Dr. K. Prashanth kumar Consultant Physician Oxygen hospitals , Vikrampuri .

Evauation of Meningitis and Management Dr. K. Prashanthkumar Consultant Physician Oxygen hospitals , Vikrampuri.

Evauation of Meningitis and Management Dr. K. Prashanthkumar Consultant Physician Oxygen hospitals , Vikrampuri.

What is meningitis?…… • The brain and spinal cord are covered by connective tissue layers collectively called the meninges which form the blood-brain barrier. 1-the pia mater (closest to the CNS) 2-the arachnoid mater 3-the dura mater (farthest from the CNS). The meninges contain cerebrospinal fluid (CSF). Meningitis is an inflammation of the meninges, which, if severe, may become encephalitis, an inflammation of the brain.

What is Meningitis? • Meningitis can be caused by many different organisms including viruses and bacteria. • Meningitis, caused by a bacteria, is life threatening and requires urgent medical attention and treatment with antibiotics. • Meningitis caused by a virus is very rarely life threatening but can cause the body to become very weak. • When bacteria invade the body they can cause meningitis, septicaemia or meningitis and septicaemia together

Causes of Meningitis -Bacterial Infections -Viral Infections -Fungal Infections (Cryptococcus neoformans Coccidiodes immitus) -Inflammatory diseases (SLE) Cancer -Trauma to head or spine.

N. meningitides G-ve diplococci E.Coli G-ve bacilli Streptococci-GBS G+ve cocci Strep. pneumoniae G+ve diplococci

Bacterial meningitis…..Etiological Agents: • Pneumococcal, Streptococcus pneumoniae (38%) • Meningococcal, Neisseria meningitidis (14%) • Haemophilus influenzae (4%) • Staphylococcal, Staphylococcus aureus (5%) • Tuberculous, Mycobacterium tuberculosis

Bacterial Meningitis Potentially life threatening disease. One million cases per year world wide. 200,000 die annually. Can affect all age groups but some are at higher risk. Treatment available : antibiotics as per causative organism Humans are the reservoir . Pneumococcal meningitis is the most common type. Approximately 6,000 cases/yr Haemophilus meningitis: Since 1985 Incidence has declined by 95% due to the introduction of Haemophilus influenza b vaccine. Other bacterial meningitis caused by E-Coli K-1, Klebsiella species and Enterobacter species are less common overall, but may be more prevalent in newborns, pregnant women, the elderly and immunocompromised hosts.

What is Meningococcal disease? Etiological Agent: Neisseria meningitidis Clinical Features: sudden onset. F,H,N,V Reservoir: Humans only. 5-15% healthy carriers Mode of transmission: direct contact with patients oral or nasal secretions. Saliva. Incubation period: 1-10 days. Usually 2-4 days Infectious period: as long as meningococci are present in oral secretions or until 24 hrs of effective antibiotic therapy Epidemiology: Sporadic cases worldwide. “Meningitis belt” –sub-Saharan Africa into India/Nepal. In US most cases seen during late winter and early spring. Children under five and adolescent most susceptible. Overcrowding e.g. dormitories and military training camps predispose to spread of infection.

Aseptic Meningitis Definition: A syndrome characterized by acute onset of meningeal symptoms, fever, and cerebrospinal fluid pleocytosis, with bacteriologically sterile cultures. Laboratory criteria for diagnosis: CSF showing ≥ 5 WBC/cu mm No evidence of bacterial or fungal meningitis. Case classification Confirmed: a clinically compatible illness diagnosed by a physician as aseptic meningitis, with no laboratory evidence of bacterial or fungal meningitis Comment Aseptic meningitis is a syndrome of multiple etiologies, but most cases are caused by a viral agent

Viral Meningitis Etiological Agents: Enteroviruses (Coxsackie's and echovirus): most common. -Adenovirus -Arbovirus -Measles virus -Herpes Simplex Virus -Varicella Reservoirs: -Humans for Enteroviruses, Adenovirus, Measles, Herpes Simplex, and Varicella -Natural reservoir for arbovirus birds, rodents etc. Modes of transmission: -Primarily person to person and arthopod vectors for Arboviruses Incubation Period: -Variable. For enteroviruses 3-6 days, for arboviruses 2-15 days Treatment: No specific treatment available. Most patients recover completely on their own.

Non Polio Enteroviruses Types:62 different types known: -23 Coxsackie A viruses, -6 Coxsackie B viruses, -28 echoviruses, and 5 other How common? -90% of all viral meningitis is caused by Enteroviruses -Second only to "common cold" viruses, the rhinoviruses. -Estimated 10-15 million/ more symptomatic infections/yr in US Who is at risk?Everyone. How does infection spread?Virus present in the respiratory secretions & stool of a patient. Direct contact with secretions from an infected person. Parents, teachers, and child care center workers may also become infected by contamination of the hands with stool.

The difference between Meningitis and Septicaemia When bacteria cause disease i.e. meningococcal disease the body can be affected in different ways: Meningitis - bacteria enter the blood stream and travel to the meninges and cause inflammation. Septicaemia - when bacteria are present in the blood stream they can multiply rapidly and release toxins that poison the blood. (The rash associated with meningitis is due to septicaemia.) Meningitis and septicaemia often occur together.

Symptoms of Meningitis and Septicemia Meningitis and meningococcal septicaemia may not always be easy to detect, in early stages the symptoms can be similar to flu. They may develop over one or two days, but sometimes develop in a matter of hours.It is important to remember that symptoms do not appear in any particular order and some may not appear at all.

Symptoms for meningitis and meningococcal septicaemia: :Babies and Young Children -High temperature, fever, possibly with cold hands and feet -Vomiting or refusing feeds -High pitched moaning, whimpering cry -Blank, staring expression -Pale, blotchy complexion -Stiff neck -Arched back -Baby may be floppy, may dislike being handled, be fretful -Difficult to wake or lethargic -The fontanelle (soft spot on babies heads) may be tense or bulging.

Older Children and Adults -High temperature, fever, possibly with cold hands and feet. -Vomiting, sometimes diarrhoea. -Severe headache. -Joint or muscle pains, sometimes stomach cramps. -Neck stiffness (unable to touch the chin to the chest) -Dislike of bright lights. -Drowsiness. The patient may be confused or disorientated. Fitting may also be seen. A rash may develop.

One of the physically demonstrable symptoms of meningitis is Kernig's sign. Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees.

Another physically demonstrable symptoms of meningitis is Brudzinski's sign. Severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed.

In the early stages, signs and symptoms can be similar to many other more common illnesses, for example flu. Early symptoms can include fever, headache, nausea (feeling sick), vomiting and general tiredness. The common signs and symptoms of meningitis and septicaemia are shown above. Others can include rapid breathing, diarrhoea and stomach cramps. In babies, check if the soft spot (fontanelle) on the top of the head is tense or bulging.

One sign of meningococcal septicemia is a rash that does not fade under pressure (see ‘Glass test’) -This rash is caused by blood leaking under the skin. It starts anywhere on the body. It can spread quickly to look like fresh bruises. -This rash is more difficult to see on darker skin. Look on the paler areas of the skin and under the eyelids.

‘Glass Test’ A rash that does not fade under pressure will still be visible when the side of a clear drinking glass is pressed firmly against the skin. If someone is ill or obviously getting worse, do not wait for a rash. It may appear late or not at all. A fever with a rash that does not fade under pressure is a medical emergency.

Be aware, be prepared Meningitis and meningococcal septicaemia (blood poisoning) are serious diseases that can affect anyone at any time. Teenagers and studentsin particular, are at increased risk.Most young people in the UK have already had the MenC vaccine. If you haven’t or can’t remember, gettingvaccinated now is a good way to protect yourself. But remember, vaccines can’t preventall forms of meningitis and septicaemia.So it is very important that you are aware of the signs and symptoms so that you can get medical help urgently if you become ill.

Public Health Importance Challenges: -Educating public -Timely reporting and records keeping -Updating information daily. -Alleviating public anxiety and concerns -Collaborating with health partners Opportunities: -Educating public -Communication -Strengthening partnerships

DEMOGRAPHY AND EPIDEMIOLOGY • The highest incidence is among neonates, who are usually infected by bacteria found in the birth canal at the time of parturition. • Group B streptococci (Streptococcus agalactiae) account for the majority of cases; other causes include Listeriamonocytogenes, E.coli, other Gram-negative bacilli, and enterococci. • From age 1 to 23 months, the most common organisms are Streptococcus pneumoniae and Neisseria meningitidis

Children from the second to the fifth year used to have a high rate of infection caused by Haemophilus influenzae type b. However the wide use of protein-polysaccharide conjugated vaccines has dramatically reduced the incidence of this infection • From age 2 through 18, N. meningitidis is the most common cause, accounting for more than one-half of cases, followed by S. pneumoniae • In adults up to age 60, S. pneumoniae is most common followed by N. meningitis • Over age 60, most cases are due to S. pneumoniae and less often L. monocytogenes

Etiology - in Adults • S. pneumoniae 30-50% • N. meningitidis 10-35% • H. influenzae 1-3% • G -ve bacilli 1-10% • Listeria species 5% • Streptococci 5% • Staphylococci 5-15%

Predisposing factors • Most cases of meningitis occur when colonization by potential pathogens is followed by mucosal invasion of the nasopharynx • However, some patients develop disease by direct extension of bacteria across a skull fracture in the area of the cribriform plate • Other patients develop meningitis following systemic bacteremia as with endocarditis or a urinary tract infection or pneumonia • Other predisposing conditions include asplenia, complement deficiency, corticosteroid excess, and HIV infection

Etiology and epidemiology of meningitis • Lack of immunity ( IgM or igG anti capsularantibody ) to specific pathogens with young age. • recent colonization with pathogenic bacteria . • Close contact with invasive disease ( respiratory tract secration) • Crowding , poverty , black race , male . • Defect in complement (C5- C8 ) associated with recurrent meningococcal infection .

Etiology and epidemiology of meningitis(con) : C • Open neural tube defect : Meningomyelocele and lumbosacral dermal sinus associated with Staphylococci aureus and gram – negative • head trauma or neurosurgical procedures ( staphylococci )

CLINICAL FEATURES • The overwhelming majority of patients with bacterial meningitis have fever and headache • Most patients have high fevers, but a small percentage have hypothermia • CNS symptoms • Some patients will have significant photophobia and/or clouding of the sensorium • Changes in mentation and level of consciousness, seizures, and focal neurologic signs tend to appear later in the course of disease

CLINICAL FEATURES • Nuchal rigidity • Passive or active flexion of the neck will usually result in an inability to touch the chin to the chest • Tests to illustrate nuchal rigidity • The Brudzinski sign refers to spontaneous flexion of the hips during attempted passive flexion of the neck • The Kernig sign refers to the inability or reluctance to allow full extension of the knee when the hip is flexed 90 degrees

CLINICAL FEATURES • Other findings • Some infectious agents, particularly N. meningitidis, can also cause characteristic skin manifestations, petechiae and palpable purpura • If meningitis is the sequela of an infection elsewhere in the body, there may be features of that infection still present at the time of diagnosis of meningitis eg, otitis or sinusitis

Differential Dx • Viral- 40 % of meningitis • Fungal • Tuberculous • Spirochete • Chemical / Drug induced • Collagen Vascular Disease • Parameningeal infection: brain abscess, epidural abscess • Subarachnoid hemorrhage • Neuroleptic Malignant Syndrome

LABORATORY FEATURES • Most often the WBC count is elevated with a shift toward immature forms • Platelets may be reduced if disseminated intravascular coagulation is present or in the face of meningococcal bacteremia • Blood cultures are often positive, and can be very useful in the event that CSF cannot be obtained before the administration of antimicrobials • At least one-half of patients with bacterial meningitis have positive blood cultures, with the lowest yield being obtained with meningococcus

LABORATORY FEATURES • CSF analysis – every patient with meningitis should have CSF obtained unless the procedure is contraindicated • Chemistry and cytologic findings highly suggestive of bacterial meningitis include a CSF glucose concentration below 45 mg/dL, a protein concentration above 500 mg/dL, and a white blood cell count above 1000/mm3 • A Gram stain should also be obtained • The Gram stain is positive in up to 10 percent of patients with negative CSF cultures and in up to 80 percent of those with positive cultures

Opening pressure>180 mmH2O White blood cells10/ L to 10,000/ L; neutrophils predominate Red blood cells Absent in no traumatic tap Glucose <2.2 mmol/L (<40 mg/dL)CSF/serum glucose <0.4Protein>0.45 g/L (>45 mg/dL) Gram's stain Positive in >60%CulturePositive in >80% Latex agglutination May be positive in patients with meningitis due to S. pneumoniae, N. meningitidis, H. influenzae type b, E. coli, group B streptococci Limulus lysate positive in cases of gram-negative meningitis PCR Detects bacterial DNA

Typical Cerebrospinal Fluid Findings in Patients with Bacterial Meningitis

Complications of Meningitis One of the most common problems resulting from meningitis is hearing loss.Anyone who has had meningitis should take a hearing test. • Young children: • Babyish behavior • Forgetting recently learned skills • Reverting to bed-wetting • Babyish behavior

Older people: • Lethargy • Recurring headaches • Difficulty in concentration • Short-term memory loss • Clumsiness • Balance problems • Depression

Serious complications • Other serious complications can include: • Brain damage • Epilepsy • Changes in eye sight

Vaccine for meningitis~~ • There are vaccines against Hib and against some strains of N. meningitidis and many types of Streptococcus pneumoniae. The vaccine against haemophilus influenze (Hib) has reduced Hib meningitis cases by 95 percent since 1985. • There are vaccines to prevent meningitis due to S. pneumoniae. The pneumococcal polysaccharide vaccine is recommended for all persons over 65 years of age and younger persons at least 2 years old with certain chronic medical problems.

Treatment and prevention of bacterial meningitis • Suspected bacterial meningitis is a medical emergency and immediate diagnostic steps must be taken to establish the specific cause • The mortality rate of untreated bacterial meningitis approaches 100 percent and, even with optimal therapy, there is a high failure rate • Empiric treatment should be begun as soon as the diagnosis is suspected using bactericidal agent(s) that achieve significant levels in the CSF

Use of bactericidal agents • Bactericidal therapy is generally necessary to cure meningitis • Bacteriostatic drugs, such as clindamycin and tetracycline, are inadequate for meningitis • Chloramphenicol is a bacteriostatic drug for most enteric Gram negative rods; however, it is usually bactericidal for H. influenzae, N. meningitidis, and S. pneumoniae and has been extensively and successfully used to treat meningitis caused by these organisms

Dr. K. Prashanth kumar Consultant Physician Oxygen hospitals , Vikrampuri .