Meningitis Karina and Allison

Name the meninges:

What are the symptoms? Stiff neck Photophobia Ache Vomiting Irritability Altered level of consciousness Poor feeding Rash: purpuric and non blanching (late sign)

Arachnoid granulations SIDE NOTE…. Arachnoid granulations Superior sagittal sinus CSF in subarachnoid space Pia mater Meningitis and subarachnoid haemorrhage can block villi causing increased ICP Falx cerebri One-way flow of CSF

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

Causative organisms? Group B strep, E. coli, Listeria monocytogenes Neisseria meningitidis Strep. pneumoniae mumps enterovirus listeria monocytogenes herpes simplex Varicella zoster Listeria 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

Differential diagnosis? Subarachnoid haemorrhage Stiff neck Headache – severe/sudden Vomiting Photophobia Blurred vision Hypoglycaemia Altered mental state TB (esp CNS TB) History of TB contact Resident in endemic area Signs of pulmonary disease Encephalitis Abnormal cerebral function such as altered behaviour Fever Brain tumour Meningitis: Fever Gradual headache SAH has a severe sudden headache whereas meningitis is often gradual.

What signs can be elicited in someone with meningitis? Brudzinski’s sign  Lift head whilst supine; Positive test if the patient flexes knees Kernig’s sign  Flex hip to 90 degrees Extend knee Positive test if the patient experiences back pain

What investigations should be carried out? CT When and why do you do this before a lumbar puncture? Lumbar puncture CSF analysis If unable to do LP do blood cultures PCR CSF or cultures for exact cause FBC U+Es Consider CT when there is evidence of raised ICP to prevent coning Lumbar 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.

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? L1 S1-S2 Skin Subcutaneous fat Supraspinous ligament Interspinous ligament Ligamentum Flavum (Pop!) Dura (Pop!)

What changes in the CSF in meningitis? Condition Appearance Cytology (mm3) Type of Cell Glucose (mmol/L) Protein (g/L) Normal Gin clear <5 No majority 2.7-4.4 0.15-0.4 Bacterial Meningitis Turbid >1000 Mostly Neutrophils Low High Viral Meningitis Clear 500-1000 Mostly Lymphocytes Glucose, white blood cells and protein. Bacteria: low glucose, high PMN and high protein. BACTERIA EAT UP ALL THE GLUCOSE Viral: normal glucose, high lymphocytes and normal protein

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.

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 IV Broad spectrum means that it acts against both gram negative and gram positive bacteria.

What are the complications of meningitis? Immediate complications: septic shock, seizures Hearing loss children should have hearing tests after meningitis Memory problems Gait problems Kidney failure Septecaemia can damags multiple organs such as the kidney

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.

Question time…. Which of the following does not commonly cause meningitis? Strep pneumoniae Clostridium tetani Listeria monocytogenes Neisseria meningitidis Haem influenzae What is the current first choice antibiotic for bacterial meningitis? Cephalosporin Penicillin Vancomycin Erythromycin Ampicillin Clostridium tetani Cephalosporin

Diagnosis of bacterial meningitis requires a sample of… Vaccination is recommended to prevent epidemic meningitis among college students resulting from infection with… Clostridium tetani Haemopilus influenzae Strep pneumoniae Neisseria meningitidis Listeria monocytogenes Diagnosis of bacterial meningitis requires a sample of… Brain Sputum CSF Urine Blood Neisseria meningitidis CSF

How far in from the skin does a needle need to move in order to reach the epidural space 2.5cm 4-3.5cm 4-4.5cm 4-5.5cm 4.5-5.5cm

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

What is the treatment of severe sepsis? Give high flow 02 Give empirical IV antibiotics Give IV fluid resusitation Take blood cultures Take (measure) FBC and serum lactate Start to Take accurate urine output measurments