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AIP: Headache > Meningitis > Flashcards

Meningitis Flashcards

1
Q

What are 4 groups of causes of infective meningitis?

A
  1. Bacterial (including mycobacterial subgroups)
  2. Fungal
  3. Viral
  4. Parasitic (uncommon)
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2
Q

Why is bacterial meningitis the most clinically signficant type of meningitis?

A

high mortality and morbidity

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3
Q

What are the 3 most common bacterial causes of meningitis age 0-3 months?

A
  1. Group B streptococcus
  2. E. coli
  3. Listeria monocytogenes
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4
Q

What are the 3 most common bacterial causes of meningitis age 3 months to 6 years?

A
  1. Neisseria meningitis
  2. Streptococcus pneumoniae
  3. Haemophilus influenzae
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5
Q

What are the 2 most common bacterial causes of meningitis age 6- 60 years?

A
  1. Neisseira meningitidis
  2. Streptococcus pneumoniae

(same as 3months - 6years but H. influenzae less common in this group)

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6
Q

What are the 3 most common bacterial causes of meningitis age >60 years?

A
  1. Streptococcus pneumoniae
  2. Neisseria meningitis
  3. Listeria monocytogenes (common at extremes of age)
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7
Q

What is the most common cause of bacterial meningitis in immunosuppressed patients?

A

Listeria monocytogenes

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8
Q

What are the 3 most common causes of viral meningitis?

A

enteroviruses e.g.:

  1. Coxsackie viruses A+B
  2. Echoviruses
  3. Poliovirus
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9
Q

In addition to the common causes of viral meningitis, what are 8 additional viral caues of meningitis?

A
  1. Herpes simplex virus 2 (more assoc. w meningitis)
  2. Herpes simplex virus 1 (more assoc. w meningoencephalitis/encephalitis, particularly affecting the temporal lobes)
  3. Paramyxovirus
  4. Measures
  5. Rubella
  6. Varicella zoster virus: complication of chicken pox
  7. Arboviruses: arthropod-borne viruses, cause meningoencephalitis
  8. Rabies virus: can cause meningo-encephalitis
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10
Q

What is an example of fungal meningitis?

A

Cryptococcus neoformans

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11
Q

In which population are fungal meningitis cases usually seen?

A

immunosuppressed

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12
Q

What are the 2 commonest parasitic causes of meningitis?

A
  1. Acanthamoeba - can cause keratitis and meningitis due to contact lens fluid contamination
  2. Toxoplasma gondii
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13
Q

What are 6 non-infective causes of meningitis?

A
  1. Malignancy (leukaemia, lymphoma, other tumours)
  2. Chemical meningitis
  3. Drugs (NSAIDs, trimethoprim)
  4. Sarcoidosis
  5. SLE
  6. Behcet’s disease
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14
Q

What are 2 examples of types of cancer which can cause non-infective meningitis?

A
  1. Leukaemia
  2. Lymphoma
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15
Q

What are 2 types of drugs which can cause non-infective meningitis?

A
  1. NSAIDs
  2. Trimethoprim
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16
Q

What are 9 cardinal clinical features of meningitis?

A
  1. Headache
  2. Fever
  3. Neck stiffness
  4. Photophobia
  5. Nausea and vomiting
  6. Focal neurology
  7. Seizures
  8. Reduced conscious level
  9. Features of overwhelming sepsis, including non-blanching petechial rash of impending DIC
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17
Q

What are the names of the 2 eponymous clinical signs for meningitis and what do they show when positive?

A
  • Kernig’s sign: physician unable to extent patient’s leg at knee when thigh flexed due to stiffness of hamstrings
  • Brudzinski’s sign: when patient’s neck is flexed, patient flexes hip ands and knees
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18
Q

What are 6 aspects of investigations for meningitis recommended by NICE?

A
  1. Glood tests: FBC, CRP, coagulation screen, glucose, urea+electrolytes
  2. Blood culture
  3. Whole-blood PCR
  4. Blood gas (arterial/venous)
  5. Lumbar puncture IF no signs of raised ICP
  6. CT head
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19
Q

What is the management of suspected acute meningitis in the community if there is a non-blanching rash, pending hospital transfer?

A

IM benzylpenicillin

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20
Q

When is IM benzylpenicillin indicated in the community?

A

suspected meningitis with non-blanching rash, pending hospital transfer - as long as doesn’t delay transit to hospital

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21
Q

What is the most important aspect of initial management of suspected bacterial meningitis?

A

start empirical antibiotic therapy: usually IV cefotaxime (or ceftriaxone)

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22
Q

In which 2 age groups is an additional antibiotic added to initial empirical antibiotic therapy of bacterial meningitis and why?

A
  • <3 months
  • >50 years
  • amoxicillin (or ampicillin) also given to cover Listeria
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23
Q

Which initial drug should be added to empirical treatment of meningitis if viral encephalitis is also suspected?

A

IV aciclovir

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24
Q

What second-line empirical antibiotic can be used in suspected bacterial meningitis if the patient is penicillin-allergic?

A

chloramphenicol

25
Q

What is the antibiotic treatment in confirmed meningococcal meningitis?

A

IV benzylpenicillin or cefotaxime (or ceftriaxone)

26
Q

What is the antibiotic treatment in confirmed pneumococcal meningitis?

A

IV cefotaxime (or ceftriaxone)

27
Q

What is the antibiotic treatment in confirmed Haemophilus influenzae meningitis?

A

IV cefotaxime (or ceftriaxone)

28
Q

What is the antibiotic treatment in confirmed meningitis caused by Listeria?

A

IV amoxicillin (or ampicillin) + gentamicin

29
Q

What is another drug which is indicated for the management of meningitis, in addition to antibiotics? Why?

A

IV dexamethasone - reduce risk of neurological sequelae

30
Q

What are 5 situations when IV dexamethasone should not be given for the management of meningitis?

A
  1. Septic shock
  2. Meningococcal sepsis
  3. Immunocompromised
  4. Meningitis following surgery
  5. Children <3 months
31
Q

What are 2 situations when lumbar puncture is contra-indicated in meningitis?

A
  1. Signs of raised ICP
  2. Meningococcal septicaemia
32
Q

What are 5 signs of raised ICP that mean that lumbar puncture is contraindicated?

A
  1. focal neurological signs
  2. papilloedema
  3. significant bulging of the fontanelle
  4. disseminated intravascular coagulation (DIC)
  5. signs of cerebral herniation
33
Q

What are 6 tests to be performed on CSF once obtained from lumbar puncture?

A
  1. Opening pressure
  2. Macroscopic examination - appearance?
  3. Haematology
  4. Biochemistry - glucose, protein
  5. Microbiological microscopy - looking for cells
  6. Culture and sensitivities
34
Q

For bacterial meningitis, state what the findings would be for each of the following on CSF analysis:

appearance, glucose, protein, white cells

A
  • Bacterial:
    • Appearance: cloudy
    • Glucose: low (<0.5 of plasma)
    • Protein: high (>1g/L)
    • White cells: 10-5000 polymorphs / mm3
35
Q

For viral meningitis, state what the findings would be for each of the following on CSF analysis:

appearance, glucose, protein, white cells

A
  • Appearance: clear/cloudy
  • Glucose: 60-80% of plasma glucose
  • Protein: normal/raised
  • White cells: 15-1000 lymphocytes /mm3
36
Q

For tuberculous meningitis, state what the findings would be for each of the following on CSF analysis:

appearance, glucose, protein, white cells

A
  • Appearance: slightly cloudy, fibrin web
  • Glucose: low (<0.5 plasma)
  • Protein: high (>1g/L)
  • White cells: 30-300 lymphocytes/ mm3
37
Q

For fungal meningitis, state what the findings would be for each of the following on CSF analysis:

appearance, glucose, protein, white cells

A
  • Appearance: cloudy
  • Glucose: low
  • Protein: high
  • White cells: 20-200 lymphocytes / mm3
38
Q

Which type of viral meningitis is unusual in that it is sometimes associated with a low glucose level in the CSF?

A

mumps

39
Q

What differentiates bacterial meningitis from other causes on CNS analysis?

A

white cells are polymorphs

40
Q

What differentiates viral meningitis from other causes on CNS analysis?

A

glucose is not low but 60-80% of that of the plasma

also appearance may be clear, protein may be normal

41
Q

Which 3 types of meningitis will show lymphocytes in the CSF?

A

viral, tuberculous, fungal (not bacterial)

42
Q

How reliable is the Ziehl-Neelson stain for detecting tuberculous meningitis and what can be used instead?

A

20% sensitive, so PCR can be used instead (sensitivity is 75%)

43
Q

How reliable are Kernig’s and Brudzinski’s signs for diagnosing meningitis?

A

not very sensitive but very specific (so can’t be relied upon)

44
Q

Why is protein raised and glucose low in the CSF in bacterial meningitis?

A

protein raised due to bacterial protein contamination, low glucose due to bacteria using it as an energy source

45
Q

With which type of cause of meningitis will the opening pressure for LP be classically very high?

A

cryptococcal meningitis (poor prognostic sign)

46
Q

What are 2 types of tests that may be of benefit in diagnostic cryptococcal meningitis?

A

cryptococcal antigen testing, or India ink staining

47
Q

What is now the preferred antibiotic prophylaxis of meningococcal meningitis contacts?

A

ciprofloxacin (rather than rifampicin, but either can be used)

48
Q

Which contacts of patients with meningococcal meningitis need to be offered prophylaxis?

A
  • household and close contacts of patients affected
  • also all people who have been exposed to respiratory secretion, regardless of closeness of contact
49
Q

Within what time frame are contacts being treated prophylactically for meningococcal meningitis traced back to?

A

people exposed to patient within 7 days before onset

50
Q

What is the type of meningitis for which contact tracing and prophylactic treatment must be performed?

A

meningococcal meningitis

51
Q

Why is ciprofloxacin the drug of choice over rifampicin for meningococcal meningitis prophylaxis?

A

widely available and only requires one dose (but both can be used)

52
Q

How long does the risk of developing meningococcal meningitis persist for after exposure?

A

highest in first 7 days but persists for at least 4 weeks

53
Q

When should meningococcal vaccination be offered to contacts of patients with meningococcal meningitis?

A

close contacts when serotype results are available, including booster doses to those who have had the vaccine in infancy

54
Q

Is prophylaxis needed following exposure to pneumococcal meningitis?

A

no, unless cluster of cases of pneumococcal meningitis occur - Health Protection Agency have protocol for offering close contacts antibiotic prophylaxis

55
Q

How does the frequency and severity of viral meningitis compare with bacterial?

A

viral meningitis much more common + may be considered to be more benign

56
Q

How does the presentation of viral meningitis compare with bacterial?

A

similar presentation: headache, neck stiffness, photophobia, confusion, fevers, focal neuro deficits

photophobia and focal neurological deficits likely to be milder/ less frequent than in bacterial

57
Q

What might the presence of seizures in meningitis suggest about the diagnosis?

A

may in fact be meningoencephalitis

58
Q

What are 4 features of the presentation of suspected meningitis that may point more towards meningoencephalitis?

A
  1. Seizures
  2. Change in behaviour
  3. Disorientation
  4. Marked deterioration in mental state

AIP: Headache (10 decks)

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