1. Suppurative Meningitis
Yu Dan
Department of Neurology
West China Second University
Hospital

2. conception CNS Pathogen Bacteria Virus Tuberculosis Fungus Parasite
Spirochetal
Pathogen
CNS

3. Suppurative Meningitis
Acute infection of central nervous system(CNS). 90% of cases occur in the age of 1mo-5yr.
The inflammation of meninges caused by various bacteria. Common features in clinical practices include: fever, increased intracranial pressure, meningeal irritation.
 One of the most potentially serious infections, associated with high mortality (about 10%) and morbidity.

4. Suppurative Meningitis
Etiology
Predisposing factors
Pathology
Clinical manifestation
Diagnosis and Differential Diagnosis
Treatment
Complication

5. Suppurative Meningitis
Etiology
Predisposing factors
Pathology
Clinical manifestation
Diagnosis and Differential Diagnosis
Treatment
Complication

6. Acute Suppurative Meningitis
Etiology:
First 2 months of life: Group B Streptococcus, gram negative bacilli, S. pneumoniae, Neisseria meningitides, Haemophilus influenzae type b. and L. monocytogenes.
Children 2 mo-12yr of age 1- S. pneumoniae
2- N. meningitides
Alterations of host defense:
Pseudomonas aeruginosa, Staphylococcus aureus, Salmonella spp., and L. monocytogenes.

7. *There are 3 main bacterial meningeal pathogens:
Haemophilus influenzae
Neisseria meningitides
Streptococcus pneumoniae
*Incidence varies by region and age.

8. Haemophilus influenzae
Small GN, pleomorphic, coccobacilli
H. flu type B causes almost ALL invasive disease
Nontypeable Hib can rarely cause meningitis.
Incidence of Hib decreased by 97% after vaccine

9.  Occurs predominantly in infants 2mo to 2yr of age
 Many cases are in winter
 Higher incidence of subdural effusion

10. Neisseria meningitidis
- GN diplococci
- Serotypes A,B,C,Y, and W135 cause most invasive disease.
- Virulence depends on:
Capsular polysaccharide
LPS(endotoxin)
Pili
IgA protease
ompS gene

11. Occur in epidemics (type A,C), which is more common in spring, or sporadic all the year (type B,C,Y)

12. Meningococcus is the only bacterium that frequently causes a rash, which is probably the most important clue to the diagnosis of meningococcal meningitis. It usually begins as a diffuse erythematous maculopapular rash. As the rash evolves, petechiae and purpura appear primarily on the trunk and lower extremities.

13. Streptococcus pneumoniae
* Small, non-motile GPC in pairs or chains.
* 8 serotypes cause 90% of invasive disease.
1, 4, 6, 9, 14, 18, 19 & 23
* Virulence depends on capsular polysaccharides
* Associated with CSF leak (skull fractures), asplenia, HIV, cochlear implants

14.  Young infants ( <1yr) are most susceptible population
 Peak season: spring and winter
 Easier to have subdural effusion and hydrocephalus
 Easily have a protracted course and relapse

15. Suppurative Meningitis
Etiology
Predisposing factors
Pathology
Clinical manifestation
Diagnosis and Differential Diagnosis
Treatment
Complication

16. Predisposing factors 免疫功能低下 Immature immunologic function
血脑屏障不完善 (BBB)
Immature blood-brain-barrier
脑脊膜膨出、颅脑手术、颅底骨折等
Impaired blood-brain-barrier

17. Route of infection brain Hematogenous dissemination
（上感、皮肤感染、腹泻）
Adjacent tissue infections
(中耳炎、乳突炎、鼻窦炎)
brain
Congenital malformations
(脑脊髓膜膨出、皮毛窦、脑脊液鼻漏)

18. Suppurative Meningitis
Etiology
Predisposing factors
Pathology
Clinical manifestation
Diagnosis and Differential Diagnosis
Treatment
Complication

21. Pathology of suppurative meningitis
Purulent exudate of leptomeningitis inflammation（ inflammation
of pia and arachnoid spaces) over the convexities of the cerebral
cortex. This may result in the additional complications of
arterial or venous thrombosis with infarction and hemorrhage

23. Suppurative Meningitis
Etiology
Predisposing factors
Pathology
Clinical manifestation
Diagnosis and Differential Diagnosis
Treatment
Complication

24. Clinical manifestion

25. The symptoms and signs are not evident in
neonates and infants younger than 3mo of
age; and patients already received irregular
antibiotic therapy.
Sequela 后遗症

26. Nervous system examination
Meningeal irritation
Neck stiffness
Kernig sign
Brudzinski sign

27. Neck stiffness
keep the child with supine position without pillow, flex his head, if resistance exists, it means the test is positive.

28. Kernig sign
keep the child with supine position without pillow, flex the hip and knee joint at 90°C, elevate a leg, if the child raises his head or has painful expression, it indicates the test is positive.

29. Brudzinski sign
keep the child with supine position without pillow, flex the head, if the child flexes his legs involuntary at the same time, it means the test is positive.

30. Suppurative Meningitis
Etiology
Predisposing factors
Pathology
Clinical manifestation
Diagnosis and Differential Diagnosis
Treatment
Complication

31. Diagnosis Step One: Meningitis, Yes or Not？
Step Two: Meningitis, Which type?

32. Attention
Making Diagnosis As Early As Possible
Noticing Atypical Case

33. Lumbar puncture

34. Contraindications of Lumbar puncture
Severe intracranial hypertension
Circulatory failure
Infection of the puncture site
If there is evident hemorrhage tendency

35. Normal CSF appearance

36. Diagnosis is confirmed by analysis of cerebrospinal
fluid ( CSF)
 Suggestion bacterial meningitis
Increased pressure (90%)
Appearance: slightly cloudy to purulent
Raised white blood cells, consisting chiefly of
polymorphonuclear leukocytes
Raised protein concentration, decreased glucose concentration (80%)

37. Cerebrospinal fluid in neurologic infection
Disease
Pressure
(Kpa)
Aspect
Total WBC
(x106/L)
Protein
(g/L)
Glucose
(mmol/L)
Smears
Cultures
normal
( )
clear
0-5
(0-20)
( ) -
Purulent
meningitis 
cloudy 
(PMN)
(1-5) 
(<2.2)
Gram’s stain + +
Tuberculous
Normal or cloudy
(MN) 
AFB stain + 
Viral meningitis/
encephalitis
Normal or 
Normal
(<1)
Fungal meningitis
India ink prep +

38. Other examination CT/MRI Indication ： Signs of abnormal localization
Treatment is not satisfied
Persistent fever
Head circumference increased
Significantly increased of intracranial pressure
EEG
Blood Tests, Blood cultures and Chest X-ray

39. Diagnosis Earlier diagnosis and prompt initiation of effective
antibiotic treatment is critical for minimizing
sequelae of purulent meningitis.
 Suspected cases: febrile infants with seizure, meningeal irritability, increased intracranial pressure, altered mental status
 Pay attention to the atypical symptoms and signs in neonate, infant and patient already received irregular antibiotic therapy

40. Differential Diagnosis
Viral meningitis or encephalitis
Febrile Seizure
Toxic encephalopathy

41. Viral meningitis or encephalitis

42. MRI scans used in the diagnosis of herpes simplex virus (HSV).
MRI typically shows temporal lobe lesions

43. Treatment Generally, management of viral encephalitis is nonspecific.
Mild case : only symptomatic relief,e.g. fever, headache, vomiting.
Severe case: Require hospitalization and intensive care.

44. Diagnosis of viral encephalitis
Diagnosis of VE can be confirmed only by finding virus from the brain specimen, but it is carried out only in dead patients.
Diagnosis of VE is relatively confirmed on the clinical presentations ,epidemiologic data, examination of CSF, findings of EEG, and neuroimaging studies.

45. Febrile Seizure Definition
Febrile Seizures are the seizures with fever occurring in children between 6 months to 6 years of age without evidence of intracranial infection or defined cause

46. Febrile Seizure Associated with a rapidly rising temperature
(usually develop when the temperature reaches 390C or greater )
Occur with the diseases out side the CNS
Age dependent: 6mon-6year
With normal CNS structure and function
No no-febrile seizure history
Genetic predisposition

47. Treatment Routine treatment: Search for the cause of fever
Control fever (avoid excessive clothing, encourage fluids, tepid sponge bath, and antipyretics)
Tepid 微温的

48. What to do in emergency Maintain clear airway
Roll the child on to one side / prone with head lowered
Diazepam mg/kg I.V. Slowly in 2-3 Minutes
May be repeated after 5 Minutes
Rectal Diazepam (0.5 mg /kg)

49. Toxic encephalopathy Seen in severe systemic infection
Can be high fever, delirium, unconsciousness, convulsions and coma
CSF pressure increased while cytological and biochemical tests normal
Bacillary dysentery

50. Suppurative Meningitis
Etiology
Predisposing factors
Pathology
Clinical manifestation
Diagnosis and Differential Diagnosis
Treatment
Complication
stimuli provoke convulsions with opisthotonos

51. Treatment 1- Initial Antibiotic Therapy: Early treatment
Antibiotics susceptible to pathogens and with high permeability through BBB
Given intravenously
Enough dose
Enough course of antibiotic therapy

52. Antibiotic therapy of bacterial meningitis
Etiology
Standard antibiotics of choice
Duration of therapy
H.influenzae
Cefotaxime /Ceftriaxone
7-10days
N.meningitidis
7days
S.pneumoniae
2-3weeks
Staphlococcus aureus
Semisynthetic penicillins (Oxacillin sodium, Cloxacillin sodium),Norvancomycin
>3weeks
E.coli
(or + ampicillin)
> 3weeks
Unknown
Cefotaxime/Ceftriaxone + ampicillin
>2-3weeks

53. 2-Supportive and symptomatic therapy
Good evaluation and monitoring are essential
Correction of dehydration and electrolyte disturbances and proper nutrition
Management of neurological complications

54. 3-Reduce intracranial pressure
Osmotic therapy: intravenous mannitol 0.5-1g/kg/every time, q4-6h
Combination with intravenous dexamethasone: mg/kg/day
Endotracheal intubation and hyperventilation

55. 4-Control seizures
Diazepam:
mg/kg iv (slowly)
mg/kg (Enteroclysis)
Phenobarbital:
Load dosage: 15-20mg/kg IV
Maintenance dosage: 3-5mg/kg.d IV

56.  Ventriculitis : lateral ventricle puncture and
Treatment
5-Others
 Ventriculitis : lateral ventricle puncture and
injection of antibiotics locally
 Epilepsy: AEDs

57. Suppurative Meningitis
Etiology
Predisposing factors
Pathology
Clinical manifestation
Diagnosis and Differential Diagnosis
Treatment
Complication

58. Complication Subdural effusion and empyema Hydrocephalus Brain abscess
Ventriculitis
Deaf and motor disabilities

59. Other Complication Deafness Blindness Epilepsy Paralysis
Mental retardation
Behavioral problems

60. Subdural effusion and empyema

61.  No response to a sensitive antibiotic therapy
Indications:
 No response to a sensitive antibiotic therapy
 Prolonged fever or fever reoccurring after an
afebrile interval with effective treatment
 Bulging fontanel, widening of sutures,
enlarging head circumference, emesis, seizure,
altered consciousness.
 Improved CSF profile with more serious clinical
manifestations

62. .Hydrocephalus
Note the marked dilation of the cerebral ventricles. Hydrocephalus can be due to lack of absorption of CSF or due to an obstruction to flow of CSF.

65. Brain abscess

66. Prognosis
The outcome of suppurative meningitis depends on the following factors:
Natures of bacteria, and severity of the initial disease
Age of the patient
Whether the diagnosis made is earlier or not
Patient’s response to the treatment, and whether the treatment is adequate or not.
Any complications

67. Most patients make a full recovery from meningitis
Most patients make a full recovery from meningitis. A small number of infected people end up with hearing or vision loss or brain damage.
Vaccinations against some forms of meningitis are available. They are recommended for children under age 5, people in close contact with someone who has developed meningitis, college students, and people travelling to certain overseas destinations

68. Suppurative Meningitis
Etiology
Predisposing factors
Pathology
Clinical manifestation
Diagnosis and Differential Diagnosis
Treatment
Complication
Cephalosporin

69. Thanks