meningitis FINAL 2.pptx

1. MENINGITIS PRESENTED BY Dr.Shyam Sunder Reddy

2. What is meningitis?  Meningitis is an infection of the pia-arachanoid and the CSF fluid that surrounds the brain. Meningitis is usually caused by an infection with a virus, with a bacterium or even with fungi.

3. How is Meningitis Caused ■ Colonization of nasopharynx by bacteria or viruses ■ Is an important way of spreading meningitis by way of cribriform fossa or viremia or bacteriaemia and can spread to others by coughing etc.

4. ■ Hematogenous ■ Many of the bacteria and viruses that cause meningitis are fairly common and are typically associated with other routine illnesses. ■ infection of the skin, urinary system, gastrointestinal or respiratory tract can spread by the bloodstream

5. ■ Direct infection ■ skull fractures possess abnormal openings to the sinuses, nasal passages, and middle ears. Organisms can pass through openings and cause infection. surgical procedures or who have had foreign bodies surgically placed within their skulls (such as tubes to drain abnormal amounts of accumulated CSF) have an increased risk of meningitis.

6. Organisms Causing Meningitis ■ Bacterial ■ Viral ■ Fungal ■ Ricketsial ■ Parasitic/Protozoal

7. Organisms Causing Meningitis ■ Purulent bacterial meningitis ■ etiology ■ newborns Group B Strep ,E. coli ■ children - H. influenzae , Str. pneumoniae ■ HIB vaccine has reduced incidence of H influnza infection ■ adults - meningococccal (small epidemies - army, holiday camps,school going students),pneumococcal

8. Organisms Causing Meningitis ■ Viral   HSV especially in infants Enterovirus (coxsackie, echovirus) ◆ HIV ◆ Lymphocytic choriomeningitis virus ◆ Arbovirus ◆ Mumps ◆ CMV ◆ EBV ◆ VZV ◆ Adenovirus ◆ Measles

9. Organisms Causing Meningitis ◆ Rubella ◆ Rotavirus ◆ Influenza and parainfluenza

10. Organisms Causing Meningitis ■ Fungal ◆ Cryptococcus ◆ Coccidiodes ◆ Histoplasmosis ◆ Mucormycosis ◆ Aspergilosis ◆ Candidasis ◆ With a particular prone settings etc

11. Organisms Causing Meningitis ■ Parasitic/protozoal ◆ Angiostrongylus ◆ Toxoplamosis ◆ Hydatid ◆ Amoeba ◆ Malaria ◆ Cysticercosis

12. Organisms Causing Meningitis ■ Others ■ Tuberculosis ◆ Borrelia burgdorferi ◆ Treponema pallidum ◆ Mycoplasma pneumoniae ◆ brucella ◆ Chlamydia

13. Pathogenesis of Meningitis ■ The virus or bacteria replicates in the initial organ system (ie, respiratory or gastrointestinal mucosa) and gains access to the bloodstream. Primary viremia or bacteremia introduces the virus or bacteria to the reticuloendothelial organs (liver, spleen, and lymph nodes.)

14. Pathogenesis of Meningitis ■ If the replication persists despite immunologic defenses, secondary bacteremia or viremia occurs, which is thought to be responsible for seeding of the CNS. Rapid viral replication likely plays a major role in overcoming the host defenses.

15. Pathogenesis of Meningitis ■ There occurs local immune response to bacteria or virus ■ Increased vascular permeability ■ oozing of fluid exudate,inflammatory cells ■ Neutrophils migrate from capillaries and release toxins ■ TNF-a and IL-B1 produced by activated macrophages and endothelial cells

16. Pathogenesis of Meningitis ■ Ensuing inflammatory response increases blood-brain permeability ■ Cerebral edema ■ Increased ICP

17. Pathogenesis of Meningitis ■ cellular damage and loss of cellular homeostasis and worsen cerebral edema ■ damage to vessels lead to vasculitis and bleed or thrombose leading to infaraction or haemorrahage ■ exudate formation etc can obstruct CSF flow and lead to hydrocephalous ■ ICP lead to herniation

18. Pathogenesis of Meningitis ■ exudative pus of dead cells ,fluid,fibrin and leucocytes (pus) cause thick whitish grey layer that covers the leptomeninges over the surface of brain and filling sulci and basal cisterns with swollen edematous brain. ■ damage to neurons can take place if extending to brain cells resulting in their degeneration.

19. The white appearance of this calf brain is caused by neutrophils within the meninges – a condition known as meningitis. This is usually due to a bacterial infection.

20. This calf brain shows similar pathology. If a glass slide is pressed to the surface of the brain and stained it would show high numbers of neutrophils.

21. This brain shows irregular red spots which are areas of hemorrhage Bov ain nd e necrosis caused by the bacteria, Histophilus somni.

22. Brain: Purulent meningitis

23. Brain: meningitis.

24. Signs & symptoms of Meningitis ◆ Acute (<1 day)- common with S. pneumoniae and N. meningitides ◆ Subacute (2-3 days)- preceding URI like symptoms, more common with H. flu and other pathogens.

25. Signs & symptoms of Meningitis  Non-specific complaints ◆ Fever ◆ Headache ◆ Nausea and vomiting --Nuchal rigidity ◆ Lethargy ◆ Irritability ◆ Restlessness ◆ Poor feeding ◆ Back pain ◆ Altered mental status (seizure, coma)

27. Signs & symptoms of Meningitis Febrile ◆ stiff neck causing may causearched position Opisthotonos ◆ Focal neurologic signs ◆ Petechia/purpura- DIC with N. menigitidis ◆ Positive Kernig’s and Brudniski’s i.e. , Meningismus (stiff neck + Brudzinski + Kernig signs)    Shock Disseminated intravascular coagulation (DIC) Cerebral edema

28. Kernig’s Sign ■ Patient placed supine with hips flexed 90 degrees. Examiner attempts to extend the leg at the knee ■ Positive test elicited when there is resistance to knee extension, or pain in the lower back or thigh with knee extension

29. Signs & symptoms of Meningitis

30. Brudzinski’s Sign ■ Patient placed in supine position and neck is passively flexed towards the chest ■ Positive test is elicited when flexion of neck causes flexion at knees and/or hips of the patient

32. Meningococcemia - Petechiae

33. Signs & symptoms of Meningitis ■ Is due to small skin bleed ■ All parts of the body are affeced ■ The rashes do not fade under pressure ■ Pathogenesis: a. Septicemia b. wide spread endothelial damage c. activation of coagulation d. thrombosis and platelets aggregation     

34. Signs & symptoms of Meningitis ■ e. reduction of platelets (cosumption )    f. BLEEDING 1.skin rashes 2.adrenal hemorrhage Arenal hemorrhage is called Waterhouse- Friderichsen Syndrome.It cause acute adrenal insufficiency and is uaually fatal

35. Meningococcemia - Purpura fulminans

36. Signs & symptoms of Meningitis ■ May also look like bruises,echymosis .

37. Complications and Outcome of Meningitis ■ Infection can spreading to ■ Dura – pachymeningitis ■ Leptomeninges - leptomeningitis ■ Brain – encephalitis ■ Spinal cord – myelitis ■ Ventricles - ventriculitis

38. Complications and Outcome of Meningitis ■ Disseminated intravascular coagulation (DIC) Cerebral edema ■ Adrenal hemorrhage is called Waterhouse- Friderichsen Syndrome.It cause acute adrenal insufficiency and is uaually fatal ■ septicaemia and infection spreading to other organs ■ motor and neurological deficits

39. Complications and Outcome of Meningitis ■ Seizures ■ SIADH ■ Subdural effusions & empyema ■ Septic sinus or cortical vein thrombosis ■ Arterial ischemia / infarction (inflammatory vasculitis) ■ CNs Palsies (esp deafness) ■ Septic shock / multi-organ failure from bacteremia (esp meningococcus & pneumococcus)

40. Complications and Outcome of Meningitis ■ risk of adrenal hemorrhage with hypo- adrenalism (Waterhouse-Friderichsen syndrome) ■ Serum sodium level may be abnormal because of dehydration or the rare occurrence of syndrome of inappropriate antidiuretic hormone secretion (SIADH).

41. Complications and Outcome of Meningitis ■ Serum amylase level may be elevated in cases caused by mumps even in the absence of parotitis. ■ Focal infarctions/microinfarcts due to endarteritis oblitrerans ■ Formation of intracranial mass ■ Cranial nerve palsies

42. Complications and Outcome of Meningitis ■ Tiredness ■ Recurring headaches ■ Memory loss, which may be severe ■ Difficulties in concentration ■ Anger outbursts ■ Clumsiness

43. Differential Diagnosis of Meningitis ■ Brain abscess ■ Encephalitis ■ Tumor like ASTROCYTOMAS,OLIGODENDROGLIOMAS ,EPENDYMOMAS ■ MIXED GLIOMAS ■ Metastatic tumor ■ Subdural and epidural empyema ■ subdural ■ subarachnoid

44. Differential Diagnosis of Meningitis ■ Chemical meningitis: Rupture of tumor ■ intracranial haemorrage like ■ Epidural ■ subdural ■ Subarachnoid ■ intraparenchymal

45. Differential Diagnosis of Meningitis ■ metabolic encephalopathy ■ hyperglycaemic coma ■ uremia ■ hepatic encephalopathy ■ vit B deficiencies ■ vascular diseases (amyloid angiopathy, vasculitis, berry aneurysms, A-V malformations

46. Investigations & Diagnosis of Meningitis

47. CSF & LUMBER PUNCTURE ■ Indirect measurement of ICP by lumber puncture. ■ The two principal objections to lumbar puncture in the diagnosis of intracranial hypertension have been the danger of inducing brain-stem compression through tentorial or tonsillar herniation and the contention that spinal fluid pressure is not always an accurate reflection of ICP.

48. CSF & LUMBER PUNCTURE ■ Indications ■ 1. Diagnostic aid ■ 2. Therapy for idiopathic intracranial hypertension ■ 3. Infusion of anaesthetic (“spinal”), chemotherapy, or contrast agents (myelography)

49. CSF & LUMBER PUNCTURE ■ Contraindications ■ - INR > 1.4 or other coagulopathy ■ - platelets < 50 ■ - infection at desired puncture site ■ - obstructive / non-communicating hydrocephalus ■ - intracranial mass ■ - high intracranial pressure (ICP) / papilloedema

50. Summary of Typical CSF Findings Culture Increased +TB +/- Increased Negative Increased Positive 5-40 Negative Protein < 30% Normal <40% CSF plasma: Glucose ratio Decreased Normal Decreased Glucose Lymphocytes Polymorphs Cells TB 25-500 +/- increased Increased Viral <1000 Early Predominate Bacterial >1000 Predominate Late Normal 0-5 0 5 60-80 66%

51. TREATMENT of MENINGITIS ■ Empiric Antibiotics: ■ Cefotaxime 2g IV q4hrs ■ add Vancomycin 1-2 g IV q8-12 hrs in all patients (till possibility of Penicillin-resistant Strep pneumoniae has been ruled out) ■ add Ampicllin 2g IV q4hrs in elderly or immunocompromised patients (for Listeria infections)

52. ■ for patients with serious penicillin allergies, Meropenem 1-2g IV q8hrs as alternative ■ Ceftazidime (2g IV q8hr) + Vancomycin for neurosurgical patients, those with shunts or CSF leaks ■ May consider adjunctive Acyclovir (10 mg/kg IV q8hrs if normal renal function)

53. ■ Therapy can be modified as the results of Gram stain, cultures, and PCR testing become available. Patients in unstable condition need critical care unit admission for airway protection, neurologic checks, and prevention of secondary complications.

54. ■ since SIADH has been reported. Fluid restriction, diuretics, and rarely hypertonic saline infusion may be used to correct the hyponatremia

55. ■ Cerebral edema does occur in cases of severe encephalitis and may require intracranial pressure control by infusion of mannitol (1 g/kg initial dose followed by 0.25-0.5 g/kg q6h), IV dexamethasone, or intubation and mild hyperventilation, with arterial PCO2 around 28-30 mm Hg

56. ■ Use of adjunctive corticosteroids: ■ - prior to or along with initial antibiotics, administer Dexamethasone 10 mg IV for suspected bacterial meningitis (based on cloudy CSF, CSF WBC counts > 1000 or + Gram stain) ■ - continue 10 mg IV q6hr x 4 days

57. ■ Prognostic Factors: ■ 1. Age ■ 2. Level of Consciousness (50% mortality if unresponsive or minimally responsive on admission) ■ 3. Seizures early in course ■ 4. Strep. pneumoniae meningitis ■ 5. CSF results (lower glucose & WBC counts, higher protein)

58. Thank you

meningitis FINAL 2.pptx

meningitis FINAL 2.pptx

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meningitis FINAL 2.pptx