Meningitis

Question 1

meningitis prodrome

Answer 1

unwell for a few days, fevers, malaise and myalgia
could attribute symptoms to a cold
severe and worsening headache and vomiting +++

Question 2

causes of meningitis

Answer 2

infective:
bacterial (neisseria meningitides - meningococcal, and strep pneumoniae - pneumococcal); viral; fungal
and less commonly aseptic

Question 3

Hx

Answer 3

HEADACHE +NECK STIFFNESS+FEVER
vomiting
altered mental state- confusion/drowsiness
photophobia
rash

Question 4

O/E

Answer 4

fever >38
cold/mottled peripheries
photophobia
reduced consciousness/confusion
shock - tachycardia and hypotension
focal neurological deficit
rash

Question 5

Kernig’s sign

Answer 5

patient lying flat on their back, fles hips to 90 degrees. positive if on passive extension of the knees there is pain. indicates meningitis

Question 6

Brudzinski’s sign

Answer 6

patient flat on back. slowly, passively flex the patient’s neck. positive if they involuntarily flex their hips at the same time

Question 7

treatment for suspected meningitis

Answer 7

DON’T WAIT
IV cefotaxime 1-2g stat (hospital)
1.2g benzylpenicillin IM/IV (community)
for viral offer supportive measures

Question 8

contraindications to LP

Answer 8

evidence of raised ICP:
very severe headache
reducing GCS
focal signs
papilloedema
seizure (new onset within one week of presentation)

trauma
immunocompromised
coagulopathy/thrombocytopaenia
infection at site of needle insertion (L4-L5)

Question 9

CSF analysis for bacterial meningitis

Answer 9

elevated neutrophils
lymphocytes lower than neuts
elevated protein
low glucose
(think bacteria = protein, and use glucose as fuel so reduce it)

Question 10

CSF analysis for viral meningitis

Answer 10

slightly elevated neutrophils
elevated lympohocytes
protein and glucose both usually normal

Question 11

CSF for fungal or TB menigitis

Answer 11

neutrophils, lymphocytes and protein

low glucose

Question 12

complications of meningitis

Answer 12

death
deafness
seizures
intellectual deficits
blindness
peripheral gangrene leading to loss of limbs

Question 13

other considerations in meningitis

Answer 13

prophylaxis (2 day course of rifampicin) for any contacts

Question 14

when to act now

Answer 14

headache
pyrexia
neck stiffness
altered mental state

if any 2 co-exist and not in hospital give ben-pen 1.2mg IM/IV before admitting

Question 15

organisms

Answer 15

meningococcus or pneumococcus

less common: haemophilus influenzae, listeria monocytogenes, CMV, cryptococcus or TB if immunocompromised

Question 16

differential

Answer 16

malaria, encephalitis, septicaemia, SAH, dengue, tetanus

Question 17

early features

Answer 17

headache
leg pains
cold hands and feet
abnormal skin colour

Question 18

late features

Answer 18

meningism - neck stiffness, photophobia, kernig’s sign
decreased GCS, coma
seizures (20%) with or without focal CNS signs, with or without opisthotonus (spasm of the muscles in the back of the neck, as seen in tetanus and sometimes meningitis)

Question 19

prophylaxis

Answer 19

for those who have kissed the patient’s mouth:

rifampicin or ciprofloxacin

Question 20

investigations

Answer 20

U&E, FBC (decreased WCC = immunocompromised), LFT, glucose, coag screen
blood culture, throat swabs
LP (usually after CT, unless GCS 15, no focal neurology and no signs of raised ICP)

Question 21

contraindications to LP

Answer 21

suspected intracranial mass lesion
focal signs
papilloedema
trauma
middle ear pathology
major coagulopathy