Acute meningitis

Introduction

An infection of the meningial covering of the brain & spinal cord, often fatal with significant morbidity &
mortality hence is a medical emergency. Duration of symptoms is usually within hours to days

Biodata
High in developing countries due to:
 Poor hygiene
 Climate (hot, dry and dusty) but decreases with onset before rain

Presenting complain (PC)

 Fever
 Headache
 Neck stiffness
 Can’t open eyes in light (photophobia)
 Vomiting
 Drowsy or Loss of consciousness
(N/B atypical presentation -lethargy with absence of classical presentation- in elderly &
immunocompromised patient)

History of presenting of complaint

Course
? Onset, duration, and course of symptom
? Coma and focal neurological signs (severe bacterial meningitis)
? Purpuric rash and very rapid, abrupt onset of obtundation and circulatory collapse (meningococcal
meningitis with septicemia)
?unwell for weeks or months with recurrent fever, sweating, joint pain and transient rash (chronic
meningococcemia)
Cause
Infections
• Exposure to pt with similar illness- (meningococcal meningitis)
• Hx of URTI, SCD, Splenectomy, Alcoholism--- (S. pneumonia)
• Immunocompromised, Hospital acquired infection, Recent brain surgery or head injury (gram – ve
organism, staph aureus)
• intake of unpasteurized milk, raw vegetables consumption and soft cheese - (L monocytogenes)
• TB meningitis:? Chronic cough, night sweat and fever. Hx of contact with chronically coughing
adult. Hx of immunosuppression.
• ?ear pain/ discharge (R/O otitis media)
• ? Painful parotid swelling (R/o mumps)

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 • Painful rash and ulceration of mouth, hands, feet, buttocks and thighs. (R/o echovirus= hand-foot-
mouth syndrome)
• ? Trauma/ skull fracture, neurosurgical procedure - r/o direct innoculation

Non-infectious
Neoplasm (malignant meningitis) - anorexia, anemia and asthenia
? SLE
Complications
 Shock (oliguria, hyperpyrexia, impaired consciousness, hyperventilation, collapse rapid thread
pulse etc.)
 Coma
 Seizures
 Cerebral abscess
 Decreased hearing or deafness
 DIC (bruising and bleeding)
 Renal failure (oliguria, decrease urine output, hyperkalemia and metabolic acidosis)
 Pericarditis (septic or reactive)
 Septic arthritis
 Peripheral gangrene
Care
Care sought including use of traditional medications, investigations and results, plans and
treatment
Past medical and surgical history
 Diagnosis of the following conditions; pneumonia, TB, otitis media, DM, HIV and cancers
 Previous surgery
Family history and social history
 Socioeconomic status, environmental hygiene, ventilation, alcohol ingestion and cigarette smoking
 Hx of similar illness in the family

Examination
 General
 Temperature
 PR, RR and BP
 Kernig’s sign(extension at the knee with hip joint flexed causes spasm of the hermstrings)
 Brudzinski’s sign(passive flexion of the neck causes flexion of the hips and knees)
 Neck stiffness
 Rashes and Petechial hemorrhages (meningococcal meningitis)
 lymphadenopathy
 CNS
Do a detailed Neurological examination including GCS

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 Investigations
 Full blood count (anemia, leukocytosis raised ESR and low platelets especially in long standing cases)
 Blood culture
 Imaging such as CT and MRI
 Lumbar puncture may show the following depending on the causative agent

Feature Normal parameters Acute bacterial Viral meningitis Tuberculous meningitis

meningitis

1 Color Clear and colourless Cloudy Clear Clear/cloudy

2 Pressure 5-18 mmHg Normal/high Normal Normal/high

3 Red blood cells 0 Normal Normal Normal

4 Leucocytes Total: <10/mm3 Very high(>1000; Slightly high(<1000; High (<1000;relative

relative granulocytosis) relative lymphocytosis)
lymphocytosis)

5 Glucose 2.2-3.9 mmol/L Low(<1/2 of plasma Normal Low(<1/2 of plasma

level) level)

6 Protein 0.15- 0.50 gll Very High(>1.5) Normal/high(<1) Very High(1- 5)

7 Culture Negative Positive for bacteria Negative for bacteria Negative/positive for
MTB

NB:
-CT scan is recommended before a lumbar puncture if there is suspicion for a raised ICP; a concomitant RBS should be
taken right before the LP
-lymphocyte predominance may occur in L. monocytogenes
-Diabetics may have elevated CSF sugar
-Gram stain & culture yield is significantly reduced with prior use of antibiotic
-CSF Ag & Ab assays most helpful in pt with prior antibiotic use
-polymorphonuclear lymphocytosis may be seen in early TB meningitis

Other CSF investigations include;-

o Lactate dehydrogenase
o Lactic acid concentration
o Bacterial antigen assay

Management
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  Admit the patient
 Commence empiric antibiotic within an hour of admission using broad spectrum antibiotics.
 Correct non-neurologic complicationb e.g. dehydration, electrolyte imbalances
 Define treatment with CSF, blood culture and other results.
 Supportive management may include O2, IVF’s, NG tube feeding, urinary catheterisation, strict fluid
balance, anticonvulsants.Patients may require neuro-monitoring and neuro-nursing-GCS, pupillary
size, regular fundoscopy.
 Monitor complication with serial U/E/Cr ( SIADH ) & repeat brain CT when necessary ( eg brain
abscess, cerebral edema, brain herniation)
 In case of suspected tuberculous commence antituberculous drugs - Refer to TB section for more
information.

Prevention
1) General measures: improvement in environmental sanitation, personal hygiene and health
education
2) Chemoprophylaxis: oral rifampin. Others: ciprofloxacin, ceftriaxone or spiromycin to close
contacts of the patients.
3) Vaccination: e.g. with polyvalent vaccine A, C, Y and W135 (Menomune).
Indicated for:
 Structural or functional asplenia
 Age>65
 Travellers to hyper endemic and epidemic areas
 Patients with component compliment deficiency
 Individuals with chronic cardiopulmonary illness