Meningitis

Question 1

What are contraindications to lumbar puncture in children?

Answer 1

Signs of raised ICP, focal neurological signs, papilloedema, significant bulging of the fontanelle, disseminated intravascular coagulation, signs of cerebral herniation.

Question 2

What should be obtained instead of a lumbar puncture for patients with meningococcal septicaemia?

Answer 2

Blood cultures and PCR for meningococcus.

Question 3

What antibiotics are recommended for children under 3 months with meningitis?

Answer 3

IV amoxicillin (or ampicillin) + IV cefotaxime.

Question 4

What antibiotics are recommended for children over 3 months with meningitis?

Answer 4

IV cefotaxime (or ceftriaxone).

Question 5

What should be considered if the lumbar puncture reveals frankly purulent CSF?

Answer 5

Dexamethasone should be considered.

Question 6

What are the common causes of meningitis in children aged 0 - 3 months?

Answer 6

Group B Streptococcus, E. coli, Listeria monocytogenes.

Question 7

What are the common causes of meningitis in children aged 3 months - 6 years?

Answer 7

Neisseria meningitidis, Streptococcus pneumoniae, Haemophilus influenzae.

Question 8

What are the common causes of meningitis in adults aged 6 years - 60 years?

Answer 8

Neisseria meningitidis, Streptococcus pneumoniae.

Question 9

What are the common causes of meningitis in individuals over 60 years?

Answer 9

Streptococcus pneumoniae, Neisseria meningitidis, Listeria monocytogenes.

Question 10

What are the neurological complications of meningitis?

Answer 10

Sensorineural hearing loss, seizures, focal neurological deficit.

Question 11

What is a risk associated with meningococcal meningitis?

Answer 11

Waterhouse-Friderichsen syndrome (adrenal insufficiency secondary to adrenal haemorrhage).

Question 12

What are the CSF findings in bacterial meningitis?

Answer 12

Cloudy appearance, low glucose, high protein, 10 - 5,000 polymorphs/mm³.

Question 13

What are the CSF findings in viral meningitis?

Answer 13

Clear/cloudy appearance, 60-80% of plasma glucose, normal/raised protein, 15 - 1,000 lymphocytes/mm³.

Question 14

What are the CSF findings in tuberculous meningitis?

Answer 14

Slight cloudy appearance, low glucose, high protein, 30 - 300 lymphocytes/mm³.

Question 15

What are the CSF findings in fungal meningitis?

Answer 15

Cloudy appearance, low glucose, high protein, 20 - 200 lymphocytes/mm³.

Question 16

What is the sensitivity of the Ziehl-Neelsen stain in detecting tuberculous meningitis?

Answer 16

Only 20% sensitive; PCR is sometimes used with a sensitivity of 75%.

Question 17

CSF findings in meningitis

Answer 17

Question 18

What is the initial management step for suspected bacterial meningitis?

Answer 18

All patients should be transferred to hospital urgently.

Question 19

What should be administered if meningococcal disease is suspected in a pre-hospital setting?

Answer 19

Intramuscular benzylpenicillin may be given, as long as this doesn’t delay transit to hospital.

Question 20

What is the ABC approach in the management of suspected bacterial meningitis?

Answer 20

Airway, Breathing, Circulation, Disability (GCS, focal neurological signs, seizures, papilloedema).

Question 21

When should a senior review be requested in suspected bacterial meningitis cases?

Answer 21

If any warning signs are present, such as a rapidly progressive rash or poor peripheral perfusion.

Question 22

What are some warning signs that require senior review?

Answer 22

Rapidly progressive rash, poor peripheral perfusion, abnormal respiratory or pulse rates, pH < 7.3, WBC < 4 * 10^9/L, lactate > 4 mmol/L, GCS < 12, poor response to fluid resuscitation.

Question 23

What is a key decision regarding lumbar puncture (LP) in suspected bacterial meningitis?

Answer 23

Deciding when/whether to attempt a lumbar puncture, considering the potential delay in treatment.

Question 24

When should lumbar puncture be delayed?

Answer 24

In cases of severe sepsis, rapidly evolving rash, severe respiratory/cardiac compromise, significant bleeding risk, raised intracranial pressure, focal neurological signs, papilloedema, continuous seizures, or GCS ≤ 12.

Question 25

What is the management protocol for patients without indication for delayed LP?

Answer 25

IV access, take bloods and cultures, perform lumbar puncture, administer IV antibiotics if LP cannot be done within the first hour.

Question 26

What antibiotics are recommended for patients aged 3 months to 50 years with suspected bacterial meningitis?

Answer 26

IV cefotaxime (or ceftriaxone).

Question 27

What additional treatment is recommended for suspected pneumococcal meningitis in adults?

Answer 27

Consider adjunctive treatment with IV dexamethasone, preferably starting before or with the first dose of antibacterial.

Question 28

What should be done for patients with signs of raised intracranial pressure?

Answer 28

Get critical care input, secure airway, administer high-flow oxygen, take bloods and cultures, give IV dexamethasone and IV antibiotics, and arrange neuroimaging.

Question 29

What is the management for patients with signs of severe sepsis or a rapidly evolving rash?

Answer 29

Get critical care input, secure airway, administer high-flow oxygen, take bloods and cultures, provide IV fluid resuscitation, and give IV antibiotics.

Question 30

What blood tests should be conducted for suspected bacterial meningitis?

Answer 30

Full blood count, renal function, glucose, lactate, clotting profile, CRP.

Question 31

What should be tested in the cerebrospinal fluid (CSF) if an LP is performed?

Answer 31

Glucose, protein, microscopy and culture, lactate, meningococcal and pneumococcal PCR, enteroviral, herpes simplex and varicella-zoster PCR.

Question 32

What is the BNF recommendation for initial empirical therapy for patients aged < 3 months?

Answer 32

IV cefotaxime + amoxicillin (or ampicillin).

Question 33

What prophylaxis should be offered to contacts of patients with meningococcal meningitis?

Answer 33

Prophylactic antibiotics should be given to households and close contacts exposed within the 7 days before onset.

Question 34

What is the drug of choice for prophylaxis in close contacts of meningococcal meningitis?

Answer 34

Oral ciprofloxacin is preferred as it is widely available and requires only one dose.

Question 35

What should be offered to close contacts when serotype results are available?

Answer 35

Meningococcal vaccination, including booster doses for those who had the vaccine in infancy.

Question 36

Mx suspected bacterial meningitis

Answer 36

Question 37

What is viral meningitis?

Answer 37

Viral meningitis is inflammation of the leptomeninges and cerebrospinal fluid attributed to a viral agent. It is generally considered a more benign condition compared to bacterial meningitis.

Question 38

How common is viral meningitis?

Answer 38

Approximately 3,000 cases of confirmed viral meningitis are reported yearly, but the actual number is likely much higher due to underreporting.

Question 39

What are the common causes of viral meningitis?

Answer 39

Common causes include non-polio enteroviruses (e.g., coxsackie virus, echovirus), mumps, herpes simplex virus (HSV), cytomegalovirus (CMV), herpes zoster viruses, HIV, and measles.

Question 40

What are the risk factors for viral meningitis?

Answer 40

Risk factors include patients at the extremes of age (< 5 years and the elderly), immunocompromised individuals (e.g., patients with renal failure, diabetes), and intravenous drug users.

Question 41

What are common clinical features of viral meningitis?

Answer 41

Common features include headache, neck stiffness, photophobia (often milder than in bacterial meningitis), confusion, and fevers.

Question 42

What are less common features of viral meningitis?

Answer 42

Less common features include focal neurological deficits on examination and seizures, which suggest meningoencephalitis.

Question 43

What is the investigation method for viral meningitis?

Answer 43

A lumbar puncture should be performed to confirm the diagnosis.

Question 44

What are the cerebrospinal fluid findings in viral meningitis?

Answer 44

Cerebrospinal fluid findings include: - Opening Pressure: 10 - 20 cm³ H²O - Cell count: 10-300 cells/µL - Cell differential: Lymphocytes - Glucose: 2.8 - 4.2 mmol/L or 2/3 serum glucose - Protein: 0.5 - 1 g/dL

Question 45

What is the management approach for viral meningitis?

Answer 45

Management includes supportive treatment while awaiting lumbar puncture results. If bacterial meningitis or encephalitis is suspected, broad-spectrum antibiotics with CNS penetration should be started.

Question 46

What is the typical prognosis for viral meningitis?

Answer 46

Viral meningitis is generally self-limiting, with symptoms improving over 7 - 14 days, and complications are rare in immunocompetent patients.

Question 47

When should aciclovir be used in viral meningitis?

Answer 47

Aciclovir may be used if the patient is suspected of having meningitis secondary to HSV.

Question 48

CSF findings in viral meningitis

Answer 48