Intracranial Infections - Meningitis

Question 1

What is Meningitis?

Answer 1

Infection and inflammation of the meninges - usually bacterial or viral.

Question 2

What is Meningococcal Septicaemia?

Answer 2

When the meningococcus bacterial infection is in the bloodstream.

Question 3

What is Meningococcal Meningitis?

Answer 3

The meningococcus bacterial infection of the Meninges and CSF.

Question 4

Commonest Causative Bacteria of Meningitis (4).

Answer 4

1. Neisseria meningitidis (Meningococcus).
2. Streptococcus pneumoniae (Pneumococcus).
3. Neonates : Group B Streptococcus (contracted during birth, from mother’s vagina) (& E.Coli, Listeria monocytogenes).
4. Haemophilus influenzae.

Question 5

Describe Neisseria meningitidis.

Answer 5

Gram-Negative Diplococcus.

Question 6

Commonest Causative Viruses of Meningitis (4).

Answer 6

1. HSV2, CMV, VZV.
2. Enteroviruses e.g. Coxsackie, Echovirus.
3. HIV.
4. Mumps, Measles.

Question 7

Clinical Features of Meningitis (7).

Answer 7

1. Fever.
2. Neck Stiffness.
3. Vomiting.
4. Headache.
5. Photophobia.
6. Altered Consciousness.
7. Seizures.

Question 8

Clinical Features of Meningococcal Septicaemia.

Answer 8

Non-Blanching Purpuric Rash in kids.

Question 9

Clinical Features of Meningitis in Neonates and Babies (5).

Answer 9

Non-Specific Signs :
1. Hypotonia.
2. Poor Feeding.
3. Lethargy.
4. Hypothermia.
5. Bulging Fontanelle.

Question 10

Differential Diagnosis of Purpuric Rash (7).

Answer 10

1. Trauma.
2. Liver Disease.
3. Drugs - Steroids, Aspirin, Warfarin.
4. Vasculitis.
5. Thrombocytopenia.
6. Renal Failure.
7. DIC.

Question 11

Lumbar Puncture Procedure (3).

Answer 11

1. Insert a needle into lower back to collect a CSF at L3-L4 (spinal cord ends at L1-L2).
2. Send sample for bacterial culture, viral PCR, cell count, protein and glucose.
3. Send Blood-Glucose Sample simultaneously to compare.

Question 12

CSF Comparison Between Bacterial and Viral and Tuberculous Meningitis (5).

Answer 12

1. B - Cloudy; V - Clear; T - Slightly Cloudy with Fibrin Web.
2. B - High Protein; V - Mildly Raised/Normal Protein; T - High Protein.
3. B - Low Glucose; V - Normal Glucose; T - Low Glucose.
4. B - High Neutrophils; V - High Lymphocytes; T - High Lymphocytes.
5. B - Bacterial Culture; V - Negative.
   * Low Glucose = < 50%.
   ** High Protein = > 1g

Question 13

Contraindications of Lumbar Puncture (6).

Answer 13

Raised Intracranial Pressure :
1. Focal Neurological Signs.
2. Papilloedema.
3. Significant Bulging of Fontanelle.
4. Disseminated Intravascular Coagulation.
5. Signs of Cerebral Herniation.
6. Meningococcal Septicaemia.

Question 14

Examination Special Tests to check for Meningeal Irritation.

Answer 14

1. Kernig’s Test.
2. Brudzinski’s Test.

Question 15

What is Kernig’s Test? (5)

Answer 15

1. Lie patient on their back.
2. Flex one hip and knee to 90 Degrees.
3. Slowly straighten the knee whilst keeping hip flexed.
4. Slight Stretch in Meninges.
5. Positive = Spinal Pain/Resistance to Movement.

Question 16

What is Brudzinski’s Test? (4)

Answer 16

1. Lie patient flat on their back.
2. Gently lift their head and neck off their bed.
3. Flex their chin to their chest.
4. Positive = Involuntary Flexing of Hips and Knees.

Question 17

Management of Bacterial Meningitis / Meningococcal Septicaemia in Community.

Answer 17

If Suspected Meningitis + Non-Blanching Rash : Urgent STAT IM/IV Injection of Benzylpenicillin before transferring to hospital (transfer is priority if allergic to Penicillin).

Question 18

Doses of Medication in Bacterial Meningitis / Meningococcal Septicaemia in Community (3).

Answer 18

1. < 1 Year - 300mg.
2. 1-9 Years - 600mg.
3. > 10 Years/Adults - 1200mg.

Question 19

Management of Bacterial Meningitis / Meningococcal Septicaemia in Hospital (6).

Answer 19

1. Blood Culture and Lumbar Puncture Before Antibiotics (but don’t delay if unwell).
2. Blood Tests for Meningococcal PCR (DNA)
3. <3 Months : Cefotaxime + Amoxicillin (Amoxicillin covers Listeria contracted from Mother).
4. > 3 Months - Ceftriaxone.
5. Notifiable Disease - PHE.
6. Immediate Hypersensitivity to Penicillin/Cephalosporin : Chloramphenicol.

Question 20

What other additional medications can be used in Bacterial Meningitis / Meningococcal Septicaemia in Hospital (2)?

Answer 20

1. Vancomycin - Risk of Penicillin-Resistant Pneumococcal Infections e.g. Recent Foreign Travel or Prolonged Antibiotic Exposure.
2. Steroids e.g. Dexamethasone QDS 4 Days in Kids Over 3 Months to reduce frequency and severity of hearing loss and neurological damage if LP is suggestive of bacterial meningitis.

Question 21

Contraindications to IV Dexamethasone (4).

Answer 21

1. Septic Shock.
2. Meningococcal Septicaemia.
3. Immunocompromised.
4. Meningitis Following Surgery.

Question 22

Management of Viral Meningitis (3).

Answer 22

1. LP - Viral PCR Testing.
2. Milder - Supportive Treatment.
3. Aciclovir : Suspected/Confirmed HSV Meningitis.

Question 23

Post-Exposure Prophylaxis (2).

Answer 23

1. Risk for People with Close Prolonged Contact withn 7 days prior to onset of illness is highest (risk persists for at least 4 weeks).
2. Guided by PHE - Antibiotic Single Dose of Ciprofloxacin/Rifampicin ASAP within 24 hours of initial diagnosis.

Question 24

Complications of Meningitis (7).

Answer 24

1. Sensorineural Hearing Loss.
2. Seizures and Epilepsy.
3. Cognitive Impairment and Learning Disability.
4. Memory Loss.
5. Focal Neurological Deficit.
6. Pressure - Brain Herniation and Hydrocephalus.
7. Risk of Waterhouse-Friderichsen Syndrome : Adrenal Insufficiency (Adrenal Haemorrhage).

Question 25

Meningitis Vaccine.

Answer 25

1. Immunisation against Serotypes A and C made Serotype B the commonest cause in the UK.
2. Now Vaccine for B 3 Doses : 2 months, 4 months and 12-13 months.