1. Meningitis
Karina and Allison

2. Name the meninges:

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

4. 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

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 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

7. 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.

8. 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

9. 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.

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

11. 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
Bacterial Meningitis
Turbid
>1000
Mostly Neutrophils
Low
High
Viral Meningitis
Clear
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

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

14. 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

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 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

17. 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

18. 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 cm

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 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