1. Meningitis: The Basics Steven M. Snodgrass M.D.

2. What is meningitis ? Inflammation of the meninges/leptomeninges – the pia, arachnoid, and dura mater. Inflammation of the meninges/leptomeninges – the pia, arachnoid, and dura mater. Can have various causes – bacteria, viruses, fungus. Can have various causes – bacteria, viruses, fungus.

3. How it happens NP colonization of susceptible individual and invasion of respiratory tract NP colonization of susceptible individual and invasion of respiratory tract Invasion of bloodstream (Bacteremia) Invasion of bloodstream (Bacteremia) Choroid plexitis Choroid plexitis Spread to meninges Spread to meninges Ventriculitis and increased intracranial pressure Ventriculitis and increased intracranial pressure Recruitment of inflammatory mediators Recruitment of inflammatory mediators

4. How it happens Damage to blood-brain barrier leads to cerebral edema Damage to blood-brain barrier leads to cerebral edema Endothelial cell damage, thrombosis Endothelial cell damage, thrombosis Increase in CSF protein, decrease in glucose from hypoxia, decreased aerobic metabolism Increase in CSF protein, decrease in glucose from hypoxia, decreased aerobic metabolism Infarction, Seizures, Abscess formation Infarction, Seizures, Abscess formation

5. Typical presentations You are seeing a 14 day old infant in the emergency room with a 2 day history of congestion. Parents note infant to be increasingly irritable and lethargic, sleeping through feeds, multiple episodes of vomiting, difficult to console. Fever of 103 rectal. Infant looks pale and feels cool with HR of 225. A spinal tap shows 5000 white blood cells and a gram stain reveals gram negative rods. You are seeing a 14 day old infant in the emergency room with a 2 day history of congestion. Parents note infant to be increasingly irritable and lethargic, sleeping through feeds, multiple episodes of vomiting, difficult to console. Fever of 103 rectal. Infant looks pale and feels cool with HR of 225. A spinal tap shows 5000 white blood cells and a gram stain reveals gram negative rods.

6. Typical presentations You are seeing a 15 yo high school student in your office with a 24 hour history of lethargy, repeated vomiting, and fever to 102. On exam he is unable to touch his chin to his chest and resists full extension of his knee while lying flat. You are seeing a 15 yo high school student in your office with a 24 hour history of lethargy, repeated vomiting, and fever to 102. On exam he is unable to touch his chin to his chest and resists full extension of his knee while lying flat.

7. Pathogens of Bacterial Meningitis Neonates (<1mo) : Neonates (<1mo) : –Group B streptococcus, E. coli, Listeria Infants (1-24 mos): Infants (1-24 mos): –Haemophilus influenzae type B, Streptococcus pneumoniae, Neisseria meningitidis Children (>2yo): Children (>2yo): –Neisseria (meningococcus), Strep pneumo (pneumococcus), H. flu

9. Meningococcemia

10. Gram negative diplococci

13. Diagnosis Must maintain a high index of suspicion in many cases Must maintain a high index of suspicion in many cases Gold standard is positive culture in CSF, may have CSF positive gram stain Gold standard is positive culture in CSF, may have CSF positive gram stain Lumbar puncture and CSF also show pleocytosis, increased protein, and hypoglycorrhea Lumbar puncture and CSF also show pleocytosis, increased protein, and hypoglycorrhea

14. CSF findings ComponentNormalBacterialmeningitisViralmeningitisHerpeticencephalitisSpirochetalencephalitis Glucosemg/dL40-80<30>30>3040-110 Proteinmg/dL20-50>10050-100>7515-150 WBCs0-6>1000100-50010-100020-500 Neutrophils0 >50 % <20 % <50 % <10 % RBCs0-20-100-2100-5000-2

15. How much does it happen 1 Pittsburgh similar to US in general Pittsburgh similar to US in general –For 5-17 yo in 2006: –Neisseria 0.4-0.5 cases per 100,000 with 50% meningitis and 8% mortality –Pneumococcus 3.3 cases per 100,000 with 6% meningitis and 2.5 % mortality –237 total cases of pneumococcal meningitis –68 total cases of meningococcal meningitis 1. http://www.cdc.gov/ncidod/dbmd/abcs/survreports.htm

16. We’re lucky 1.1 cases per 100,000 in US in 2004 as compared to: 1.1 cases per 100,000 in US in 2004 as compared to: Cases per 100,000: Cases per 100,000: –Pakistan 4.4 –Haiti 6.1 –Iraq 5.9 –China 7.7 –India 53.5

17. Treatment Antibiotics – Penicillins, Vancomycin, Cephalosporins Antibiotics – Penicillins, Vancomycin, Cephalosporins ? Steroids - Dexamethasone ? Steroids - Dexamethasone Treat underlying hemodynamic compromise (shock) and other complications Treat underlying hemodynamic compromise (shock) and other complications Monitor for and treat sequelae Monitor for and treat sequelae

18. Complications and Sequelae Complications: Complications: Shock/Sepsis Shock/Sepsis Cerebral edema Cerebral edema Subdural empyema Subdural empyema Subdural effusion Subdural effusion Ventriculitis Ventriculitis Abscess Abscess Seizures Seizures Sequelae: Sequelae: Deafness Deafness Developmental delay, cognitive impairments Developmental delay, cognitive impairments Chronic seizure disorder Chronic seizure disorder Hydrocephalus Hydrocephalus

22. Vaccines… Menactra Menactra –Protects against four most common serogroups of Neisseria A, C, Y and W-135 –Most cases in infants due to serogroup B –Adolescents and adults aged 11-55 yo –Give at entry to H.S., college dorm residents, other at risk groups –Conjugate vaccine as compared to MPSV

23. Prophylaxis Most often for meningococcal meningitis and Haemophilus influenzae Most often for meningococcal meningitis and Haemophilus influenzae Close contacts Close contacts Rifampin or Ciprofloxacin Rifampin or Ciprofloxacin

24. Steve Snodgrass Steve Snodgrass Children’s Hospital of Pittsburgh of UPMC Children’s Hospital of Pittsburgh of UPMC Steven.Snodgrass@chp.edu Steven.Snodgrass@chp.edu Steven.Snodgrass@chp.edu Please e-mail with questions or comments Please e-mail with questions or comments