Meningitis

Question 1

Clinical Features

Answer 1

• Headache (Se 50%)
• Fever (>38 C)
• Neck stiffness (Se 70%)
• Altered mental status
• Nausea, vomiting
• Photophobia
• Seizure and focal neurologic deficits (especially in Listeria)
• Rhombencephalitis (manifested as ataxia, cranial nerve palsies, and/or nystagmus)
• Petechiae and palpable purpura (especially in N meningitidis)
• Arthritis (especially in N meningitidis)

Question 2

Pediatric Clinical Features

Answer 2

• Poor feeding, ↓LOC, irritability, prolonged crying

Question 3

Risk Factors

Answer 3

• Age ≥65 years old, Neonates
• Aboriginal groups, Students living in residence
• PMHx: Immunocompromised (16%): HIV, DM; hepatic / renal failure; Comorbid Infection: otitis media or sinusitis (25%), mastoiditis, Pneumonia (12%), Endocarditis
• Recent neurosurgery, Head trauma
• Recent travel to area with endemic meningococcal disease (eg. sub-Saharan Africa)
• Alcoholism, IVDU

Question 4

Meningeal Irritation Maneuvers on Physical Exam

Answer 4

• Jolt accentuation (Sn 97% Sp 60%)
Accentuation of headache by horizontal rotation of the head at a frequency of two to three times per second
• Neck stiffness
• Brudzinski (Sn 97%):
Spontaneous flexion of the hips during attempted passive flexion of the neck
• Kernig’s (Sn 57%):
Inability or reluctance to allow full extension of the knee when the hip is flexed 90 degrees
• Bulging fontanelle in children

Question 5

Indications for CT Scan

Answer 5

• Immunocompromised (HIV, immunosuppressive therapy)
• CNS disease (mass lesion, stroke, or focal infection)
• Seizure (new onset within 1 week)
• Focal neurological deficit (excluding cranial nerve palsies)
• Papilledema
• Altered mental status (GCS<10)

Question 6

Specific measurements on Lumbar Puncture

Answer 6

• CSF opening pressure (if done in left lateral decubitus)
• CSF leukocyte count, protein, glucose
• CSF culture
• CSF Gram stain

Question 7

CSF Findings for Bacterial vs. Viral Meningitis

Answer 7

• Bacterial: ↑WBC ↓Glucose ↑↑Protein, 80-90% neutrophils, gram stain
• Viral: WBC (10-500), lymphocytes, mod ↑Protein

Question 8

Most common pathogens and empiric antibiotics in neonates (0-29 days)

Answer 8

Listeria monocytogenes
E Coli
Group B Strep (S agalactiae)

Ampicillin + Cefotaxime

Question 9

Most common pathogens and empiric antibiotics in 1 month-2 years

Answer 9

S Pneumonia
H influenza (less common now)
N Meningitidis
E. Coli

Vancomycin + 3rd Generation cephalosporin
(ceftriaxone or cefotaxime)

Question 10

Most common path and Abx in >50

Answer 10

Vanco +3rd generation cephalosporin+Amp

S pneumo
H meningitidies
Gram negatives
Add the amp because of listeria coverage

Question 11

When should you add on amp for listeria

Answer 11

Alcoholism
Immunosuppression 
Malignancy
Diabetes
HIV
Neonates 
Elderly

Question 12

Most common path and what to treat in 2-50 years old

Answer 12

S. Pnumo
N meningitidies

Vanco and 3 rd generation cephalosporin (ceftriazone or Cefotazime

Question 13

5 possible pathogens for menigitis

Answer 13

TB
N Meningititis
H influenza
S pneumonia 
E coli 
Listeria 
GBS

Viral

Question 14

What to use for prophylaxis after meningitis exposure

Answer 14

Rifampin (watch for orange body fluids)
Ciprofloxacin
Ceftriaxone

Question 15

When to give steroids

Answer 15

Ideally before abx. but can be within 2 hours
Don’t delay abx for this

Give to try to prevent hearing loss

Question 16

Contraindications to LP

Answer 16

Bleeding
Brain mass
Hypotension
Rash or blisters at site

Question 17

List two public health measures to take after diagnosing someone with meningitis

Answer 17

Report to public health
Vaccinate
Treat close contacts