Meningitis and Headaches... Flashcards
Give as many features you may wish to obtain in a history for meningitis.
- Exposure
- Petechial rash
- Recent infection
- Recent travel – endemic regions?
- History of IVDU
- History of recent or remote head trauma
- Otorrhea or rhinorrhea
- HIV infection or risk factors
- Immunocompromising conditions
Give 5 constitutional symptoms/signs of meningitis and 5 symptoms and signs more specific to meningitis.
- Stiff neck**
- Altered mental state (confusion, delirium, drowsiness, impaired consciousness)
- Non-blanching rash
- Bulging fontanelle (infants)
- Photophobia (Meningiococcal disease)
- Kernig’s Sign
- Brudzinski’s Sign
- Coma
- Paresis
- Focal neurological deficit
- Seizures
Constitutional: • Fever • Nausea • Vomiting • Lethargy • Irritable • Anorexia • Headache • Muscle ache • Joint pain • Cough
What is Kernig’s Sign? What feature may follow?
Thigh is flexed at the hip and knee at 90 degree angles, and subsequent extension in the knee is painful (leading to resistance)
What is Brudzinski’s Sign?
Forced flexion of the neck elicits a reflex flexion of the hips
Mr. X, A 67 year old builder, presents with headache and a fever. He says the lights are blinding him and he has been lethargic lately. He says his parents were proponents of anti-vaccination thus he has not had childhood immunisations.
O/E he has a temperature of 38.5ºC but all other observations are normal. You notice a purpuric rash on his back. Additionally, you identify neck stiffness and a focal neurological deficit.
When lying supine and flexed thigh at 90º, he finds it difficult to extend his leg. Additionally, when flexing his neck, he has involuntary flexion of his knees.
i) What risk factors for disease does this gentleman have?
ii) What type of rash might this be?
iii) What two signs are shown? Give them in order as they appear in the text.
Outline the investigations you wish to conduct and state any anticipated finds you might expect.
The CSF culture comes back as positive with protein present, hypoglycaemia and CRP raised.
iv) Give a DDx.
v) Outline the Management of the disease
i)
- Age > 65 years
- No immunisations
ii) Purpuric, non-blanching Meningiococcal rash
iii) Brudzinski’s Sign + Kernig’s Sign
Investigations:
• FBC: Leukocytosis, Anaemia, Thrombocytopenia
• Lumbar puncture to obtain CSF: Cell count and differential: Polymorphonuclear pleocytosis
• Blood culture: Positive
• CRP: Elevated
• Electrolytes: Acidosis; Hypomagnesemia; Hypocalcemia or Hyper/Hypoglycemia
• CSF Protein: Elevated protein
• CSF Glucose: Low < 2.5mmol/L
• CSF Gram stain: Positive
• CSF Culture: Positive
• Antigen detection in CSF: Neisseria meningitides capsular polysaccharide antigen
• Cranial CT: Raised ICP; Intracranial lesion
• Serum procalcitonin: Normal or elevated (99% sensitivity, 83% specificity bacterial vs viral)
DDx: Bacterial Meningitis
Management:
• ABCs: Airway, Breathing, Circulation
• Supportive: Electrolyte balance (ORT); Fluid balance
• ABX: Targeted
e.g. N. meningitidis: Cefotaxime 2g IV every 4 hours (adults)/ 200mg/kg/day IV in divided doses every 6 hours (neonates);
e.g. S. pneumoniae: Ampicillin: 2g IV every 4 hours (adults)/100-200mg/kg/day IV in divided doses every 6 hours (neonates)
What is Neonatal Meningitis?
inflammation of the lining of the brain (meninges) in newborns with bacterial colonization of maternal tract causing bacteremia in 1st week of life and meningitis at 2-3 weeks
Give the three aetiologies for neonatal meningitis. For each aetiological cause, give different pathogens which may be infective in each aetiology.
1) Transplacental • Rubella virus • Cytomegalovirus • HPV • Herpes Simplex Virus • HIV • Varicella Zoster Virus • Listeria monocytogenes • Treponema pallidum • Toxoplasma gondii
2) Intrapartum • CMV • HSV • HBV • HIV • Escherichia coli • Group B streptococcus • Chlamydia trachomatis • Neisseria gonorrhea • Listeria monocytogenes
3) Postpartum • CMV • HBV • VZV • HIV • HSV • Enteroviruses
Outline the pathophysiology of neonatal meningitis.
• Haematogenous spread (intrapartum) or direct extension from contiguous site (placenta/postpartum) -> bacteria spread -> Bacteria multiple in subarachnoid space -> induction of pro-inflammatory response -> inflammatory infiltrate: leukocytes, neutrophils… -> BB damaged via acute inflammation: PRISH ≈ permeability: proteins and cells enter CSF ± protein accumulation/fibrin deposition occludes aqueduct causing hydrocephalus ->
cerebral oedema and raised intracranial pressure ≈ neurological deficits ± damage
List the signs and symptoms of Neonatal Meningitis.
- Fever
- Headache
- Irritability (infants)
- Hypotonia (infants)
- Purpuric, non-blanching rash: Meningiococcal disease
- Bulging fontanelle (infants): raised ICP
- Opisthotonus (arching of back) (infants)
- Kernig’s Sign (supine and thigh flexed to 90º angle, difficult to extend or straighten leg – resistance)
- Brudzinski’s Sign: Flexion of neck causes involuntary flexion of knees and hips
- Focal neurological deficit: non-reactive pupil; ocular motility abnormalities; abnormal visual fields; gaze palsy; arm or leg drift
Master K, a 4 month old baby, presents with fever, headache and hypotonia.
O/E he has a temperature of 38.6ºC. You notice he has hypotonia and a purpuric, non-blanching rash. You notice bulging fontanelles, opisthotonos, positive Kernig’s and Brudzinski’s Sign.
i) Give the suspected DDx of the condition.
ii) What signs and Symptoms make you think this? List the others for this condition.
iii) List the investigations for the condition and any anticipated finds.
Your blood culture comes back and a bacterial pathogen of N. meningitidis is identified.
iv) Outline the management for this condition. Give the full prescription detail for any drugs given.
i) Neonatal meningitis
ii) Signs and Sx: • Fever • Headache • Irritability (infants) • Hypotonia (infants) • Purpuric, non-blanching rash: Meningiococcal disease
- Bulging fontanelle (infants): raised ICP
- Opisthotonus (arching of back) (infants)
- Kernig’s Sign (supine and thigh flexed to 90º angle, difficult to extend or straighten leg – resistance)
- Brudzinski’s Sign: Flexion of neck causes involuntary flexion of knees and hips
- Focal neurological deficit: non-reactive pupil; ocular motility abnormalities; abnormal visual fields; gaze palsy; arm or leg drift
iii) Investigations: Treat neonate < 3 months without delay if suspected bacterial meningitis
• FBC: Leukocytosis, Anaemia, Thrombocytopenia
• Lumbar puncture to obtain CSF: Cell count and differential: Polymorphonuclear pleocytosis
• Blood culture: Positive
• CRP: Elevated
• Electrolytes: Acidosis; Hypomagnesemia; Hypocalcemia or Hyper/Hypoglycemia
• CSF Protein: Elevated protein
• CSF Glucose: Low < 2.5mmol/L
• CSF Gram stain: Positive
• CSF Culture: Positive
• Antigen detection in CSF: Neisseria meningitides capsular polysaccharide antigen
• Cranial CT: Raised ICP; Intracranial lesion
• Serum procalcitonin: Normal or elevated (99% sensitivity, 83% specificity bacterial vs viral)
iv) Management: • ABCs: Airway, Breathing, Circulation • Supportive: Electrolyte balance (ORT); Fluid balance ABX: Targeted e.g. N. meningitidis: a) Suspected • Benzylpenicillin - < 1 year: 300mg IV - 1-6: 600mg - 6+: 1.2g
Known Meningitis
Cefotaxime: 200mg/kg/day IV in divided doses every 6 hours (neonates);
e.g. Group B streptococcus: Cefotaxime: 200mg/kg/day IV in divided doses every 6 houses for 14 days minimum
e.g. S. pneumoniae: Ampicillin: 100-200mg/kg/day IV in divided doses every 6 hours (neonates)
e.g. Gram-negative enteral bacilli: Cefotaxime: 200mg/kg/day IV in divided doses every 6 hours for 21 days minimum
List the 3 worst serogroups of Meningococcal meningitis.
A, B, C and W135
What pathogen causes meningococcal meningitis?
Neisseria Meningitidis
Outline the prophylaxis of meningococcal diseases.
List any patient groups you may wish to protect and how you do this.
- Ciprofloxacin PO 500mg single dose
- Pregnancy: Ceftriaxone IM 1g single dose
- Teenagers: ACW vaccine 0.5ml IM or deep SC
- Infants: Conjugate Meningococcus C vaccine
Should a child with suspected Meningococcal disease be allergic to Penicillin, what drug should be prescribed.
Chloramphenicol:
- child: 50-100mg/kg daily
- adult: 2-3g in 3 or 4 doses IV or orally
What are the risk factors for viral meningitis?
- Infants and young children
- Young adults
- Older people
- Seasonal: Summer and Autumn
- Exposure to mosquito or tick vector
- Unvaccinated for mumps
Outline 3 pathogens which may cause viral meningitis.
- Coxsackieviruses
- Echoviruses
- Enteroviruses
- Polioviruses
- Herpes virus-1 (HSV-1)
- VZV
- Mumps
- West Nile Virus
Outline the pathophysiology of viral meningitis.
• Transmission of pathogen into host -> replicate in tissues such as muscle, liver, respiratory or GI tract -> haematogenous spread -> viral penetration of BBB by infection of endothelial cells or migrating leukocytes -> virus spreads within subarachnoid space causing meningitis ± encephalitis or myelitis -> leukocytosis within CSF, pro-inflammatory cascade of IL-6 and TNF-a -> increased permeability of BBB allowing increased permeability of BBB
List the signs and symptoms of viral meningitis.
- Headache
- Nausea + Vomiting
- Photophobia
- Neck stiffness
- Fever
- Rash: Indicates infecting agent: Herpangina (Coxsackie Virus A); Maculopapular rash (Echovirus-9); Genital herpes (HSV-2)
- Kernig’s Sign
- Brudzinski’s Sign
What pathogen does a herpangina rash indicate in a patient with suspected viral meningitis?
Coxsackie Virus A
What pathogen does a maculopapular rash indicate in a patient with suspected viral meningitis?
Echovirus-9
What pathogen does a Genital herpes rash indicate in a patient with suspected viral meningitis?
Herpes Simplex Virus-2
Outline the investigations you would wish to conduct in a patient with suspected viral meningitis.
- FBC: WBC/CRP+ESR/Glucose
- U+E: Creatinine/eGFR/Urea
- CSF microscopy: Children = WBC > 5 cells/mm3 or Adults = > 20 cells/mm3
- CSF gram stain: Negative
- CSF bacterial culture: Negative
- CSF protein: Normal or elevated > 0.45g/L
- CSF glucose: may be low
- CSF viral culture: May be positive
• CT/MRI Head: Unremarkable in viral meningitis
Outline the management for Viral Meningitis for:
- HZV
- VZV
- CMV
- HZV/VZV: Aciclovir: 10mg/kg IV every 8 hours; higher doses for neonates (consult)
- CMV: Ganciclovir: 5mg/kg IV every 12 hours; consult for child doses
What is a brain abscess?
Focal, intracerebral infection evolving from area of cerebritis into collection of purulent material enveloped in a gliotic, vascularisaed capsule within the brain parenchyma
Outline the causes of a brain abscess.
- Direct spread from infection in paranasal sinuses, middle ear and teeth
- Indirect spread from infection in paranasal sinuses, middle ear and teeth
List 5 risk factors for a brain abscess.
- Male Sex
- Age < 30 years
- Sinusitis
- Otitis media
- Dental procedure/infection
- Meningitis
- Congenital heart disease
- Endocarditis
- Diabetes mellitus
- HIV
- Immunocompromised
- IVDU
- Granulomatous disease
- Hemodialysis
- Premature birth
