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Meningitis Flashcards

1
Q

What is meningitis

A

Infection and inflammation of the meninges

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2
Q

What is meningism

A

Thunderclap headache
Photophobia
Vomiting
Neck stiffness due to spasm on flexion

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3
Q

What can cause meningism

A

Meningitis
SAH
Migraine
Sinusitis

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4
Q

What should you beware of

A 
Fever
Vomiting
Lethargy
Confusion 
Even in absence of headache / photophobia
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5
Q

What are bacteria causes

A

Neisseria meningitides
S.pneumonia
H.influenza - more in young-18

Neonate
E.coli
GBS
Listeria monocytogene - also in >50

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6
Q

What are viral causes

A 
HSV and VZV = most common 
Enterovirus
Mumps 
EBV 
HIV
CMV - immunocompromised
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7
Q

What causes shunt associated meningitis (VA / VP)

A

Coag -ve staph - S.epiderdimis
S.aureus
Coliforms

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8
Q

What do you do for shunt associated

A

Refer to neurosurgeon

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9
Q

What are non-infective causes

A 
Drugs
SLE
Sarcoid
Malignancy
Treat as infective 1st then look for these if no infection
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10
Q

What does CSF show in non-infective

A

No organism

Excessive WCC / protein

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11
Q

What are RF for meningitis

A 
Alcohol 
Immunocompromised - HIV / DM / congenital 
ENT condition
Surgery 
Splenectomy 
Skull trauma
FH / contact
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12
Q

How is meningitis transmitted

A 
Close contact
Vertical from mother to baby - group B strep 
Adjacent infection - sinusitis
Neurosurgery 
Head injury / trauma
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13
Q

How do you Dx meningitis

A

Blood culture before Ax if possible
Blood PCR
LP = definite if no CI
Always do CT prior to LP to ensure no mass

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14
Q

What do you send CSF for

A 
Gram stain and culture - bacteria
PCR - viral
AAFB on ZN for TB
Cell count
Antigen detection
Glucose
Protein
WCC
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15
Q

What other tests do you do

A 
Bedside obs 
NPA and throat swab to isolate 
Bloods- FBC, U+E, LFT, clotting, CRP
Blood glucose
ABG or VBG 
CXR as part of sepsis screen
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16
Q

What are CI to LP

A 
Focal neuro suggesting mass
- Papilloedema
- Seizure 
Chairi malformation
Raised ICP
Unstable patient
Bleeding disorder / DIC
Immunocompromised 
Infection over LP site
Meningococcal septicaemia as thrombocytopenia
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17
Q

What are complications of LP

A 
Spinal headache
Nerve root trauma
Cyst 
Infection
Brain herniation if raised ICP
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18
Q

How does spinal headache present

A

Bilateral

Improves when supine

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19
Q

How do you Rx

A

Fluid
Caffeine
Epidural blood patch

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20
Q

What are symptoms of nerve root trauma

A

Electric shock
Back pain
Altered mental
CN abnormalities

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21
Q

How do you Rx and Dx if nerve been injured

A

Raise head
Mannitol
Steroid
Intubate

Nerve conduction studies

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22
Q

What empirical therapy do you give for meningitis

A 
BenPen in community 
Amox +cefaxime if <3 months or >60
Cefotaxime if >3 months
Chloroamphenicol if allergic
Aciclovir if any signs of encephalitis 
Steroid if >3 months and not meningococcus
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23
Q

What does CSF show in bacterial meningitis

A 
Turbid colour 
Increased opening pressure
Elevated WCC
Neutrophils predominate >50%
Reduce glucose 
Increased protein
Increased lactate
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24
Q

What does CSF show in viral meningitis

A 
Clear colour 
Increased opening pressure can be normal 
Elevated WCC (lymphocytes) 
Neutrophils <10%
Normal glucose
Normal or raised protein
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25
What does CSF show in TB
``` Cloudy Increased pressure Increased WCC Reduced glucose Increased protein Mixed cell / lymphocytes ```
26
When may opening pressure be normal
Viral TB FUngal
27
What do you do if organism killed by Ax before LP
Look at protein / glucose
28
What should you never do
Delay Rx if life-threatening
29
What causes meningococcal
Neisseria meningitdes | Gram -ve
30
How does meningococcal present
``` Meningism Rapid deterioration in mental Systemic upset - flu / fever Seizures Irritable Skin rash - petechial / maculopapular (20%) Petechiae conjunctiva SEPTIC SIGNS ```
31
What should you never wait for
Skin rash to appear
32
How do you assess
``` A - can't maintain if unconscious B - increased RR / O2 C - shock D - AVPU / pupils / GCS / papilloedema / focal neuro E - rash / temp / ```
33
What is Kernig sign
Can't extend knee joint when hip joint flexed | Signs of meningeal irritation
34
What is Bruzinski sign
Hip and knees flex when neck flexed
35
When do you do a CT
Most people get a CT just to make sure Rule out abscess Make sure safe to do LP ``` Indication Immunocompromised Hx CNS - stroke Seizure within one week of feeling unwell Swollen optic disc Low GCS Focal ```
36
When may you not need LP
Confident Dx with typical rash
37
Do you still do LP if Ax given
Yes as changes in CSF can stay for 48 hours
38
How do you treat meningococcal
Early Ax - cefotaxime Fluid resus ICU Support shock and raised ICP due to cerebral oedema
39
What do you give pre-hospital
Benpen IM | Always give if suspect
40
What do you give on discharge
Rifampicin or ciprofloxacin
41
What do you do for raised ICP
Low threshold for intubation and ventilation | Mannitol
42
What do you give prophylaxis
``` Public health must be notified of all bacteria meningitis All close contacts Ciprofloxacin preferred to Rifampicin Target immunisation Eliminate carriage ```
43
What vaccine are available
Meningococcal A and C Pneumococcus H. influenza
44
What suggests bad prognosis
``` Delay in therapy Age extreme Purpura Shock + no meningism DIC Metabolic acidosis Neuro deficit Absence of raised WCC ```
45
DDX
Encephalitis - headache / reduced GCS SAH - fever unlikely Migraine
46
What is DIC
Abnormal clotting in small blood vessels Low platelet Increased fibrin
47
What suggests chronic meningococcaemia
``` Meningococcal sepsis in absence of meningitis Fever >1 week Rash Joint pain Malaise ```
48
What is meningococcal septicaemia
CSF sterile | Septicaemia from meningococcal source (bug) - not infection in the menigniges
49
Wha is mortality
50% die in 24 hours
50
How does meningococcal septicaemia present
``` Rapid decreased GCS/ change in mental Fever Headache Purpuric rash = common feature - Not always present in meningitis Septic shock Low urine / tachy / hypotension DIC Acidosis Adrenal insufficiency ```
51
How do you Dx
Blood culture / PCR | LP sterile so if suspect septicaemia don't bother
52
How do you Rx
``` Treat sepsis Supportive Inotropes Vasodilators Steroids Senior ```
53
What causes WCC to decrease
Seizure infection with septicaemia and DIC
54
What are complications of septicaemia
Seizures Organ failure Permanent neuro Limb gangrene
55
What is Waterhouse Fredrickson Syndrome
Haemorrhage into adrenal gland causes insuffieincy Hypotensive Low Na and high K
56
What causes Pneumococcal meningitis
Strep pneumonia
57
What else can s.pneumonia cause
Otitis media Sinusitis Pneumonia
58
What is most common in adults
Pneumococcal
59
How does it present
Acute Meningism More likely altered consciousness/ focal neuro / seizures GCS <15
60
What is uncommon in pneumococcal
Petechiae
61
What are RF
``` Age URTI Pneumonia Sinusitis Endocarditis Head trauma Alcohol Splenectomy ```
62
What should you also do
CXR as 50% will have pneumonia
63
How do you treat
Benzypen | Ceftriaxone if resistant
64
What else do you give and why
Dexamethasone Reduce likelihood of neuropathy / hearing loss Same time as 1st dose of Iv Ax
65
How do you prevent
``` Once off Pneumococcal vaccine if >65 Children DM Immunocomprmoised Chronic disease inc chronic liver Asplenia + CKD = 5 year booster HIV Cochlear implant / skull trauma Cerebral spinal fluid leaks ```
66
What are complications
``` Increased ICP and brain herniation Brain damage Sensorineural hearing loss Visual loss CN palsies Ataxia Hemiparesis Obstructive hydrocephalus Seizure Epilpesy ```
67
When do you give dex
All meningitis except meningococcus
68
What does H.influenza B cause
Mild URTI Rapid deterioration Fever Lethargy
69
What is rare
Meningism Petechiae Nuchal rigidity
70
Who is at risk
Young children | Rare as vaccine
71
How do you treat
Cefotaxime as B-lactamase resistance Dexamethasone Vaccine
72
What do you give prophylaxis
Rifampicin
73
What is Listeria monocytogenes
Gram +ve rod Important cause of neonatal meningitis Brain abscess
74
Wha does it cause in pregnancy
Febrile flu
75
When is it important to think of
Immunocompromised | Newborn
76
How do you Dx
Blood culture
77
How do you Rx
Iv amoxicillin + Gent | Ceftriaxone
78
What are complications of Listeria
Long term neuro Brain abscess Abortion Neonatal sepsis
79
How does TB meningitis occur
Rupture of subependymal tubercle into SAH Post primary event Extrameningeal TB
80
What are symptoms of TB meningitis
``` Meningism Low grade fever Extra-meningeal TB Lethargy Chronic headache Change in mentation Weight loss Night sweats Malaise ```
81
How do you Dx TB meningitis
``` AAFB ZN CSF Only 30% +Ve Repeat LP PCR sputum / urine Mantoux ```
82
When should you always consider TB
Reduced glucose and gram stain -ve
83
How do you treat
Speicalist
84
What can Leptospirosis and Lyme cause
``` Septicaemia Meningism Fever Rigors Myalgia Vomiting Conjunctival effusio Rash Hepato-renal damage ```
85
How do you Dx
Serology | Only small % develop
86
What are viral causes
``` HSV and VZV = most common Enterovirus - Echo / Coxsackie EBV HIV CMV ```
87
When is CMV common
Immunocompromised
88
How does viral present
``` Non specific prodromal Rapid headache Low grade fever Phosphobia Stiff neck Usually lucid and alert ```
89
What virus presents with rash
Enterovirus
90
What is viral meningitis often associated with
``` Encephalitis Lethargy Confusion Seizures Focal neuro ```
91
When is viral common
Young adults and children Immunocompromised Travel
92
How do you Dx
PCR CSF Throat swab PCR HIV test
93
How do you treat
IV acyclovir Most make full recovery Supportive IV Ig if chronic
94
How do you prevent
MMR and Hib vaccine
95
What causes fungal meningitis
Cryptococcus neoformans
96
How does it present
``` Subacute Low grade fever Headache Nausea Lethargy Confusion ```
97
Who is at risk
HIV DM Lymphoma Immunocompromised
98
How do you Dx
India ink CSF Gram stain candida Term cryptococcal antigen in CSF
99
How do you treat
Specialist | IV amphotericin B
100
How you prevent
Long term chemoprophylaxis with fluconazole if HIV

Infection (14 decks)

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