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MENINGITIS OUTCOME  VARIABLE Acute Benign Form of Viral TO

MENINGITIS OUTCOME  VARIABLE Acute Benign Form of Viral TO Rapidly Fatal Bacterial Meningitis WITH Local Progressive mental deterioration and death. Meningitis is an inflammatory disease of the leptomeninges

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MENINGITIS OUTCOME  VARIABLE Acute Benign Form of Viral TO

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  1. MENINGITIS OUTCOMEVARIABLE Acute Benign Form of Viral TO Rapidly Fatal Bacterial Meningitis WITH Local Progressive mental deterioration and death

  2. Meningitis is an inflammatory disease of the leptomeninges • Defined by an abnormal number of white blood cells in the cerebrospinal fluid (CSF).

  3. Bacterial meningitis can be community-acquired or healthcare-associated

  4. MENINGITIS • The possible presence of bacterial meningitis is suggested by the symptoms : fever, altered mental status, headache, and nuchal rigidity. virtually all patients (99 to 100 percent) have at least one of the classic triad .

  5. S pneumoniae • A gram-positive cocci, • It is the most common bacterial cause of meningitis, and • in meningitis associated with basilar skull fracture and CSF leak. • It may be associated with other foci of infection, such as: pneumonia, sinusitis, or endocarditis

  6. N meningitides • is a gram-negative diplococcus that is carried in the nasopharynx of otherwise healthy individuals. It initiates invasion by penetrating the airway epithelial surface. • Most sporadic cases (95-97%) are caused by serogroups B, C, and Y, while the A and C strains are observed in epidemics (< 3% of cases).

  7. N meningitides • Currently, it is the leading cause of bacterial meningitis in children and young adults, accounting for 59% of cases.

  8. APPROACH TO PATIENTWITH POSSIBLE MENINGITIS • I) Maintain diagnostic VIGILANCE a.) Suspect the diseasesb.) Look for classical features 1) Headache 2) meningeal irritation….HOW? 3) Obtundation c.) Confirm or exclude the diagnosis

  9. CASE I A 12 year old Nigerian boy who has arrived to Riyadh 2 days prior to presentation - C/O severe headache & Photophobia? • How do you approach & manage him?

  10. Presence of fever & neck stiffness. • Neurological deficit & Fundus. • Skin  RASH • CSF examination: • Contraindications: •  ICP reported to increase risk of herniation • Cellulitis at area of tap • Bleeding disor

  11. Opening pressure: 260 mm H20 & cloudy • WBC: 1500/ ml. 96% segmented • Glucose: 24mg / dl • Protein: 200 mg.

  12. Gram stain : • Gram-negative , "diplococcal" arrangement of cells. Diagnosis ?

  13. inflammatory cells and kidney-shaped, gram-negative diplococci

  14. Epidemiology • Rates highest in infancy with second peak in adolescence • 20% of cases occurs among adolescents and young adults ages 14–24 • Nost are sporadic cases (97%); • Minority is associated with outbreaks (3%) • Disease is seasonal, with cases peaking in December and January.

  15. PREVENTION : CHEMOPROPHYLAXIS • Neiseria meningitidis • Eradication of nasopharyngeal carriage..(post exposure ) for : • 1)house hold contact • 2)Treating doctor who has examined patient very closely

  16. Drug for prophylaxis : • Penicillin does not reliably eliminate nasopharyngeal carriage of meningococci. • Rifampicin , ceftriaxone or ciprofloxacin is used for prophylaxis in contacts to prevent further infection.

  17. Drug of choice : • Rifampicin 600 BID FOR 2 days. • Ciprofloxacin 500mg stat . • Ceftriaxon 125mg I.M stat .

  18. Prevention : • Meningococcal Conjugate Vaccine (MCV4) A. Covers Serogroups A, C, Y and W-135 B. There are two meningococcal vaccines available : Meningococcal polysaccharide vaccine (MPSV4) ..1981 Meningococcal conjugate vaccine (MCV4) ..

  19. CASE 2 A 26 YEAR OLD Saudi female who has been C / O unwell & fever & cough and headache for the last 3 days. Examination revealed ill – looking women with sign of consolidation R Lung base. • DIAGNOSIS: Bacteria Pneumonia. Organism?

  20. Six (6) hours after admission, her headache became worse and she became obstunded. • DIAGNOSIS:? MENINGITIS • CSF: WBC: 3000 99% DML • Sugar: Zero • Protein: 260 mg/dl. • Gram Stain: Gram + • DIAGNOSIS: • Bacterial…..?

  21. inflammatory cells and gram-positive diplococci. Streptococcus pneumoniae grew from this specimen.

  22. Epidemiological Features ofPneumococcal meningitis • The most common. Cause • The most killing. 20 - 30 % DEATH • May be associated with other Focus: • a. Pneumonia 25%

  23. b.Otitis Media 30% • c. Sinusitis 15 % • d. Head Trauma & CSF Leak 10%. • E. splenectoy and SS disease.. • Global emergence of Penicillin – Resistant.

  24. History • Serious drug allergies • Recent exposure to someone with meningitis • A recent infection (especially respiratory or ear infection) • Recent use of antibiotics • Recent travel, particularly to areas with endemic meningococcal disease such as sub-Saharan Africa

  25. Diagnostic tests • complete blood count with differential, and two sets of blood cultures, which are positive in 50 to 90 percent of adults with bacterial meningitis • lumbar puncture to determine whether the cerebrospinal fluid (CSF) findings are consistent with the diagnosis

  26. A history of injection drug use • A progressive petechial or ecchymotic rash, which would be most suggestive of meningococcal infection • A history of recent or remote head trauma • Otorrhea or rhinorrhea

  27. Management Algorithm for Adults Suspicion of bacterial meningitis YES new onset seizure, papilledema, altered level ofconsciousness, or focal neurological deficit or delay in performance of diagnostic L.P NO YES Blood c/s & Lumbar puncture B/C stat Dexamethasone + empirical Abx Dexamethasone + empirical Abx CSF is abnormal -ve CT-scan of the head YES +ve CSF gram stain Perform L.P NO YES Dexamethasone + empirical Abx Dexamethasone + targeted Abx

  28. CSF should be sent for • cell count and differential, • glucose and protein concentrations, • Gram stain, and culture.

  29. Characteristic findings in bacterial meningitis : • a white blood cell count above 1000/microL, usually composed primarily of neutrophils • glucose concentration <45 mg/dL, a CSF to serum glucose ratio of <0.4, protein concentration of 100 to 500 mg/dL, and

  30. GENERAL PRINCIPLES OF THERAPY • Avoidance of delay • Causes of delay : • Atypical presentation : The most dramatic clinical predictor of death was the absence of fever at presentation . • Delay due to imaging

  31. performance of a computed tomography (CT) scan of the head to exclude an occult mass lesion that could lead to cerebral herniation during subsequent CSF removal

  32. a screening CT scan of the head is NOT necessary in the majority of patients. • Two large series, 3 to 5 percent of patients had a finding that was a contraindication to LP . • Arch Intern Med. 1999;159(22):2681 • N Engl J Med. 2001;345(24):1727

  33. Risk factors • Immunocompromised state • Seizure within the previous week • Certain findings on neurologic examination: • Reduced level of consciousness, • Focal motor or • Cranial abnormalities, and • Papilledema

  34. Antibiotic regimen : • Bactericidal drugs effective against the infecting organism • Drugs that enter the CSF, since the blood-brain barrier prevents macromolecule entry into the CSF • Structuring the regimen to optimize bactericidal efficacy based on the pharmacodynamic characteristics of the antimicrobial agent

  35. WHAT DETERMINE THE OUTCOME? 1. Etiological organism 2. Speed and appropriation of the therapy. MORTALITY Bacterial Meningitis : 40 %

  36. Choice of regimen — • Antibiotic selection must be empiric immediately after CSF is obtained or • IF lumbar puncture is delayed: In such patients, antibiotic therapy needs to be directed at the most likely bacteria based upon patient age and underlying comorbid disease (table 2A-B) [3]. Knowledge of local susceptibility patterns also may be important

  37. 2-50 years N. meningitidis, S. pneumoniae. Vancomycin plus a third-generation cephalosporin. • >50 years S. pneumoniae, N. meningitidis, L. monocytogenes, aerobic gram-negative bacilli. Vancomycin plus ampicillin plus a third-generation cephalosporin

  38. Adjunctive dexamethasone ; • •Dexamethasone significantly reduced both mortality • and all unfavorable outcomes ;

  39. Treatment Bacterial meningitis is a medical emergency. immediate steps must be taken to : 1.Establish the specific cause and 2.Initiate effective therapy. • The mortality rate of untreated disease approaches 100 percent and, • even with optimal therapy, there is a high failure rate

  40. MALARIA Febrile illness caused by Plasmodium. 200 – 300,000,000 cases. 700,000---2.7,000,000 death/year more in rural area.. more during rainy season • Human ---- ----- Another Mosquito

  41. Transmission • BITE OF FEMALE ANOPHELES • BETWEEN DUSK AND DAWN • BLOOD TRANSFUSION • CONTAMINATED NEEDLES • CONGENITAL.

  42. ETIOLOGY • Four species. Death is mostly due to ..? SYPMTOMS --- Non-specific Headache & fatigue & muscle pain Fever DX:  Viral infection..?

  43. The clinical manifestations of malaria vary with • geography, epidemiology, immunity, and age • Groups at highest risk include • young children (6 to 36 months), who can develop severe illness, and • pregnant women, who are at risk for delivering low birth weight newborns

  44. older children and adults develop partial immunity after repeated infections and are at relatively low risk for severe disease

  45. Travelers to malarious areas generally have had 1) No previous exposure to malaria parasites or 2) have lost their immunity if they left the endemic area; They are at very high risk for severe disease if infected with Plasmodium falciparum

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