1. Sarah Guillard Nurs 870 Pennsylvania State University
Meningitis
Sarah Guillard
Nurs 870 Pennsylvania State University

2. Definition
Meningitis is an inflammation of the brain or spinal cord. It can be bacterial, viral, fungal, parasitic or due to toxins. It can also be idiopathic. (
reference_image/6878/large/Meningitis.jpeg? ).
(McCance, Huether, Brashers, & Rote, 2014).

3. Pathophysiology
Bacterial meningitis occurs at a rate of about 1.2 million cases per year nationwide
Affects the pia mater, arachnoid villi, the subarachnoid space, the ventricular system and CSF.
The most common bacteria types are neisseria meningitides and streptococcus pneumoniae.
Secondary to systemic or localized infection
Bacteria enters the CNS through the choroid plexus or another area with altered blood/brain barrier permeability.
Bacteria reproduces in the subarachnoid space and inflames the meninges which increases their permeability. Neutrophils enter the subarachnoid space and produce exudate which interferes with the normal CSF flow, causing further inflammation.
The meninges becomes edematous further increasing ICP. Inflammation of the blood vessels causes them to be engorged, disrupting blood flow, and possibly leading to thrombosis
(McCance, Huether, Brashers, & Rote, 2014); (Tunkel, 2015).

4. Pathophysiology
Aseptic meningitis covers all other meningitis that does not have a positive routine bacterial culture after lumbar puncture including viral, fungal, and tubercular infections.
(Johnson, 2012).

5. Pathophysiology Viral Meningitis Generally limited to the meninges.
The most common cause is enterovirus such as coxsackievirus, non-polio enterovirus or echovirus.
Other common viruses involved are nonparalytic poliomyelitis, arbovirus, and herpes simplex 2.
Viral meningitis is blood borne and enters the brain either directly or indirectly through infected migrating leukocytes which then infect the vascular endothelial cells.
The blood-brain barrier becomes permeable as inflammatory cytokines are released in response
(Johnson, 2012); (McCance, Huether, Brashers, & Rote, 2014).

6. Pathophysiology Other Types of Meningitis:
Fungal - usually immunocompromised person such as an HIV patient. More insidious development over days to weeks. Most common source is cryptococcus. A granuloma or gelatinous mass is formed in the meninges with resulting fibrosis and often cranial nerve dysfunction due to compression.
Tubercular – also found in immunocompromised patients. A tuberculin nodule forms that erodes the pia mater allowing mycobacteria to enter the CSF and inflaming the meninges, cerebrum and spinal nerves.
Spirochetes - Lyme disease and syphilis. Other tick borne illnesses such as Rocky Mountain spotted fever and erlichosis can also be considered as differentials in aseptic meningitis.
Drugs can also induce aseptic meningitis such as NSAIDs, immunoglobulins, rofecoxib, antiepileptic drugs, and OKT3 antibodies.
(McCance, Huether, Brashers, & Rote, 2014) (Johnson, 2012).

7. History Common symptoms for bacterial meningitis
Classic triad – mental status change, fever, nuchal rigidity
Headache
Hypothermia
Seizure
photobobia
(Tunkel, 2015)

8. History Common symptoms for viral meningitis Nausea Vomiting Fever
Headache
Nuchal rigidity
(Johnson, 2012)

9. History
Those with acute meningitis generally seek help within around 24 hours.
Subacute bacterial and viral meningitis occur over 1-7 days, while fungal and tubercular meningitis may have a more chronic presentation over more than 7 days.
Acute HIV meningitis may present similarly to mononucleosis with sore throat, lymphadenopathy, fever, rash, and malaise. Be sure to screen for HIV risk factors when these symptoms are present with symptoms of meningitis such as seizure, confusion, headache, or cranial nerve palsies.
(Hasbun, R. 2016); (Tunkel, 2015).

10. History
Besides screening for the common symptoms listed above, other patient history questions to ask include:
Travel to area of the world where meningococcal meningitis is endemic
Living situation
Recent antibiotic use or drug allergies
Recent IV drug use
Exposure to other sick persons
Recent infections or illness
Recent rash, petechiae, or ecchymosis
Recent or remote head trauma
Otorrhea or rhinorrhea
Any immunocompromising conditions (Johnson, 2012)

11. Physical Assessment
General: Bacterial meningitis patients appear very ill, and bacterial or aseptic meningitis may cause lethargy.
HEENT: Perform optholmoscopic exam to assess for papilledema. Perform otoscopic and upper respiratory system exam as bacterial meningitis may be secondary to another infection such as sinusitis or otitis media). Viral meningitis may present with upper respiratory symptoms. Hearing loss is a late complication of bacterial meningitis. Assess for enlarged lymph nodes that may indicate acute HIV infection.
Skin: 11-25% of patients with bacterial meningitis will have a rash, palpable purpura or petechiae and it is more common with meningococcal meningitis.
Chest/Lungs: Bacterial or viral meningitis may be secondary infections. Primary infection may originate in the lungs so they should be assessed for signs of bacterial pneumonia or viral infection.
GI: Assess for nausea and or vomiting which is common especially with viral meningitis
GU: 85% of patients with HSV-2 meningitis will have genital lesions that precede it by about seven days.
Musculoskeletal: Assess for stiffness or pain in the joints as many patients with bacterial meningitis will have arthritis. The Brudzinski and Kernig maneuvers and assessment of nuchal rigidity were not shown to be particularly useful for identification of bacterial meningitis in a prospective study of 297 adults. Brudzinski’s and Kernig’s signs were shown to have a 5% sensitivity and nuchal rigidity had a 30% sensitivity.
Neurological: Assess for photophobia, a common symptom in both aseptic and bacterial meningitis. Assess for focal neurologic deficits and cranial nerve palsies which may occur early or late in the infection for bacterial meningitis. Assess for change in mental status such as lethargy or confusion
(Johnson, 2012); (Thomas, Hasbun, Jekel, & Quagliarello, 2002); (Tunkel, 2015).

12. Labs and Diagnostics Immediate blood cultures and lumbar puncture
Normal CSF values are less than 50 mg/dL of protein, a CSF-to-serum glucose ratio greater than 0.6, less than 5 white blood cells/microL, and a lactate concentration less than 3.5 mEq/L”
If there are no signs of bacterial infection, lumbar puncture should be repeated hours later and possibly screened with PCR for enterovirus. Seventy five percent of patients who are negative for bacterial meningitis will have a positive PCR for enterovirus
CBC - For bacterial meningitis, the white count may be elevated with a left shift. Leukopenia and thrombocytopenia may be present and are indicators of poorer prognosis.
BNP
Coagulation studies may be consistent with DIC
Procalcitonin and serum lactate will help to rule out sepsis.
(Tunkel, 2015); (Johnson, 2012)

13. Differentials Bacterial vs. Aseptic Meningitis
Viral gastroenteritis or other acute viral infection
Red Flags:
Sepsis
Neoplasm
Bacterial meningitis
(Wong &Wu, 2016); (Neviere, R, 2016); (Tunkel, 2015).

14. Treatment

15. Treatment
Adults younger than 50 - vancomycin mg/kg IV q12h and a third generation cephalosporin such as cefotaxime or ceftriaxone IV 2g q6h and 2g q12h respectively, as the most common infectious agents are N. meningitides and S. pneumoniae.
Over 50 years old - ampicillin 2g IV q12h should be added as well to cover L. monocytogenes and aerobic gram-negative bacilli.
The gram stain results may require revising the antibiotic therapy to target the infecting microbe.
Antibiotic therapy lasts for 7-21 days depending on the bacteria involved.
All adult patients with suspected or confirmed pneumococcal meningitis should also receive dexamethasone 0.15 mg/kg IV q6h for 2-4 days to mitigate the inflammatory process.
(Tunkel, 2015)

16. Treatment
Treatment for viral meningitis is supportive with most cases resolving in 7-10 days.
HSV meningitis has no consensus treatment but the recommendation is to treat it with acyclovir 10mg/kg every 8 hours IV and then switched to po, for a total of days, to be taken outpatient
Treatment for tuberculosis meningitis is isoniazid 5 mg/ kg/day, rifampin 10 mg/ kg/day, pyrazinamide 15 to 30 mg/kg/day, and ethambutol 15 to 25/ kg/day.
Cryptococcus, the most common cause of fungal meningitis is treated with amphotericin B IV 0.7 to 1.0 mg/ kg/day plus flucytosine Ancobon 25 mg/kg every six hours orally
(McCance, Huether, Brashers, & Rote, 2014); (Johnson, 2012); (Bamberger, 2010)

17. Patient Teaching
Family and friends in close contact with those diagnosed with bacterial meningitis will need to be treated with antibiotics.
The patient will likely follow with infectious disease after their course in the hospital and may need rehabilitation if they are elderly or had an extended course resulting in deconditioning.
Those with viral meningitis will need teaching on the difference between viral and bacterial meningitis and why it is not treated with antibiotics. Like other viral illness, they should get fluids and rest and return to the primary care office if their symptoms worsen
(UpToDate,2016)

18. Outcomes Mortality due to bacterial meningitis increases with age.
In one study, patients had a case fatality rate of 8.9% while those over 65 had a case fatality rate of 22.7%.
Nosocomial infection has a higher mortality rate than community acquired.
Mortality is highest in those with S. pneumoniae and L. monocytogenes and lowest with N. meningitides.
Twenty eight percent of community acquired bacterial meningitis has neurologic complications. Lasting complications include sensorineural hearing loss, intellectual impairment, residual deficits due to meningitis induced CVA, and hydrocephalus.
Aseptic meningitis has varying outcomes depending on etiology, but generally viral meningitis has good outcomes without residual effects and can often be treated at home after it has been established that it is nonbacterial in origin.
(Tunkel, 2015); (Sexton, 2015); (Johnson, 2012)

19. Questions and Discussion

20. References
Bamberger, D. (2010) Diagnosis, Initial Management and Prevention of Meningitis. American Family Physician. 82(12):
Goroll, A., Mulley, A. (2014). Primary Care Medicine: Office Evaluation And Management Of The Adult Patient (7th ed.). Philadelphia: Wolters Kluwer Health
Hasbun, R. (2016) Meningitis Clinical Presentation. Medscape. Retrieved from:
Hasbun, R., Abrahams, J., Jekel, J., Quagliarello, V. (2001) Computed Tomography Of
The Head Before Lumbar Puncture In Adults With Suspected Meningitis. New England Journal of Medicine. 345(24):
Johnson, R. (2012) Aseptic Meningitis in Adults. UpToDate. Retrieved from: adults?source=search_result&search=meningitis&selectedTitle=6~150
McCance, K., Huether, S., Brashers, V., Rote, N. (2014) Pathophysiology: the Biologic Basis For Disease In Adults and Children (7th ed.). St. Louis, MO: Elsevier Mosby
Neviere, R. (2016). Sepsis Syndromes in Adults: Epidemiology, Definitions, Clinical Presentation, Diagnosis, and Prognosis. UpToDate. Retrieved from: prognosis?source=search_result&search=sepsis&selectedTitle=1~150
Sexton, D. (2015) Neurologic Complications of Bacterial Meningitis. UpToDate. Retrieved from: bacterial-meningitis-in-adults?source=see_link
Thomas, K., Hasbun, R., Jekel, J., Quagliarello, V. (2002). The Diagnostic Accuracy of Kernig's
Sign, Brudzinski's Sign, and Nuchal Rigidity in Adults with Suspected Meningitis. Clinical Infectious Disease. 35(1): 46-52
Tunkel, A. (2015). Clinical Features And Diagnosis Of Acute Bacterial Meningitis In Adults. UpToDate. Retrieved from: features-and-diagnosis-of-acute-bacterial-meningitis-in-adults?source=machineLearning&search=meningitis&selectedTitle=1~150&sectionRank=1&anchor=H3#H3
Tunkel, A., Hartman, B., Kaplan, S., Kaufman, B., Roos, K., Scheld, W., Whitley, R. (2004) Practice Guidelines For The Management Of Bacterial Meningitis. Clinical Infectious Disease. 39(9):
Tunkel, A. (2015) Initial Therapy And Prognosis Of Bacterial Meningitis In Adults. UpToDate. Retrieved from: meningitis-in-adults
UpToDate. (2016) Patient Information: Viral Meningitis (The Basics). Retrieved from:
UpToDate (2016) Patient Information: Bacterial Meningitis (The Basics) Retrieved from: basics?source=search_result&search=patient+teaching+meningitis&selectedTitle=2~150
Wong, E., Wu, J. (2016) Clinical Presentation and Diagnosis of Brain Tumors. UpToDate. Retrieved from: tumors?source=machineLearning&search=brain+neoplasm&selectedTitle=1~150&sectionRank=1&anchor=H2#H2