Meningitis

Question 1

Definition

Answer 1

Inflammation of the membranes covering the brain & spinal cord.
Types: - Bacterial
- Aspetic e.g. viral → most common, fungal
- Tuberculous

Question 2

Bacterial (Septic) meningitis

Causes more then 1m

Answer 2

Pneumococci

Staphylococci

Streptococci

Nisseria meningitides

Question 3

Acute Bacterial Meningitis

.neonat

Answer 3

y E.coli

y Listeria monocytogenes

y Hemophilus influenza.

Question 4

Transmission /Bacterial (Septic) meningitis

Answer 4

Droplet infection mostly (Blood borne in neonatal sepsis)

Question 5

Clinical picture/Non specific

Answer 5

• High fever (may be hypothermia in neonates).
• Poor feeding

• Rose spots may appear on the trunk & extremities in meningeococcal septicemia.
. irritability, restlessness, depressed mental status

Question 6

Features of increased intracranial pressure (ICP)

Answer 6

• Before fontanel closure p tense, bulging anterior fontanel
• After closure of fontanels:

Severe bursting headache (irritability)
Blur of vision
Projectile vomiting (in the morning, not preceded by nausea)
😱Cushing response (hypertension & bradycardia)

Question 7

Features of meningeal irritation: (less sensitive in infants)

Answer 7

• Neck rigidity (stiffness) p limited neck flexion
• Opisthotonus p arched back
• Kernig’s sign p inability to extend the leg after the thigh is flexed to a right angle with the axis of the trunk.
• Brudzinski leg sign: Passive flexion of one hip p flexion of the other hip and knee
• Brudzinski neck sign: Passive flexion of the neck p flexion of the hip & knee.

Question 8

Neurologic signs

Answer 8

• Stupor & drowsiness

• Convulsions ➡️ usually generalized
😓 „ Coma

Question 9

Complications

Answer 9

1- Syndrome of inappropriate secretion of antidiuritic hormone (SIADH) p so, maintenance fluids must be at 2/3 normal to avoid brain edema.

2- Neurologic complications:

• Increased intracranial pressure (ICP) p May leads to cerebral or cerebellar herniation
• Subdural effusion
• Cranial nerve lesions (commonly oculomotor, 6 th & 8 th nerves).
• Hydrocephalus.

3- Peripheral circulatory complications
i- Waterhouse Friedrichson syndrome

• Septicemia
• Shock
• Extensive purpura
• Adrenal hemorrhage (acute adrenal failure).

ii- DIC: Gangrenous patches & extremities

4- Dissemination of infection: endocarditis, arthritis , osteomyelitis

Question 10

Investigations in the bacterial form

Answer 10

1. CBC➡️⬆️PMNL
2. Blood culture reveals the responsible bacteria in up to 80-90% of cases
3. C-reactive protein, ESR, and procalcitonin have been used to differentiate bacterial (usually elevated) from viral causes of meningitis
4. Lumbar puncture (LP) & CSF examinations

Question 11

Lumbar puncture (LP) & CSF examinations/Value

Answer 11

-Diagnostic➡️organism,⬆️PMNL, ⬆️ protein,⬇️glucose, Turbid fluid

• Determine appropriate antibiotics by culture & sensitivity.
• Evaluate treatment: CSF become sterile within 24- 48 hours of appropriate antibiotics

Question 12

Lumbar puncture (LP) & CSF examinations/Contraindications for an immediate LP

Answer 12

1. Evidence of increased ICP (other than a bulging fontanel), such as 3rd or 6th cranial nerve palsy with a depressed level of consciousness, or hypertension and bradycardia with respiratory abnormalities
2. Severe cardiopulmonary compromise requiring prompt resuscitative measures for shock
3. Infection of the skin overlying the site of the LP

Question 13

Lumbar puncture (LP) & CSF examinations -What to do if an LP is delayed?

Answer 13

• Initiate empirical antibiotic therapy
  _ CT scanning for evidence of a brain abscess or increased ICP
• LP may be performed after increased ICP has been treated

Question 14

CSF in Viral meningitis

Answer 14

Clear,,⬆️protein,N. Glucose,⬆️ mononuclear cells predominate

Question 15

In partially treated meningitis

Answer 15

: Culture and gram stain are usually negative
: But Pleocytosis with a predominance of neutrophils, elevated protein level, and a reduced CSF glucose usually persist for several days

Question 16

Differential diagnosis

Answer 16

1- From other causes of meningitis

2- Meningism:

• Noninfectious meningeal irritation due to extra cranial lesions
• Causes: Upper lobe pneumonia, otitis media, shigellosis
• CSF is normal

3- Brain abscess

4- Encephalitis

Question 17

Management

Answer 17

1- antibiotics

• Ceftriaxone 100mg/kg/d given twice daily, or cefoaxime 200mg/kg/d given 6hourly, plus vancomygin 60 mg/kg/ d given 6hourly.
• duration 2-3

2- supportive
😗-Dexamethasone if initiated just before or concurrently with the first dose of antibiotics, significantly diminishes the incidence of hearing loss and neurologic deficits resulting from H. inflenzae meningitis

😗-Measures to q ICp

• Mannitol 0.5 –1gm/kg iv
• Furosemide 1mg/kg iv

😗 Treatment of complications e.g. convulsions
- Immediate relief by diazepam or lorazepam
- Then phenytoin loading and maintenance
😗fluid , nutrition

Question 18

Prevention

Answer 18

• Isolation of the case
• Vaccination against H.influenza, meningococci, pneumococci
• Chemoprophylaxis for contacts: e.g. rifampicin 10-20 mg/k/day

Question 19

Aseptic meningitis definition

Answer 19

Meningitis with no micro organisms detected in CSF by gram stain or bacterial culture.

Question 20

Aseptic meningitis, causes

Answer 20

• Mostly viral , Herpes simplex virus, Enteroviruses (Echo & coxachie) Mumps, Ebstein barr virus
• Protozoa ➡️ Malaria & Toxoplasma
• Non infectious ➡️ CNS leukemia p Intrathecal injection p Post vaccination.

Question 21

Diagnosis aseptic

Answer 21

• CSF analysis

- Viral isolation

Question 22

Treatment

Answer 22

• Supportive ± antiviral.

Question 23

Encephalitis

Answer 23

Encephalitis presents as diffuse or focal neuropsychological dysfunction. Although it primarily involves the brain, it often involves the meninges as well (meningoencephalitis). From an epidemiologic and pathophysiologic perspective, encephalitis is distinct from meningitis, though on clinical evaluation both can be present, with signs and symptoms of meningeal inflammation.

Question 24

Encephalitis causes

Answer 24

Encephalitis caused by varicella-zoster virus (VZV), Epstein-Barr virus (EBV), cytomegalovirus (CMV), measles virus, or mumps virus: Rash, lymphadenopathy, hepatosplenomegaly, and parotid enlargement

Question 25

Acute disseminated encephalomyelitis (ADEM)

Answer 25

is the abrupt development of multiple neurologic signs related to an inflammatory, demyelinating disorder of the brain and spinal cord.

ADEM follows childhood viral infections (such as measles and chickenpox) or vaccinations and resembles multiple sclerosis clinically.

Question 26

ADEM clinical manifestations

Answer 26

• preceded by a prodrome of several days of nonspecific symptoms such as sore throat, fever, headache, and abdominal complaints followed by the characteristic symptoms of progressive lethargy, behavioral changes, and neurologic deficits.
• Seizures are common at presentation.
• Children with encephalitis also may have a maculopapular rash and severe complications such as fulminant coma, transverse myelitis, anterior horn cell disease, or peripheral neuropathy
• flaccid paralysis

Question 27

ADEM TREATMENT

Answer 27

• With the exception of HSV, varicella-zoster virus➡️ acyclovir’cytomegalovirus, and HIV, there is no specific therapy for viral encephalitis.
• Management is supportive and frequently requires intensive care unit admission to facilitate aggressive therapy for seizures, timely detection of electrolyte abnormalities, and, when necessary, airway monitoring and protection or reduction of increased intracranial pressure and maintenance of adequate cerebral perfusion pressure.