Meningitis

Question 1

Meningitis is defined

Answer 1

as inflammation of the meninges

Question 2

The meninges are

Answer 2

the three membranes which enclose the brain and spinal cord

Question 3

Meningism refers to

Answer 3

the signs and symptoms that accompany the inflammation. Areas of the brain affected by meningitis are somewhat green due to capillary damage and blood clot formation.

Question 4

Highest incidence

Answer 4

in sub-Saharan Africa (poor resources). It is the 6th largest infectious disease killer in the world, with fatality rates of 25-30%. For those who survive, 1 in 5 suffer from a disability as a result. In children under 5, meningitis & combined sepsis is the 2nd largest infectious disease killer.

Question 5

Meningitis is caused by a variety of microbial agents;

Answer 5

most commonly bacteria/ viruses. Meningitis is acquired by the colonisation of pathogenic microorganisms (Neisseria meningitidis and meningococcus) or acquisition at birth (group B streptococci). NSAIDs can lead to meningitis.

Question 6

Meningitis is most often spread

Answer 6

via coughing & sneezing (droplet transmission) and kissing (direct contact). Toothbrushes and cutlery may allow for transmission, depending on how quickly they are shared, due to fragility of organism. Viral forms can be spread by faecal-oral route.

Question 7

Everyone is at risk from meningitis

Answer 7

but in particular babies and young children, teenagers and young adults, the elderly and immunocompromised (HIV, chemotherapy) are at higher risk.

Question 8

Symptoms

Answer 8

Meningitis
* Rash
* Stiff neck (increased pressure in
brain)
* Dislike of bright light
* Confused/delirious
* Seizures
* Severe headache
* Fever, with cold hands and feet * Vomiting
* Sleepy/vacant
* In babies:
o High pitched, moaning cry o Irritability
o Tongue sticking out

Question 9

Meningococcal septicaemia

Answer 9

• Muscle pain (particularly legs)
• Cold hands and feet
• A rash (pin prick spots à purple
  bruising)
• Confused/delirious * Fever
• Vomiting
• Difficulty breathing

Question 10

Diagnosis

Answer 10

Meningitis is a notifiable disease; registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team (HPT) of suspected cases of certain infectious disease.

Question 11

Tumbler test

Answer 11

Someone who becomes unwell rapidly should be examined particularly carefully for the meningococcal septicaemia rash. People with meningococcal septicaemia may develop a rash of tiny ‘pink prick’ spots which can rapidly develop into purple bruising.
A non-blanching rash is one that does not fade when pressed with, and viewed through, a glass; to identify, press a glass tumbler against it and if the rash does not fade, it could be meningococcal septicaemia. On dark skin, check for the rash on lighter parts of the body, e.g. finger tips, soles of feet.

Question 12

Cerebrospinal fluid

Answer 12

Cerebrospinal fluid (CSF) is a clear, colourless liquid that bathes the brain and spinal cord providing shock absorption and support. CSF is obtained by performing a lumbar puncture or “spinal tap.” A long, thin, hollow needle is inserted between two bones in the lower spine and into the space where the CSF circulates. CSF is visually inspected and will appear turbid in meningitis. A cell count is performed on an unspun sample, giving CFU/ml. The CSF often shows low glucose (in bacterial – not affected in viral), increased white blood cell count & increased protein (more pronounced in bacterial).

Question 13

Bacterial meningitis

Answer 13

Usually more severe than viral meningitis, with high fatality rate unless treated immediately. Even with antibiotic therapy, many sufferers are left with disability – most commonly hearing loss but also vision loss, issues with concentration or memory, epilepsy, movement/ balance issues.

Question 14

Neisseria meningitis

Answer 14

N. meningitis causes meningitis and meningococcal septicaemia. It is a gram-negative diplococcus with various virulence factors that aid infection of the meninges:
* Type 4 pili allows adherence to cell
* Transcytosis is the ability to pass into cells
* Capsule aids adherence & offers protection from phagocytosis. The strains of certain bacteria (e.g. A, B, C, W & Y) refer to antigenic nature of capsule

Question 15

Meningococci colonisation of the oropharynx

Answer 15

does not always mean meningitis will occur. At this time, individuals are carriers, with the reason for transition from carrier state to invasive disease unknown, but bacteria enter the bloods, cross the BBB and cause meningitis.
Septicaemia results when bacteria enter the blood & multiply uncontrollably. Toxins damage lining of the blood vessels leading to leakage, reducing blood volume and presenting as a non-blanching rash. This means there is insufficient blood to carry enough oxygen to all parts of the body, so blood supply restricted to extremities. Clots may form in skin/muscle tissue, resulting in amputation.

Question 16

To treat (in a hospital setting)

Answer 16

give benzylpenicillin (cefotaxime or chloramphenicol). Consider adjunctive treatment with dexamethasone, only if patient does not have meningococcal septicaemia.

Question 17

Streptococcus pneumoniae

Answer 17

Can cause meningitis disease in any age group, but especially children and elderly. It is sometimes spread by an ear infection. To treat, cefotaxime should be given. If sensitive, give benzylpenicillin; if resistant vancomycin/rifampicin.

Question 18

Group B streptococci

Answer 18

Occurs primarily in babies; organism can be acquired during birth which leads to symptoms developing within a few days.

Question 19

Type B Haemophilus influenzae

Answer 19

Causes meningitis in infants and toddlers.

Question 20

M. tuberculosis

Answer 20

Cases are rare in the UK but should be considered when assessing patients from areas of high-risk of TB.

Question 21

Viral meningitis

Answer 21

Most common form, which is relatively benign & usually does not need medical attention; it may even go unrecognised. Viral meningitis usually presents as a mild flu-like illness (headache, fever, general malaise). In more severe cases, neck stiffness, muscular/joint pain, nausea, vomiting, diarrhoea and photophobia may be experienced; severe symptoms require hospital admission. Patients usually make a full recovery and are rarely left with residual side effects/ disabilities.
Enteroviruses (e.g. echovirus), paramyxoviruses (e.g. mumps) and herpes viruses are most common viral causative agents. There is no specific antiviral therapy, but Aciclovir may be used for meningitis caused by herpes simplex virus.

Question 22

Fungal meningitis

Answer 22

Meningitis caused by Cryptococcus neoformans is usually associated with pre-existing HIV infection but may also occur in patients with cell-mediated immune defects. Symptoms appear more gradually, over days or weeks, including headache, fever, nausea, vomiting, stiff neck, dislike of bright lights, changes in mental state and hallucinations.

Question 23

treatment of fungal meningitis

Answer 23

Amphotericin B, flucytosine, fluconazole

Question 24

Influenza

Answer 24

Flu is a highly contagious viral infection of the respiratory tract. It is transmitted via droplets & direct contact of respiratory secretions.

Question 25

Individuals in vulnerable groups are more likely to contract flu;

Answer 25

infants/ young children, the elderly, pregnant women, chronic respiratory and cardiac conditions, immunosuppressed, those with chronic neurological conditions will also become more seriously ill if they contract influenza.

Question 26

Symptoms include

Answer 26

fever, chills, headache, extreme fatigue and muscle pain. Complications may include secondary bacterial pneumonia, meningitis, encephalitis (inflammation of the brain) and perinatal mortality, in pregnant women. Normal recovery takes less than 14 days with bed rest.

Question 27

It is most commonly caused by

Answer 27

Influenza A & B strains, but prevalence varies year-to-year due to antigenic drift. Antigenic shift is more likely in strain A, especially H1N1, and may result in the emergence of a new subtype, causing serious outbreaks.

Question 28

Flu vaccines are reviewed annually

Answer 28

by WHO and JCVI, with annual changes required which predict the most prevalent strain for the next season. Flu vaccines are now offered at pharmacies; it is highly accessible to get vaccinated for those who are eligible. In addition, it promotes the clinical abilities of pharmacists and supports burdened GP services. However, there is a lack of coordinated documentation systems and it may be difficult to manage vaccines supplies as it is harder to predict who will attend.

Question 29

Unfortunately, the flu vaccine uptake is very low for the key groups who need it. NHS campaigns are in place to promote uptake, such as offering vouchers as visual reminders. The following receive free flu vaccinations:

Answer 29

• Over 65s
• Chronic conditions (6 months and above): asthma, COPD, heart failure, CKD, liver disease, neurological disease, diabetes,
  sickle cell, immunosuppressed
• Pregnant women
• Front line health & social care workers
• Carers
• Residential care/nursing home residents
• Children aged 2-16