Meningitis in ICU in adults is common neurological emergency where timely treatment saves and improves life quality free of disability.

1. Meningitis
Mohd Saif Khan
EPIDEMIOLOGY, DIAGNOSIS AND MANAGEMENT

2. Headings
• Background and Definition
• Anatomy
• Pathophysiology
• Etiology
• Clinical presentation
• Diagnosis
• Treatment
• Subacute meningitis-diagnosis and management
• Nosocomial meningitis

3. • Meningitis is a clinical syndrome
characterized by inflammation of
the meninges.
CNS infections
Meningitis Encephalitis
Leptomeningitis
Pachymeningitis

4. Anatomy
Emissary veins

5. PATHOPHYSIOLOGY
WBC
Mechanical effects Inflammatory effects
Impairment of CSF flow
Occlusion of cortical blood vessels
Cytokines
Oxidants
Proteolytic
enzymes
Hydrocephalus
Disruption of BBB

6. Disruption of BBB
Enhanced bacterial entry
Enhanced WBC recruitment
Overwhelming damage to neural structures
Breach in piamater
Infection of brain parenchyma (encephalitis)
Brain abscess
PATHOPHYSIOLOGY
Cranial nerve palsies (VIII CN)
Thrombophlebitis of cortical veins
Ischemia and infarcts

7. Etiology
Predisposing risk MC organisms
Trauma or
neurosurgery
Staphylococcus aureus
species, gram negative
bacilli,
Infected VP shunt Staph. epidermidis, S
aureus
Elderly individuals
(>60 years)
And pregnant women
Listeria monocytogenes
Neonates Streptococcus agalactiae
Immunocompromized Cryptococci,
Mycobacterium
tuberculosis,
Infectious
Non-Infectious
Bacteria, viruses, fungi, parasites
Drugs
NSAIDs,
metronidazole,
and IVIG
Tumor
Leukemia,
lymphoma

9. Presentation
Fever
Neck stiffnessHeadache
Only about 44% of adults with bacterial
meningitis
Altered mentation
Nausea and vomiting
Photophobia
Double visions
Confusion
Irritability
Delirium
Seizures
Coma
Symptom onset
Acute (<24 hours)
Subacute (1-7 days)
Chronic (>7 days)
Bacterial
Viral
Tuberculosis,
Syphilis,
Fungi (especially cryptococci),
Carcinomatosis

10. Physical examination
• focal neurologic deficits.. Signs of cranial nerve palsies
• Meningeal signs
• Signs of Extracranial infection (eg, sinusitis, otitis
media, mastoiditis, pneumonia, or urinary tract
infection [UTI])
• Exanthemas
• Symptoms of pericarditis, myocarditis, or conjunctivitis
Nonblanching petechiae and
cutaneous hemorrhages may be
present in meningitis caused by N
meningitidis (50%), H influenzae, S
pneumoniae, or S aureus.

11. Complications
• Immediate
complications:
• Septic shock with DIC
• Coma
• Seizures, which occur in
30-40% of children and
20-30% of adults
• Cerebral edema
• Septic arthritis
• Pericardial effusion
• Hemolytic anemia ( H
influenzae)
• Late complications:
• Decreased hearing or
deafness
• Multiple seizures
• Focal paralysis
• Subdural effusions
• Hydrocephalus
• Intellectual deficits
• Ataxia
• Blindness
• Waterhouse-Friderichsen
syndrome
• Peripheral gangrene

12. D/Ds
• Central nervous system (CNS) vasculitis
• Stroke
• Encephalitis
• All causes of altered mental status and coma
• Leptospirosis
• Subdural empyema

13. Management

14. The initial treatment approach to the patient
with suspected acute meningitis depends on:
early recognition of the meningitis syndrome,
rapid diagnostic evaluation, and
emergent antimicrobial and adjunctive
therapy.

15. Diagnosis

16. • Lumbar puncture (LP) should be performed
emergently in all patients suspected of having
bacterial meningitis unless contraindicated,
although it is commonly unnecessarily delayed
while neuroimaging is performed to exclude mass
lesions.
• Life-threatening brain herniation has been
reported to range from less than 1% to 6%
(Neurology. 1959;9(4):290–297, Ann Neurol.
1980;7(6):524–528.).

17. Typical CSF Parameters in Patients
with Meningitis
Etiology WBC Count
(cells/mm3)
Predominant
cell type
Protein
(mg/dL)
Glucose
(mg/dL)
Opening
Pressure
(cm H2O)
Normal 0-5 Lymphocyte 15-40 50-75 8-20
Viral 10-500 Lymphocyte Normal normal 9-20
Bacterial 100-5000 Neutrophil >100 <40 20-30
Tubercular 50-300 Lymphocyte <100 <40 18-30
Cryptococcal 20-500 Lymphocyte 50-200 <40 18-30
Characteristic CSF findings for bacterial meningitis consist of polymorphonuclear
pleocytosis, hypoglycorrhachia, and raised CSF protein levels.

18. CT scan
Antibiotics+Dexa
Antibiotics+Dexa
Stat LP
Management of Adults with Acute Meningitis Syndrome
(Fulminant course (<48 h) with fever, headache, usually with impaired sensorium and stiff neck.)
Blood Cultures
1. Comatose
2. Inadequate History (patient unable to provide history and no family available)
3. Risk of Mass Lesion (papilledema, focal neurologic defects, recent head trauma, malignant neoplasm, or
history of CNS
mass lesion)
4. Immunosuppressed (HIV, transplant, neoplasm, steroids)
No Yes
LPCSF findings s/o Bacterial meningitis
Continue therapy
Yes
negative

19. Other laboratory test
• Gram staining of bacteria in CSF
• India Ink preparation
• CSF lactate: to distinguish bacterial from aseptic
meningitis
• PCR
• Latex agglutination-based rapid tests
• Procalcitonin
• C-reactive protein
• Limulus lysate assay: useful test for patients with
suspected gram-negative meningitis, detect ∼103 gram-
negative bacteria/mL of CSF and as little as 0.1 ng/mL of
endotoxin.

20. Antimicrobial therapy
Predisposing conditions Antibiotics
Age
<1 month
1 month – 2 years
2-50 years
>50 years
Ampicillin+cefotaxime/aminoglycoside
Vanco+ 3rd Gen Cephalo
Vanco+ 3rd Gen Cephalo
Vanco+Ampi+3rd Gen Cephalo
Head trauma
Basilar fracture
Penetrating
Vanco+ 3rd Gen Cephalo
Vanco+ Cefepime/Ceftazidime/Meropenem
Postneurosurgery Vanco+ Cefepime/Ceftazidime/Meropenem
CSF Shunt Vanco+ Cefepime/Ceftazidime/Meropenem
Impaired cellular immunity
Vancomycin plus ampicillin plus either cefepime
or meropenem

21. Duration of antimicrobial therapy

22. Supportive treatment
• Analgesics
• Antipyretics
• Anticonvulsants
• ICP lowering measures
• Intubation and mechanical ventilation

23. Nosocomial meningitis
Invasive Procedures (e.g., craniotomy, placement of internal or
external ventricular catheters, lumbar puncture, intrathecal infusions
of medications, or spinal anesthesia), VP shunt/EVD
Complicated Head Trauma
Removal of the internal ventricular
catheters
For MDR GNB
Intraventricular antibiotic
administration
Not FDA approved, indications
are not well defined.
Vancomycin and gentamicin
are most commonly given via
this route

24. Viral meningitis
• CAUSED BY
• ENTEROVIRUSES,
• HERPES SIMPLEX VIRUS (HSV),
• HUMAN IMMUNODEFICIENCY
VIRUS (HIV),
• WEST NILE VIRUS (WNV),
• VARICELLA-ZOSTER VIRUS (VZV),
• MUMPS, AND
• LYMPHOCYTIC CHORIOMENINGITIS
VIRUS (LCM)
Most common Coxsackie, echovirus, other non-
poliovirus enteroviruses
Seasonal variation
Etiology WBC Count
(cells/mm3)
Predominant
cell type
Protein
(mg/dL)
Glucose
(mg/dL)
Opening Pressure
(cm H2O)
Normal 0-5 Lymphocyte 15-40 50-75 8-20
Viral 10-500 Lymphocyte Normal normal 9-20
CSF PCR
Mollaret's meningitis
HSV-2

25. Treatment of viral meningitis
• Generally supportive treatment is given.
• Pleconaril has been evaluated for enteroviral meningitis
with modest benefit.
• Acyclovir (10 mg/kg IV every 8 hours) for HSV meningitis
(controversial).
• Intravenous immunoglobin has been used in
agammaglobulinemic patients with chronic enteroviral
meningitis.
• Arboviruses, mumps, or LCM: No specific therapy
• HIV-associated meningitis should be treated with
combination antiretroviral therapy.
• CMV meningitis: Ganciclovir

26. Cryptococcal meningitis
• 14-day induction phase of amphotericin B, 0.7 to 1
mg/kg/day IV, with or without flucytosine, 100 mg/kg/day
PO dosed every 6 hours.
• Consolidation therapy with fluconazole, 400 mg daily,
should be continued for 8 weeks following induction.
• Maintenance (or suppressive) therapy with fluconazole,
200 mg per day.
Risk factors: HIV patients, Organ transplant recepients
Diagnosis: CSF analysis, India ink staining
Detection of cryptococcal antigen (CrAg) by lateral flow immunoassay
and latex agglutination assay.

27. Other fungal meningitis
• T/t of coccidioidal meningitis is oral
fluconazole.
• Therapy for H. capsulatum meningitis consists
of amphotericin B, 0.7 to 1 mg/kg/day to
complete a total dose of 35 mg/kg.

28. Tuberculous meningitis
• Sole manifestation of TB or concurrent with
pulmonary or other extrapulmonary sites of
infection.
• Cranial nerve (CN) palsies, hemiparesis,
paraparesis, and seizures are common and
should raise the possibility of MTB as the
etiology of meningitis.
• Chest X-ray is suggestive of active or previous
pulmonary TB in approximately 50% of cases

29. Lab Diagnosis
• CSF: Pleocytosis with lymphocytic predominance,
high protein levels, and low glucose levels.
• In all suspected case send CSF for Ziehl-Neelsen
(ZN) staining for AFB, Gram staining for bacteria,
India ink preparations for fungi, and antigen
testing for Cryptococcus neoformans.
• MTB cultures can take several weeks.
• Xpert MTB/RIF detect MTB and rifampicin
resistance simultaneously in less than 2 hours.

30. Neuroimaging in TBM
• CECT or MRI scan
• The most common
findings in
descending order are
meningeal
enhancement,
hydrocephalus, basal
exudates, infarcts,
and tuberculomas

31. Treatment
• The WHO guidelines recommend a first-line
regimen of 2 months of HRZE(children) or
HRZS (adults) followed by 10 months of HR.

32. • HIV infected patients receiving ART are at risk
for clinical deterioration after initiation of
antiretroviral therapy (ART) due to immune
reconstitution inflammatory syndrome (TBM-
IRIS).
• Defer ART to 4–6 weeks after beginning ATT.
• Steroid are of great use.

33. Summary
• Clinical triad is the hallmark of meningitis but absent in
nearly half of the patients.
• Neuroimaging studies should precede lumbar puncture
in the presence of papilledema, focal findings on
neurologic examination, immunocompromise (human
immunodeficiency virus [HIV]infection, malignancy, or
transplant), seizures in the week priorto presentation,
or coma.
• Empirical antibiotic therapy should begin as soon as
possibleafter appropriate cultures have been obtained;
these can bemodified later based on results of
erebrospinal fluid (CSF) Gramstain and culture.

34. • Patients with negative cultures and limited
clinical response after 48 hours of therapy
should undergo repeat lumbar puncture and
head computed tomography (CT) or magnetic
resonance imaging (MRI) scans.
• Initial combination therapy with
dexamethasone and antibiotics has been
associated with improved outcomes in
patients with pneumococcal meningitis.

35. Thank you