3 What are the symptoms? Stiff neck Photophobia Ache Vomiting IrritabilityAltered level of consciousnessPoor feedingRash: purpuric and non blanching (late sign)
4 Arachnoid granulations SIDE NOTE….Arachnoid granulationsSuperior sagittal sinusCSF in subarachnoid spacePia materMeningitis and subarachnoid haemorrhage can block villi causing increased ICPFalx cerebriOne-way flow of CSF
5 What are the brain changes? Leptomeningeal enhancement (the arachnoid and pia matter) and distension of the subarachnoid space.What imaging is best for viewing these changes?FLAIR (Fluid Attenuated Inversion Recovery) analysis.Leptomeninges = pia and arachnoid mater.Fluids e.g. CSF are nullified from the image - thus making is particularly good for viewing periventricular lesions such as gliosis and leptomeningeal scarring also deep cortical lesions, MS and tumours
6 Causative organisms?Group B strep,E. coli,Listeria monocytogenesNeisseria meningitidisStrep. pneumoniaemumpsenteroviruslisteria monocytogenesherpes simplexVaricella zosterListeria is most common in those who are immunocompromised and aged over 50.NM aka nisseria meningitidis aka meningococcus is the most severe!If someone is immunocompromised (e.g. HIV), what is the likely causative pathogen?Listeria monocytogenes
7 Differential diagnosis? Subarachnoid haemorrhageStiff neckHeadache – severe/suddenVomitingPhotophobiaBlurred visionHypoglycaemiaAltered mental stateTB (esp CNS TB)History of TB contactResident in endemic areaSigns of pulmonary diseaseEncephalitisAbnormal cerebral function such as altered behaviourFeverBrain tumourMeningitis:FeverGradual headacheSAH has a severe sudden headache whereas meningitis is often gradual.
8 What signs can be elicited in someone with meningitis? Brudzinski’s sign Lift head whilst supine;Positive test if the patient flexes kneesKernig’s sign Flex hip to 90 degreesExtend kneePositive test if the patient experiences back pain
9 What investigations should be carried out? CTWhen and why do you do this before a lumbar puncture?Lumbar puncture CSF analysisIf unable to do LP do blood culturesPCR CSF or cultures for exact causeFBCU+EsConsider CT when there is evidence of raised ICP to prevent coningLumbar puncture is diagnostic in most cases. However, if AB have been given before lumbar puncture takes place, they can give false negative readings. So be wary of giving the all clear!Also note that there are contraindications of lumbar puncture….focal neurological signs, cradioresp distress, signs ogf RICP, coagulopathy, thrombocytopaenia, local infection at site of LP.
10 Lumbar Puncture What layer does the adult spinal cord terminate? What layer does the subarachnoid space end?What layers does a needle move through in a LP?L1S1-S2SkinSubcutaneous fatSupraspinous ligamentInterspinous ligamentLigamentum Flavum (Pop!)Dura (Pop!)
11 What changes in the CSF in meningitis? ConditionAppearanceCytology (mm3)Type of CellGlucose (mmol/L)Protein(g/L)NormalGin clear<5No majorityBacterial MeningitisTurbid>1000Mostly NeutrophilsLowHighViral MeningitisClearMostly LymphocytesGlucose, white blood cells and protein.Bacteria: low glucose, high PMN and high protein. BACTERIA EAT UP ALL THE GLUCOSEViral: normal glucose, high lymphocytes and normal protein
12 What is xanthochromia in the CSF? What could its presence indicate? When RBC have been in the CSF for > 6 hours they take on a yellowish tint.Presence may indicate a recent subarachnoid haemorrhage.
13 What is the treatment for meningitis? Use a broad spectrum AB until the causative agent is determined…..If immunocompromised/ pregnant/ over 55 years then also give high dose of….Ceftriaxone (a cephlosporin)Amoxicillin IVBroad spectrum means that it acts against both gram negative and gram positive bacteria.
14 What are the complications of meningitis? Immediate complications: septic shock, seizuresHearing losschildren should have hearing tests after meningitisMemory problemsGait problemsKidney failureSeptecaemia can damags multiple organs such as the kidney
15 What is the prevention for meningitis? Meningitis vaccine: this vaccine prevents against meningitis caused by the A, C, X, Y and Z variants of the Neisseria Meningitis bacterium.There is no protection against the B strain.
16 Question time….Which of the following does not commonly cause meningitis?Strep pneumoniaeClostridium tetaniListeria monocytogenesNeisseria meningitidisHaem influenzaeWhat is the current first choice antibiotic for bacterial meningitis?CephalosporinPenicillinVancomycinErythromycinAmpicillinClostridium tetaniCephalosporin
17 Diagnosis of bacterial meningitis requires a sample of… Vaccination is recommended to prevent epidemic meningitis among college students resulting from infection with…Clostridium tetaniHaemopilus influenzaeStrep pneumoniaeNeisseria meningitidisListeria monocytogenesDiagnosis of bacterial meningitis requires a sample of…BrainSputumCSFUrineBloodNeisseria meningitidisCSF
18 How far in from the skin does a needle need to move in order to reach the epidural space 2.5cm4-3.5cm4-4.5cm4-5.5cmcm
19 Short Answers Questions Meningitis can present with symptoms of shock. What is the definition of septic shock? Defined by sepsis, hypotension of SBS under 90mmHg (despite fluid resus) and perfusion abnormalities How do you diagnose systemic inflammatory response syndrome? >1 of: Temperature less than 36 or greater than 38 Heart rate over 90/minute RR over 20/minute WWC under 4 or over 12x109/dl
20 What is the treatment of severe sepsis? Give high flow 02Give empirical IV antibioticsGive IV fluid resusitationTake blood culturesTake (measure) FBC and serum lactateStart to Take accurate urine output measurments