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Meningitis “An Update” Saad A. Alsaleh. Objectives Introduction Introduction Classification Classification Can you exclude meningitis without an LP? Can.

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Presentation on theme: "Meningitis “An Update” Saad A. Alsaleh. Objectives Introduction Introduction Classification Classification Can you exclude meningitis without an LP? Can."— Presentation transcript:

1 Meningitis “An Update” Saad A. Alsaleh

2 Objectives Introduction Introduction Classification Classification Can you exclude meningitis without an LP? Can you exclude meningitis without an LP? When is a CT necessary? When is a CT necessary? Bacterial meningitis scores? Bacterial meningitis scores? What antibiotics should I use? What antibiotics should I use? What about steroids? What about steroids? Complications Complications Summary Summary

3 Introduction Meningitis is the inflammation of the meninges. Meningitis is the inflammation of the meninges. Caused by bacteria, viruses or rarely other causes. Caused by bacteria, viruses or rarely other causes. The WHO estimates that bacterial meningitis strikes 426,000 children younger than 5 years annually, with 85,000 deaths. The WHO estimates that bacterial meningitis strikes 426,000 children younger than 5 years annually, with 85,000 deaths.

4 Introduction In History: In History: Meningitis was first accurately identified by the Swiss Vieusseux (a scientific - literary association) during an outbreak in Geneva, Switzerland in 1805.Meningitis was first accurately identified by the Swiss Vieusseux (a scientific - literary association) during an outbreak in Geneva, Switzerland in 1805. In the 1 st decade of the 20th century, meningococcal meningitis was associated with a mortality rate of 75 to 80 %.In the 1 st decade of the 20th century, meningococcal meningitis was associated with a mortality rate of 75 to 80 %.

5 Introduction In History: In History: In the 1920s, at Boston Children's Hospital 77 of 78 children who had Haemophilus influenzae M. died and all patients (300) with pneumococcal M. died.In the 1920s, at Boston Children's Hospital 77 of 78 children who had Haemophilus influenzae M. died and all patients (300) with pneumococcal M. died. In the past 15 years, mortality rates for:In the past 15 years, mortality rates for: meningococcal meningitis 10 % meningococcal meningitis 10 % H. influenzae meningitis 5 % H. influenzae meningitis 5 % Pneumococcal meningitis 20 % Pneumococcal meningitis 20 %

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7 Classification Infectious Infectious BacterialBacterial ViralViral FungalFungal Non-infectious Non-infectious Drug-InducedDrug-Induced AutoimmuneAutoimmune NeoplasticNeoplastic

8 Bacterial meningitis in Canada (1994-2001). Deeks SL. Canadian Communicable Disease Report. Dec 2005.

9 Bacterial meningitis in Saudi Arabia: the impact of Haemophilus influenzae type b vaccination. Almuneef M, Alshaalan M, Memish Z, Alalola S. J Chemother. 2001 Apr;13 Suppl 1:34-9

10 Viral Meningitis

11 Clinical Features (Can you exclude meningitis without an LP? )

12 Clinical Features: Symptoms

13 Clinical Features: Signs Signs of shock: ↓ BP, tachycardia, poor capillary refill, oliguria. Signs of shock: ↓ BP, tachycardia, poor capillary refill, oliguria. Altered mental status, from irritability to somnolence, delirium, and coma. Altered mental status, from irritability to somnolence, delirium, and coma. Meningeal signs: Meningeal signs: Photophobia.Photophobia. neck stiffness.neck stiffness. positive Kernig’s or Brudzinski’s signs (sensitivity & specificity are uncertain).positive Kernig’s or Brudzinski’s signs (sensitivity & specificity are uncertain).

14 Clinical Features: Signs

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16 Signs of ↑ ICP: papilloedema, anisocoria, ptosis, 6 th nerve palsy, bradycardia with HTN. Signs of ↑ ICP: papilloedema, anisocoria, ptosis, 6 th nerve palsy, bradycardia with HTN. Focal neurological signs in up to 15% of patients and are associated with a worse prognosis. Focal neurological signs in up to 15% of patients and are associated with a worse prognosis. Generalized or focal seizures are observed in as many as 33% of patients. Generalized or focal seizures are observed in as many as 33% of patients.

17 Clinical Features: Signs Skin findings: petechial or purpuric rash (meningococcal meningitis). Skin findings: petechial or purpuric rash (meningococcal meningitis). Signs of DIC. Signs of DIC. Extracranial infection (eg, sinusitis, otitis media, mastoiditis, pneumonia, infective endocarditis) may be noted. Extracranial infection (eg, sinusitis, otitis media, mastoiditis, pneumonia, infective endocarditis) may be noted.

18 Meningococcal Meningitis

19 Clinical Features: Signs In 1909 In 1909 Brudzinski reported that, for patients with bacterial or tuberculous meningitis: Kernig’s sign was 57% sensitive. Brudzinski’s sign was 96% sensitive. Verghese A, Gallenmore G. Kernig’s and Brudzinski’s signs revisited. Rev Infect Dis 1987; 9:1187–92.

20 “The diagnostic accuracy of Kernig's sign, Brudzinski's sign, and nuchal rigidity in ADULTS with suspected meningitis” Clin Infect Dis 35 (1): 46-52 Thomas K, Hasbun R, Jekel J, Quagliarello V (2002). the sensitivity of both Kernig’s sign and Brudzinski’s sign is 5% the specificity of both signs is 95% Nuchal rigidity had a sensitivity of 30% & specificity of 68%

21 The Rational Clinical Examination Does this adult patient have acute meninigitis? Attia J. JAMA. 281:2. 175 (1999).

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23 Clinical history has low accuracy in the Dx of Meningitis. Clinical history has low accuracy in the Dx of Meningitis. The absence of fever, neck stiffness AND altered mental status effectively eliminates meningitis from the differential diagnosis (Sensitivity of at least 1 finding is 99-100%) The absence of fever, neck stiffness AND altered mental status effectively eliminates meningitis from the differential diagnosis (Sensitivity of at least 1 finding is 99-100%) The presence of jolt accentuation in a patient with fever and headache is 100% sensitive and 54% specific for meningitis. The presence of jolt accentuation in a patient with fever and headache is 100% sensitive and 54% specific for meningitis.

24 Investigations

25 Investigations Complete blood count (CBC) with differential Complete blood count (CBC) with differential Coagulation profile (DIC) Coagulation profile (DIC) Serum glucose (to compare) Serum glucose (to compare) Erythrocyte sedimentation rate (ESR) Erythrocyte sedimentation rate (ESR) U/E (SIADH) and LFT U/E (SIADH) and LFT Cultures of blood, nasopharynx, respiratory secretions, urine, and skin lesions. Cultures of blood, nasopharynx, respiratory secretions, urine, and skin lesions. Bacterial antigen studies can be performed on urine and serum (mostly useful in cases of pretreated meningitis) Bacterial antigen studies can be performed on urine and serum (mostly useful in cases of pretreated meningitis)

26 Lumbar Puncture Do you need CT before LP??

27 When do you need CT before LP? CT : CT : Useful for identifying other lesions (abscesses, ICH, neoplasms).Useful for identifying other lesions (abscesses, ICH, neoplasms). May delay time to antibiotics (So, you have to start empirical Abx before CT)May delay time to antibiotics (So, you have to start empirical Abx before CT) Harmful Effects of radiation on the developing brain.Harmful Effects of radiation on the developing brain.

28 When do you need CT before LP? Computed tomography of the head before lumbar puncture in adults with suspected meningitis Hasbun J. N Engl J Med. 345:24. Dec. 2001. 1727-1733

29 When do you need CT before LP? The clinical features that were associated with an abnormal finding on CT of the head were: The clinical features that were associated with an abnormal finding on CT of the head were: Patients who are older than 60 years.Patients who are older than 60 years. Patients who are immunocompromised.Patients who are immunocompromised. Patients with known CNS lesions.Patients with known CNS lesions. Patients who have had a seizure within 1 week of presentation.Patients who have had a seizure within 1 week of presentation. Patients with abnormal level of consciousness.Patients with abnormal level of consciousness. Patients with focal findings on neurological examination.Patients with focal findings on neurological examination.

30 Contraindications to Lumbar Puncture ?

31 Absolute Contraindications to LP: Unequal pressures between the supratentorial and infratentorial compartments, inferred by characteristic findings on brain CT scan*: Unequal pressures between the supratentorial and infratentorial compartments, inferred by characteristic findings on brain CT scan*: Midline shiftMidline shift Loss of suprachiasmatic and basilar cisternsLoss of suprachiasmatic and basilar cisterns Posterior fossa massPosterior fossa mass Loss of the superior cerebellar cisternLoss of the superior cerebellar cistern Loss of the quadrigeminal plate cisternLoss of the quadrigeminal plate cistern Infected skin over the needle entry site. Infected skin over the needle entry site. * Contraindications to lumbar puncture as defined by computed cranial tomography. J Neurol Neurosurg Psychiatry. 1987 Aug;50(8):1071-4. Gower DJ, Baker AL, Bell WO, Ball MR.

32 Relative contraindications to LP: Cardiopulmonary instability. Cardiopulmonary instability. Coagulopathy. Coagulopathy. Signs of ↑ ICP. Signs of ↑ ICP. Focal neurological signs. Focal neurological signs.

33 Investigations CSF studies: CSF studies: Protein and glucose levelsProtein and glucose levels Cell count and differentialCell count and differential Gram stain and C/SGram stain and C/S Latex antigen test of CSF for Haemophilus influenzae, Streptococcus pneumoniae, Neisseria meningitidis.Latex antigen test of CSF for Haemophilus influenzae, Streptococcus pneumoniae, Neisseria meningitidis. Viral titers or cultures.Viral titers or cultures. PCR; increasingly useful in CNS viral infectionsPCR; increasingly useful in CNS viral infections ZN stain for AFB, TB culture & PCR.ZN stain for AFB, TB culture & PCR. India ink stain, cryptococcal antigen & fungal culture.India ink stain, cryptococcal antigen & fungal culture.

34 CSF Findings NormalBacterialViralTB WBC <4 / <4 /μL 60-70% Lymph 30-40% mono 1-3% PMNs 100 - 60,000 / 100 - 60,000 /μL PMNs predominate 20 – 1000 / 20 – 1000 /μL PMNs predominate early*, Lymphoctes later 10 – 500 / 10 – 500 / μL PMNs early, Lymphocytes and Mono later Protein 20 – 45 mg/dl 80 – 500 mg/dl 20 – 100 mg/dl 100- 500 mg/dl Glucose ≥ 50 mg/dl or 75% of blood glucose < 40 mg/dl or ↓ ↓ ratio Normal but may be depressed < 50 mg/dl, decreases with time Other Gram Stain Antigen testing CulturePCR Viral culture AFBCulture Cerebrospinal Fluid Findings in Aseptic Versus Bacterial Meningitis Barbara Negrini, Kelly J. Kelleher and Ellen R. Wald Pediatrics 2000;105;316-319

35 Bacterial Meningitis Scores ??

36 Performance of a predictive rule to distinguish bacterial and viral meningitis J Infect. 2007 Apr ;54(4):328-36. Epub 2006 Aug 2 Chavanet P, et al. The aim of this study was to establish a simple scoring tool and compare it to other available decision making systems. Main categories for bacterial etiology were, Leucocytosis >15 giga, CSF leucocytes count >1700 per ml, CSF neutrophil percentage >80, CSF protein >2.3 g/l Glucose CSF/blood ratio <0.33

37 Meningitest Meningitest Value of ≥ 6 → BM in Adults Value of ≥ 2 → BM in Children

38 Performance of a predictive rule to distinguish bacterial and viral meningitis

39 Clinical prediction rule for identifying children with cerebrospinal fluid pleocytosis at very low risk of bacterial meningitis. JAMA. 2007 Jan 3;297(1):52-60. Nigrovic LE, et al Clinical prediction rule for identifying children with cerebrospinal fluid pleocytosis at very low risk of bacterial meningitis. JAMA. 2007 Jan 3;297(1):52-60. Nigrovic LE, et al Bacterial Meningitis Score (BMS)*: Bacterial Meningitis Score (BMS)*: positive CSF Gram stain CSF absolute neutrophil count (ANC) of at least 1000 cells/μL CSF protein of at least 80 mg/dL peripheral blood ANC of at least 10 000 cells/μL history of seizure before or at the time of presentation * Patients are classified as very low risk if none of these variables are present.

40 Of the 1714 patients categorized as very low risk for bacterial meningitis by the BMS, only 2 had bacterial meningitis (sensitivity, 98.3%). Of the 1714 patients categorized as very low risk for bacterial meningitis by the BMS, only 2 had bacterial meningitis (sensitivity, 98.3%) and both were younger than 2 months old. in predicting BM. Those with at least 1 risk factor (BMS ≥ 1)had a sensitivity of 100%, specificity of 61.5% in predicting BM.

41 Treatment

42 IDSA GUIDELINES 2004 Practice Guidelines for the Management of Bacterial Meningitis

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45 What about steroids ?

46 Treatment Corticosteroids: Corticosteroids: Antibiotics used in the treatment of meningitis are bactericidal.Antibiotics used in the treatment of meningitis are bactericidal. Lysis of bacteria results in release of toxins which trigger an inflammatory response.Lysis of bacteria results in release of toxins which trigger an inflammatory response. Anti-inflammatories could reduce this response, resulting in less meningeal inflammation.Anti-inflammatories could reduce this response, resulting in less meningeal inflammation.

47 Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD004405 van de Beek D, de Gans J, McIntyre P, Prasad K. corticosteroids significantly reduced rates of mortality, severe hearing loss and neurological sequelae. corticosteroids significantly reduced rates of mortality, severe hearing loss and neurological sequelae.. In adults with community acquired bacterial meningitis, corticosteroid therapy should be administered in conjunction with the 1 st antibiotic dose.

48 Treatment Isolation: Isolation: generally isolate cases of bacterial meningitis for up to 24 hours of appropriate antibiotics.generally isolate cases of bacterial meningitis for up to 24 hours of appropriate antibiotics. All patients with meningitis should be reported to the health authority.All patients with meningitis should be reported to the health authority.

49 Treatment ChemoProphylaxis for N. Meningitidis: ChemoProphylaxis for N. Meningitidis: Indicated for those at increased risk;Indicated for those at increased risk; Such as those who were in close contact with patient for at least 4 hours during the week before onset (e.g., house mates, daycare center)Such as those who were in close contact with patient for at least 4 hours during the week before onset (e.g., house mates, daycare center) Or were exposed to patient's nasopharyngeal secretions (e.g., kissing, mouth-to-mouth resuscitation, intubation, nasotracheal suctioning).Or were exposed to patient's nasopharyngeal secretions (e.g., kissing, mouth-to-mouth resuscitation, intubation, nasotracheal suctioning).

50 Treatment Rifampin: Rifampin: pediatric dose:pediatric dose: children <1 mo - 5 mg/kg q12h for 4 doseschildren <1 mo - 5 mg/kg q12h for 4 doses children >1 mo - 10 mg/kg q12h for 4 doseschildren >1 mo - 10 mg/kg q12h for 4 doses adult dose: 600 mg PO bid for 4 dosesadult dose: 600 mg PO bid for 4 doses Alternative: Alternative: Ciprofloxacin (adults) 500 mg PO single dose orCiprofloxacin (adults) 500 mg PO single dose or If pregnant, Ceftriaxone (250 mg) IM single dose.If pregnant, Ceftriaxone (250 mg) IM single dose.

51 Treatment ChemoProphylaxis for HiB: ChemoProphylaxis for HiB: If any of the contacts is < 4 y/o and not immunized for HiB, give prophylaxis to ALL contacts.If any of the contacts is < 4 y/o and not immunized for HiB, give prophylaxis to ALL contacts. Rifampin:Rifampin: pediatric dose: 10 mg/kg PO q12h x 4 doses pediatric dose: 10 mg/kg PO q12h x 4 doses adult dose: 600 mg PO q12h x 4 doses adult dose: 600 mg PO q12h x 4 doses

52 Treatment Aseptic Meningitis: Aseptic Meningitis: Usually a benign, self-limited disease.Usually a benign, self-limited disease. For most aseptic meningitis (Enterovirus), treatment is primarily supportive.For most aseptic meningitis (Enterovirus), treatment is primarily supportive. If HSV infection is a possibility, acyclovir should be added to the treatment regimen.If HSV infection is a possibility, acyclovir should be added to the treatment regimen. Headache can be treated with NSAIDs or mild narcotics.Headache can be treated with NSAIDs or mild narcotics.

53 Complications Acute complications: Acute complications: Seizures (30%).Seizures (30%). Syndrome of inappropriate antidiuretic hormone (SIADH) secretion.Syndrome of inappropriate antidiuretic hormone (SIADH) secretion. Hemodynamic instability.Hemodynamic instability. Subdural effusions.Subdural effusions. Hydrocephalus.Hydrocephalus. Focal neurologic deficits (10-15% of patients).Focal neurologic deficits (10-15% of patients).

54 Complications Chronic complications: Chronic complications: Deafness (20-30% of affected children with HiB ).Deafness (20-30% of affected children with HiB ). Seizure disorders.Seizure disorders. Motor deficits.Motor deficits. Language deficits.Language deficits. Behavior disorders.Behavior disorders. Mental retardation.Mental retardation.

55 Summary

56 Provided by: Emergency diagnosis and treatment of adult meningitis. Michael T Fitch, Van de Beek. Lancet Infect Dis 2007 March; 7: 191–200 Algorithm for the management of patients with suspected community- acquired bacterial meningitis

57 Thank You


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