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Human Disease > Meningitis > Flashcards

Meningitis Flashcards

1
Q

What was mortality rate for meningitis caused by S pneumoniae, 90yrs ago / today?

A

90 yrs ago = 98-100%

Today = 40%

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2
Q

What was mortality rate for meningitis caused by N meningitidis, 90yrs ago / today?

A

90 yrs ago = 77%

Today = 10%

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3
Q

What was mortality rate for meningitis caused by H influenzae, 90yrs ago / today?

A

90 yrs ago = 98-100%

Today = 5-10%

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4
Q

When was penicillin discovered / on the market?

A

Discovered - 1928

On the market - 1942

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5
Q

What is mortality rate for meningitis now?

A

S pneumoniae - 40%
N meningitidis - 10%
H influenzae - 5-10%

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6
Q

What morbidity is associated with meningitis?

A 
deafness
paralysis
speech issues
epilepsy
neuro-psychiatric issues
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7
Q

Who gets meningitis?

A

neonates

  • poorly developed capillaries (not closely knit)
  • from flora from mother’s birth canal

young & old
- weaker BBB

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8
Q

Why do neonates get meningitis?

A
  • poorly developed capillaries (not closely knit)

- from flora from mother’s birth canal

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9
Q

What are three meninges layers?

A

dura mater
arachnoid mater
pia mater

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10
Q

where is CSF?

A

subarachnoid space

between arachnoid and pia mater

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11
Q

What is in subarachnoid space?

A

CSF (cerebrospinal fluid)

Blood vessels

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12
Q

Define meningitis

A

inflammation of lepto-meningeal membranes

ie dura / arachnoid / pia mater

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13
Q

What are 4 main causes of meningitis?

A
  • inflammation
  • infection
  • parameningeal foci (max sinus, venous plexus)
  • neo-plastic / para-neoplastic (ie a consequence of cancer, eg lymphoma)
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14
Q

What parameningeal foci can cause meningitis?

A
  • infection in maxillary sinus / venous plexus
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15
Q

What is a neoplastic / paraneoplastic cause of meningitis?

A

a consequence of cancer, eg lymphoma

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16
Q

What infectious agents cause meningitis?

A

Virus - most common
- enterovirus, mumps, herpes
Bacteria - 2nd most common
- meningococci, Pneumococci, H. influenzae
Fungal
- Cryptococus neoformans, Coccidioidomycosis
- NOT usually candida
Parasitic
- Naegleria fowleri, Acanthamoeba spp. (ie amoeba)

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17
Q

What viruses cause meningitis?

A
  • enterovirus
  • mumps
  • herpes
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18
Q

What bacteria cause meningitis?

A
  • meningococci
  • pneumococci
  • H influenzae
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19
Q

What fungus causes meningitis?

A
  • Crytococcus neoformans
  • Coccidioidomycosis
  • NOT candida
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20
Q

What parasites cause meningitis?

A
  • Naegleria fowleri

- Acanthamoeba spp

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21
Q

How does the blood brain barrier (BBB) work?

A

closely knit capillaries

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22
Q

Where is the likely entry point into the BBB?

A

choroid plexus - weaker emissary veins (connect the extracranial venous system with the intracranial venous sinuses)

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23
Q

What three ways can organisms reach the CSF?

A

BBB
- bacteraemia / viraemia / parasitaemia
- can enter anywhere, but most likely at choroid plexus
Direct
- chronic infections in cranial bones, ears, sinuses, oral cavity, upper respiratory tract
Neuronal
- infection in peripheral neurons, axonal transport, replication, cell-to-cell spread of infection to connection neurons in CNS
- eg rabies

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24
Q

How do organisms causing meningitis DIRECTLY access the CSF?

A

chronic infections in:

  • cranial bones
  • ears
  • sinuses
  • oral cavity
  • upper respiratory tract
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25
Q

What type of blood infections can cause meningitis?

A

bacteraemia
viraemia
parasitaemia

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26
Q

How does a neuronal infection reach the CSF to cause meningitis?

A
  • infection in peripheral neuron
  • axonal transport
  • replication
  • cell-to-cell spread
  • infection passed to connecting neurons in CSF
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27
Q

What is the pathogenesis of meningitis?

A
  • mucosal colonisation - eg in sinus / oropharyngeal fossa
  • intravascular survival (ie pathogen gets from origin into blood)
  • meningeal invasion (through dura and arachnoid mater)
  • survival in subarachnoid space
  • inflammatory response / increase BBB permeability / cerebral vasculitis
  • vessels leaky and blocked, therefore cerebal oedema
  • CSF flow disturbances
  • increased intercranial pressure
  • decreased cerebral blood flow
  • loss of cerebro-vascular autoregulation
  • coma / death
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28
Q

What are the 4 main risk factors for meningitis?

A

Age

  • neonates - close knit capillaries not well dev
  • young / old (75+) - weaker BBB

Geography

  • overcrowding
  • tropical climates - increased organisms, meningitis ‘belt ‘ in Africa

Immunity
- steroids, chemotherapy, HIV

Trauma / post-neurosurgical

  • esp base of skull trauma
  • Neurosurgery (cerebral shunt, external vascular drain)
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29
Q

What are the GEOGRAPHICAL risk factors for meningitis?

A
  • overcrowding

- tropical climates - increased organisms, meningitis ‘belt ‘ in Africa

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30
Q

What are the IMMUNITY risk factors for meningitis?

A
  • steroids, chemotherapy, HIV
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31
Q

What NUEROLOGICAL SURGERY could cause meningitis?

A
  • cerebral shunts

- external vascular drain

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32
Q

Where is worst place to have skull fracture?

A

Base of skull (base of occipital / temporal bones)

- rare

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33
Q

What bacteria commonly cause meningitis in neonates?

A

Group B streptocuccus
E coli
Listeria
K pneumoniae (NOT S pneumoniae)

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34
Q

What bacteria commonly cause meningitis in

A

S pneumoniae

N meningitidis

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35
Q

What bacteria commonly cause meningitis in >50yrs?

A

S pneumoniae
N meningitidis
Listeria
aerobic gram -ve bacilli

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36
Q

What bacteria commonly cause meningitis in immunocompromised?

A 
S pneumoniae
N meningitidis
Listeria
gram -ve bacilli
Pseudomonas aeruginosa
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37
Q

What bacteria commonly cause meningitis in basilar skull fracture (base of skull)?

A

S pneumoniae
H influenzae
Group A beta-haemolytic streptococci

ie oral organisms

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38
Q

What bacteria commonly cause meningitis in head injuries / post-neurosurgery?

A

A aureus
S epidermidis
aerobic gram -ve bacilli
P aeruginosa

ie skin flora

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39
Q

What oral organisms can cause meningitis and what type of person is at risk?

A

S pneumoniae
H influenzae
Group A beta-haemolytic streptococci

Base of skull fracture

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40
Q

What skin flora organisms can cause meningitis and what type of person is at risk?

A

A aureus
S epidermidis
aerobic gram -ve bacilli
P aeruginosa

Head injury / post-neurosurgery

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41
Q

Who is at risk of S pneumoniae and N meningitidis meningitis?

A

50yrs

immunocompromised

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42
Q

Who is at risk of S pneumoniae meningitis?

A

50yrs
immunocompromised
base of skull fracture

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43
Q

Who is at risk of N meningitidis meningitis?

A

50yrs

immunocompromised

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44
Q

Who is at risk of H influenzae meningitis?

A

basilar skull fracture (base of skull)

45
Q

Who is at risk of Listeria meningitis?

A

neonates
>50yrs
immunocompromised

46
Q

Who is at risk of gram -ve bacilli meningitis?

A

> 50ys
immunocompromised
head injury
post-neurosurgery

47
Q

What are four clinical signs of meningitis?

A
  • fever
  • neck stiffness
  • altered mental state
  • headache / photophobia
48
Q

What % get 3 of 4 signs of meningitis?

A

44%

49
Q

What % get 2 of 4 symptoms of meningitis?

A

95%

50
Q

What could fever and headache be a symptom of?

A

meningitis!

51
Q

What positional tests are there to diagnose meningitis?

A

Kernig’s sign
- lie flat, lift head, if meningitis - knees will bend too

Brudzinski’s sign
- lie flat, lift one left 90 degrees in air, if can’t straighten leg = meningitis (stiff hamstring)

52
Q

What is Kernig’s sign?

A
  • lie flat, lift head, if meningitis - knees will bend too
53
Q

What is Brudzinski’s sign?

A
  • lie flat, lift one left 90 degrees in air, if can’t straighten leg = meningitis (stiff hamstring)
54
Q

What is sensitivity of Kernig’s and Brudzinski’s sign?

A

5% !

55
Q

What is gold std to diagnose meningitis?

A

Lumber puncture

56
Q

How do you do lumber puncture?

A

foetal position
insert needle between L3 and L4
collect CSF

57
Q

What are normal CSF values?

A
  • clear appearance
  • opening pressure 5-20cm
  • cell count
58
Q

What is the opening pressure during a lumber puncture?

A

The pressure measured in CSF when needle first inserted

Normal = 5-20cm

59
Q 
What is 
- cell count
- cell type 
- glucose CSF : blood ratio
- Protein
levels in CSF in viral meningitis?
A
  • cell count = 50-1000
  • cell type = lymphocytes
  • glucose CSF : blood ratio >0.45 (ie >45% of blood glucose)
  • Protein
60
Q 
What is 
- cell count
- cell type 
- glucose CSF : blood ratio
- Protein
levels in CSF in bacterial meningitis?
A
  • cell count = 1000-10,000
  • cell type = neutrophils
  • glucose CSF : blood ratio
61
Q 
What is 
- cell count
- cell type 
- glucose CSF : blood ratio
- Protein
levels in CSF in fungal meningitis?
A
  • cell count = 20-500
  • cell type = lymphocytes
  • glucose CSF : blood ratio 45mg/dL
62
Q 
What is 
- cell count
- cell type 
- glucose CSF : blood ratio
- Protein
levels in CSF in TB meningitis?
A
  • cell count = 50-300
  • cell type = lymphocytes
  • glucose CSF : blood ratio
63
Q 
What is 
- cell count
- cell type 
- glucose CSF : blood ratio
- Protein
levels in CSF in partially treated meningitis? (ie with antibiotics)
A

unknown!

64
Q

When should lumber puncture be done?

A

ASAP

- antibiotics will affect results of CSF

65
Q

What type of meningitis has CSF with:

cell count 750?

A

Viral

66
Q

What type of meningitis has CSF with:

cell count 300?

A

viral, TB, fungal

67
Q

What type of meningitis has CSF with:

cell count 9000?

A

bacterial

68
Q

What type of meningitis has CSF with:

lymphocytes as main cell type?

A

viral, fungal, TB

69
Q

What type of meningitis has CSF with:

neutrophils as main cell type?

A

bacterial

70
Q

What type of meningitis has CSF with:

A

bacterial, TB, fungal

71
Q

What type of meningitis has CSF with:

>0.45 CSF : blood glucose ratio?

A

viral

72
Q

What type of meningitis has CSF with:

0.5 CSF : blood glucose ratio?

A

viral

73
Q

What type of meningitis has CSF with:

0.6 CSF : blood glucose ratio?

A

This is the normal level!

74
Q

What type of meningitis has CSF with:

protein 150mg/dL?

A

viral (45mg/dL)

75
Q

What type of meningitis has CSF with:

The highest protein?

A

bacterial (100-500mg/dL)

76
Q

What type of meningitis has CSF which is sterile?

A

viral

77
Q

What type of meningitis has CSF with:

the highest glucose CSF : blood ratio?

A

viral (>0.45)

78
Q

What extra tests can be done on CSF?

A

PCR - Meningococci, Pneumococci
Virology PCR
Antigen test - Cryptococcal Ag, Pneumo latex
India ink - Cryptococci
Fungal cultures - Crytococcus neoformans, Coccidioidomycosis
ZN stain
AFB culture - acid fast bacilli smear and culture - test for TB
Cytology
Oligoclonal bands - bands of Ig seen in CSF after electrophoresis
Xanthochromia - yellow discolouration = bilirubin present (likely subarachnoid haemorrhage)

79
Q

What is a Xanthochromia test?

A

tests CSF for yellow discolouration = bilirubin present (likely subarachnoid haemorrhage)

80
Q

What is a Oligoclonal bands test?

A

tests CSF for bands of Ig seen in CSF after electrophoresis

81
Q

What is a AFB culture?

A

acid fast bacilli smear and culture - test for TB in CSF

82
Q

What can india ink test for?

A

Cryptococci

83
Q

Is an MRI / CT needed before lumbar puncture?

A

most people have normal MRI / CT with meningitis
but should do MRI / CT
- exclude other diagnoses
(intracranial haemorrhage, migraine, cerebral tumour)
- all get headaches and neck stiffness

84
Q

Apart from meningitis, what other diagnoses for headaches and neck stiffness?

A
  • intracranial haemhorrhage
  • migraine
  • cerebral tumour
85
Q

How you do determine if it’s meningitis or a haemorrhage?

A

MRI / CT

86
Q

When should you do neuro-imaging in meningitis?

A 
Before lumbar puncture
If history of unconsciousness
history of seizures
focal neurology (specific area of body affected)
low GCS
87
Q

What is GCS?

A

Glasgow Coma Scale

88
Q

Where is the inflammation in meningitis?

A

subarachnoid space mainly

89
Q

Why do you do neuro-imaging (MRI / CT) in meningitis?

A

if cerebral abcess, then can’t do lumbar puncture
- it may rupture and cause hernia

Symptoms of cerebral abcess

  • seizures
  • focal neurology (specific area of body affected)
  • Low GCS (Glasgow Coma Scale
90
Q

What are 4 main complications of meningitis?

A

Seizures
- scar tissue from infection / inflam = scar epilepsy

Hydrocephalus

  • increase in CSF in ventricles, therefore compression of brain
  • CSF is thicker (increase cell count), therefore reduced flow, therefore increased risk blockage
  • pressure released down and out via foramen magnum (pons compressed = cardiorespiratory arrest)
  • rare

Transtentorial herniation

  • brain expands inwards, towards pons/brain stem (motor / respiratory centre)
  • can cause coma, death

Infarcts
- caused by vasculitis and vascular compression

91
Q

What is Seizure complication in meningitis?

A
  • scar tissue from infection / inflam = scar epilepsy
92
Q

What is hydrocephalus complication in meningitis?

A
  • increase in CSF in ventricles, therefore compression of brain
  • CSF is thicker (increase cell count), therefore reduced flow, therefore increased risk blockage
  • pressure released down and out via foramen magnum (pons compressed = cardiorespiratory arrest)
  • rare
93
Q

What is transtentorial herniation complication in meningitis?

A
  • downward brain hernia
  • brain expands inwards, towards pons/brain stem (motor / respiratory centre)
  • can cause coma, death
94
Q

What is infarct complication in meningitis?

A
  • caused by vasculitis and vascular compression
95
Q

How do you manage meningitis?

A

Supportive care

  • specialist input
  • if lacking, most common reason meningitis gets worse

Specific antimicrobial therapy

  • give ASAP
  • via IV (not all AB can cross BBB), IT (intrathecal - into spinal cord), IM, PO
  • duration of treatment
  • consider allergies / renal function

Steroids (?)

  • views keep changing on use
  • evidence shows in developed world - steroids beneficial if used before or with first dose AB.
  • if given after 1st dose AB - effects unknown

Surgical intervention

Prophylaxis

  • vaccinations - universal
  • antibiotics - for ppl close to others with meningitis - prevents secondary infection
96
Q

What is most common cause of meningitis getting worse?

A

Lack of supportive care / specialist input

97
Q

What is early meningitis treatment?

A

ABCDE

98
Q

What is late meningitis treatment?

A

Nutrition
Physiotherapy
Rehabilitation

99
Q

What is issue with IV antibiotics?

A

Some drugs cannot cross BBB

100
Q

What is alternative to IV is drug cannot cross BBB to treat meningitis?

A

Intrathecal injection (IT)

101
Q

Which AB can cross BBB?

A

Penicillin
Ceftriaxone
Meropenem
Choramphenicol

102
Q

Which AB cannot cross BBB?

A

Vancomycin

Gentamicin

103
Q

What should your chose of AB depend on in treating meningitis?

A
  • cause of meningitis

- route of administration

104
Q

What other medication can be used with AB in meningitis treatment?

A

Steroids

  • views keep changing on use
  • evidence shows in developed world - steroids beneficial if used before or with first dose AB.
  • if given after 1st dose AB - effects unknown
105
Q

What types of supportive methods can be used with neurosurgery in meningitis?

A
  • EVD - external ventricular drain (needed for hydocephalus)

- IT of AB (intrathecal injection of AB) - port needs to be added by surgeon

106
Q

What surgery can be done in hydrocephalus?

A

EVD - external ventricular drain

107
Q

What types of prophylaxis is available for meningitis?

A
  • vaccinations - universal

- antibiotics - for ppl close to others with meningitis - prevents secondary infection

108
Q

Who should you tell about pt with meningitis?

A

BACTERIAL meningitis is a notifiable disease

  • public health issue
  • legal requirement to tell public health authorities

Human Disease (10 decks)

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