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Stage 2: Inflammation > Meningitis > Flashcards

Meningitis Flashcards

1
Q

What is meningitis?

A

Inflammation of the meninges

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2
Q

What are the different causes of meningitis?

A

1) Acute bacterial
2) Chronic bacterial e.g. TB, lyme disease
3) Viral e.g. mumps, HSV, enterovirus
4) Spirochaetal e.g. due to syphilis
5) Protozoal
6) Non-infectious e.g. autoimmune or medication
7) Fungal e.g. cryptococcus esp. in HIV

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3
Q

Which bacteria causes pneumococcus meningitis?

A

S.pneumoniae

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4
Q

Which bacteria causes meningococcus meningitis?

A

Neisseria meningitidis (meningococcus)

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5
Q

How would you treat viral meningitis?

A

Supportively (milder form of disease)

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6
Q

What is the pathogenesis of acute bacterial meningitis?

A
  • Organisms usually enter via the bloodstream

- Direct spread of e.g. sinusitis or otitis media

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7
Q

What does the cause of acute bacterial meningitis depend on?

A

1) Community or hospital acquired
2) Age, immune suppression
3) Contact with another case
5) Travel and relevant exposures

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8
Q

When does nosocomial meningitis generally occur?

A

Post neurosurgery

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9
Q

What type of meningitis is common in 20-40 year olds?

A

Viral meningitis

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10
Q

What is the most common cause of pneumonia globally?

A

S.pneumoniae

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11
Q

Which type of meningitis causing bacteria can be acquired from the maternal reproductive system in utero in neonates/the most common cause in newborns (up to 3 months)?

A

Streptococcus agalactiae (group B strep)

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12
Q

What is the most common cause of acute bacterial meningitis in young people < 25

A

N.meningitidis

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13
Q

What is the mortality of acute bacterial meningitis?

A

10-30%

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14
Q

What are complications of acute bacterial meningitis?

A

1) Hearing loss esp. with S.pneumoniae
2) Limb loss
3) Subdural empyema
4) Hydrocephalus (bulging fontanelle)
5) Seizures
6) Neurocognitive dysfunction e.g. difficulties sleeping

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15
Q

What are the classic symptoms and signs in meningitis?

A
  • Fever (shivering)
  • Altered mental state
  • Neck stiffness
  • Headache
  • Nausea
  • Vomiting
  • Lethargy/irritability/reduced feeding
  • Photophobia
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16
Q

What is the classic meningitis triad in ~50% of patients?

A

Fever + altered mental state + neck stiffness

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17
Q

What to almost all meningitis patients present with?

A

At least 2 of fever, altered mental state, neck stiffness and headache

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18
Q

Can clinical features distinguish between viral and bacterial meningitis?

A

No

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19
Q

What is meningism?

A

Fever + headache + neck stiffness

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20
Q

What symptom is more likely in older than younger people?

A

Altered consciousness

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21
Q

What symptom is more likely in younger people than older people?

A

Neck stiffness

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22
Q

What is the gold standard of meningitis diagnosis?

A

Examine CSF via a lumbar puncture

23
Q

What are diagnostic features of meningitis CSF?

A

1) Elevated opening pressure (may not be in viral)
2) Elevated white cells (and red cells) - may be low in early infection (low = worse prognosis)
3) Elevated protein
4) Reduced glucose compared to plasma (used up and altered metabolism of glucose in CSF)
5) CSF lactate (useful to determine if bacterial before abx)
6) CSF gram stain (to determine bacteria, before abx)
7) CSF bacterial culture - if isolated means that is cause, before abx
8) PCR - useful if abx given can identify DNA of dead bacteria

24
Q

What would be the appearance of the CSF in bacterial (not viral) meningitis?

A

Turbid - cloudy, opaque, thick due to inflammatory cells (TB = clear or cloudy)

25
Q

What is normal opening pressure of CSF?

A

cmH2O

26
Q

What are the main WBCs in bacterial meningitis CSF?

A

Neutrophils (in early stages, if abx given prior to LP, in listeria monocytogenes or leptospiral infection may be lymphocytes)

27
Q

What are the main WBCs is viral or TB meningitis CSF?

A

Lymphocytes (may be neutrophils in enteroviral meningitis)

28
Q

CSF protein is raised in all meningitis. State of the order of meningitis with increasing CSF protein

A

Viral, bacterial, TB

29
Q

What would the CSF/plasma glucose ratio be in bacterial or TB meningitis (not viral)?

A

Very low (viral = normal)

30
Q

What would investigation results be of someone presenting with acute meningitis (not LP or blood tests)?

A

1) GCS v low (7/15)
2) Normal blood glucose
3) CT scan - mildly dilated temporal horns (?cerebral oedema)
4) No focal signs/neurology or papilloedema so no sign of raised ICP
5) CXR clear

31
Q

Why would you nurse a patient with meningitis in respiratory isolation?

A

Bc the organism lives in the respiratory tract before it invades the meninges

32
Q

How would you immediately treat someone presenting with serious acute meningitis?

A

Intubate and ICU

33
Q

What blood tests would you do for someone presenting with acute meningitis?

A
  • Hb
  • WCC
  • Platelets
  • Clotting (fibrinogen)
  • Creatinine
  • Salicylate and paracetamol (overdose)
34
Q

What blood test results would be significant in acute meningitis?

A
  • High Hb
  • High WCC
  • High fibrinogen > 6 g/L - clotting deranged, prone to bleeding
35
Q

What is the normal amount of RBCs/WBCs in CSF?

A

< 5

36
Q

What is normal protein in CSF?

A

150-400 mg/L

37
Q

What kind of bacteria are gram positive pneumococci?

A

Diplococci (look like 2 circles attached)

38
Q

What is urgent treatment for acute bacterial meningitis?

A

1) Immediate antibiotics e.g. penicillin or ceftriaxone (can be given IM so don’t need to give IV in community before hospital)
2) IV ceftriaxone (empiric ab) in A&E - ideally after CSF and blood cultures but if LP delayed then give treatment
3) Dexamethasone - give before or with first dose of abx (reduced M&M), can be given up to 12 hours after abx started
4) Aciclovir if possible viral encephalitis
5) IV amoxicillin if listeria risk
6) Contact tracing + antibiotic prophylaxis

39
Q

What other investigations would you do for acute bacterial meningitis?

A

1) Blood cultures
2) Urinary pneumococcal antigen
3) EDTA blood (meningo and pneumococcal PCR)
4) CT scan head
5) CSF stain for acid fast bacilli e.g. if thinking TB meningitis
6) Throat swab for carriage to detect meningococcus (first lives harmlessly in URT) - may be useful if abx started before LP, might still find it in throat if not in CSF

40
Q

How does meningococcus cause acute bacterial meningitis?

A
  • Meningococcus picked up from contact
  • Often colonises throat and lives harmlessly
  • But it can invade the bloodstream and enter the CNS (also causing septicaemia)
  • Some evidence of genetic susceptibility e.g. abnormality in complement pathway
41
Q

What are signs of meningococcal septicaemia?

A
  • Deranged blood clotting
  • Rash e.g. small haemorrhagic lesion on foot
  • Haemorrhagic spots due to bleeding into skin
  • The spots may not be so obvious in early disease - more like light red rash
  • Purpura
42
Q

What is the glass test in meningitis?

A

When you apply pressure to haemorrhagic spots they do not blanche (spot is still evident beneath glass)

43
Q

Describe the features of a purpuric rash/purpura

A
  • Bleeding into the skin or mucosa produces a purpuric (haemorrhagic) rash or smaller petechiae
  • Not diagnosis, sign of meningococcal sepsis
  • Does not blanch on pressure
  • In meningitis, almost always caused by meningococcus (N.meningitidis) - but not always present
44
Q

Explain the different between a blanching and non-blanching rash

A

1) Blanching = caused by dilated blood vessels, RBCs still in blood vessels - so when compress blood vessel, redness goes away
2) Non-blanching = RBCs have leaked from outside bleeding blood vessel so when apply glass, RBCs are still there

45
Q

What are the key symptoms of meningococcal meningitis + septicaemia?

A
  • Headache, nausea, vomiting
  • Photophobia
  • Neck stiffness
  • Non-blanching rash
46
Q

What are the first symptoms of meningococcal disease (prodrome) lasting 4-8 hours in young children/adolescents similar to?

A

Self-limiting viral disease (but after 24h close to death)

47
Q

What are red flag symptoms in children of meningococcal infection/sepsis?

A
  • Limb pain
  • Cold hands and feet
  • Pale and mottled skin
  • Drowsiness, fast/laboured breathing, diarrhoea (younger patients)
  • Thirst (older children)
48
Q

What is normally the first classic symptom in children of meningococcal infection/sepsis?

A

Rash (might take hours to develop into petechial rash)

49
Q

How do endotoxins leading to inflammatory response in meningococcal septicaemia cause damage?

A

1) Widespread vasodilation and myocardial damage (cardiovascular/septic shock)
2) Intravascular coagulation - blocked blood vessels
3) Vessel damage - haemorrhage into tissues e.g. petechial rash
4) This leads to disruption of normal cardiovascular system physiology and its role in delivering oxygen and nutrients to tissues

50
Q

How does abnormal clotting in blood vessels to specific distal areas in meningococcal septicaemia cause damage?

A

1) Gangrene
2) Amputation
3) Disseminated intravascular coagulation in meningococcal septicaemia looks like dark blue/purple hands/limbs

51
Q

What are the 5 types of meningococcus?

A

1) A (not in England)
2) B (predominates)
3) C (reduced)
4) W135 (increasing)
5) Y (increasing)

52
Q

What vaccines are available against meningococcus?

A

1) Men B
2) ACWY
3) Men C
- Pneumococcal vaccine (prevenar) also helps
- Haemophilus influenzae type B

53
Q

What is key to remember in early meningococcal disease?

A

Classic symptoms may not be present

Stage 2: Inflammation (39 decks)

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