiltrates, alone is,parotitis,orchitis, myocopericarditis

Leukopenia,thrombocytopenia,abnormal liver function test

CSF pleocytosis (>1000 cells/ul) and hypoglycorrhachia (<30%)

42
Q

Acute viral meningitis

A

Intravenous Acyclovir (15-30mg/kg per day in three divided doses

Followed by an oral drug such as acyclovir (800mg five times daily) famciclovir (500mg TID) or valacyclovir (1000 mg TID) for total course of 7-14 days.

43
Q

Vaccination is effective method of preventing the develop emend of meningitis and other neurologic complications associated with poliovirus, mumps, measles, rubella and varicella infection.

A

A live attenuated vaccine (zostavax) is recommended for prevention of herpes zoster skin goes in adults more than >60

HZ/su for age >70 years

44
Q

Sub acute meningitis

A
  1. H. Capsulatum
  2. C. Immitis
  3. T. Pallidum
  4. M. Tuberculosis
  5. C. Neoformans

CIP-TN

45
Q

C. Neoformans: soil and birds

H. Capsulatum: ohio, Mississippi River, central US, central and sought America

C. Immitis: desert

Syphilis: sexually transmitted disease
CN VII and CN VIII

A

TB meningitis:

  1. Elevated opening pressure
  2. Lymphocytic pleocytosis (10-500)
  3. Elevated protein concentration in range of 1-5g/L
  4. decrease glucose concentration 1.1-2.2mmol/L 20-40 mg /dl

Culture 4-8 weeks
-gold standard

46
Q

CSF fungal meningitis

A

Mononuclear or lymphocytic pleocytosis

Increased protein concentration

Decreased glucose concentration

C. Immitis: eosinophils

47
Q

Treatment for sub acute meningitis

A

Empirical therapy
- basis on the high index of suspicion without adequate laboratory support.

Isoniazid (300mg/d) rifampin (10mg/kg per day pyrazinamide (30mg/kg per day in divided doses) ethambutol (15-25mg/kg) pyridoxine (50mg/day)

Dexamethasone for TB meningitis
12-16 mg/day for 3 weeks, then tapered over 3 weeks

48
Q

Meningitis: c. Neoformans in non-HIV

Non transplant patients: amphotericin B (AmB) (0.7mg/kg/IV per day plus flucytosine (100mg/kg/day in four divided doses fo r 4 weeeks
Extended to 6 weeks for patients with neurologic complications

Consolidation phase 400mg/day for 8 weeks

A 
Or again transplant
Liposomal AmB (3-4mg/kg/per day) or AmB lipid complex (ABLC) 5mg/kg per day plus flucytosine (100mg/kg/ day in 4 divided doses) for at least 2 weeks

8-10 week course of fluconazole 9400-800mg/d (6-12mg/kg) PO if the CSF culture is sterile after 10 weeks

Then decreased to 200mg/d for 6 months to a year

49
Q

HIV meningitis

A

AmB or lipid formulation plus flucytosine for 2 weeks by fluconazole for a minimum of 8 weeks

HIV infected: fluconazole 200mg/d

Harrisons 20th A (15 decks)

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