| ID | 390 |
|---|---|
| Name | MENINGITIS |
| Cause | M eningococcal bacteria – there are several different types, called A, B, C, W, X, Y and Z. pneumococcal bacteria. Haemophilus influenzae type b (Hib) bacteria. enteroviruses – viruses that usually only cause a mild stomach infection. the mumps virus. |
| Signs Symptoms | a high temperature (fever) being sick. a headache. a rash that does not fade when a glass is rolled over it (but a rash will not always develop) a stiff neck. a dislike of bright lights. drowsiness or unresponsiveness. seizures (fits) |
| Diagnosis | Diagnosis: A. Clinical history presentations (see c/f) B. Physical examinations (see c/f) C. Laboratory Investigations- 1. CSF (by L.P)- physical, cytological, biochemical & bacteriological tests & culture. 2. Blood count (routine). 3. Blood culture. 4. X-ray skull & chest. 5. Other tests- urine R/E, sputum gram stains & culture. D. Specialized tests for meningitis - 1. Counter current immunoelectrophoresis (CIE). 2. Latex agglutination test. 3. Indirect ELIS A test. 4. C.Tscan/MRI. |
| Investigations | A spinal tap to collect cerebrospinal fluid. In people with meningitis, the fluid often shows a low sugar level along with an increased white blood cell count and increased protein. Analyzing the fluid also may help identify which bacterium caused the meningitis |
| Management | Management: Treatment of bacterial meningitis: Principles: A. Appropriate antimicrobial therapy. B. Symptomatic treatment/treatment of complications. C. Supportive therapy/care. D. Nursing care & diet. E. Follow up & rehabilitations. A. Antimicrobial therapy: If a patient is suspected of bacterial meningitis after L.P, treatment should be started emperically before laboratory confirmation. Generally a combined broad-spectrum antibiotic therapy is practiced. Emperical antibiotic therapy for bacterial meningitis: (All drugs to be given i.v) Indications Antibiotics Preterm infants to Ampicillin + Ceftriaxone; Or, infants <1 month Ampicillin + Gentamicin Infants 1-3 months Ampicillin + Cefotaxime or Ceftriaxone; Or, Ampicillin + Gentamicin Children > 3 months Cefotaxime; Or, Ceftriaxone Where there is prevalence of resistance to P-lactum antibiotics: Cefotaxime or Ceftriaxone (or cefepime) + Vancomycin; Or, Ampicillin + Chloramphenicol. Children > 3 months who Ceftazidime + Vancomycin; Or, are immunocompromized, Ampicillin + Chloramphenicol. or having gram-negative bactrial meningitis or post surgical meningetis Total daily dose & dosing interval of drugs used in the treatment of bacterial meningitis and focal CNS infection: Ampicillin- 200-400mg/kg/day i.v divided every 6 hours Cefepime- 150mg/kg/day -- -- -- 8 -- Cefotaxime- 200mg/kg/day -- -- -- 6 -- Ceftriaxone- l00mg/kg/day -- Once daily or divided 12 hourly Ceftazidime- 150mg/kg/day i.v divided every 8 hours Chloramphenicol- lOOmg/kg/day -- -- -- 6 -- Gentamicin- 5-7.5mg/kg/day -- -- -- 8 -- Metronidazole- 30mg/kg/day -- -- -- 6 -- Penicillin G- 4 Lac unit/kg/day -- -- -- 6 -- Vancomycin- 60mg/kg/day -- -- -- 6 -- Duration of antibiotic therapy: Older children: Meningococcal infection - 5-7 days. H. influenze infection - 7-10 days Pneumococcal infection - 10-14 days Gram-negative bacilli - 14-21 days. Neonate: Gram-negative bacilli - 21 days, or at least 14 days after sterilization of CSF, whichever longer. Group B Streptococcus - 14-21 days. Other organisms - 14-21 days. Indications to stop therapy- 1. No fever for 3 days. 2. CSF protein concentration, & the CSF: blood glucose ratio may not have returned to normal at the conclusion of treatment, but Gram stain should show no organism & CSF culture should be sterile. Retreatment is mandatory if they are not & may be necessary if > 10% of cells are polym-orphs, & if the CSF glucose is < 30 mg/dl. 3. Cell count in CSF is less than 50/cmm (most are mononuclear). Check up the child again after 2nd and 3rd week following completion of treatment- his hearing, vision, OFC any convulsive episode, or neurologic deficit should be looked for. Prophylaxis:13 In meningococcus- Family contacts should receive rifampicin l0mg/kg/dose (max. 300mg) every 12 hours for 2 days. In hemophilus influenze Family contacts should receive rifampicin 20mg/kg/day (max. 600mg) in single dose for 4 days from the date of discharge from the hospital (to destroy the colonization of nasopharynx by h. influenze). B. Symptomatic treatment/treatment of complications: 1. Frequent monitoring of pulse, respiration, B.P. 2. Screening neurologic examinations should be performed daily. 3. Regular monitoring of body wt, serum electrolytes, serum & urine osmolalities, urine volume & specific gravity. 4. In meningitis often there is inappropriate (excess) secretion of ADH (SIADH). So, if the patient is given excessive amount of water, a further increase in intracranial pressure occurs. Retention of fluid is usually in excess of solute (i.e. more water, low solute or Na). So fluid is restricted to 800-1000ml/m2/day until it can be established that inappropriate ADH secretion is not a factor or has dissipated. The best indicator of retention of fluid in excess of solute are detection of daily- i. body wt & ii. serum Na+ cone. As serum Na+ increases toward normal (i.e 140meq/l) fluid admin, may be liberalized progersively to normal maintenance levels of 1500-1700ml/m/24 hours. 5. Head circumference- measured regularly to find whether developing subdural effusions or hydrocephalus. Treatment of subdural effusions- subdural paracentesis is done only when specific symptoms of increased intracranial pressure or seizure activity or focal neurological sings are present. Usually no subdural taps are required. 6. Seizures/convulsions - Airway must be maintained clean. Anticonvulsant- diazepam 0.3mg/kg (or lmg/1 year) to a max. of l0mg may be given i.v as a bolus to control episode of seizure. Phenytoin 13-20mg as an initial dose may be given perenterally. Seizure control may be sustained with phenytoin 5mg/kg/24 hour i.v in 2 divided doses. Benefits ofphenytoin- - dose not depress resp. centre, - also inhibit secretion of ADH Phenytoin should not be added to soln containing glucose in which the drug will precipitate. 7. DIC- heparin therapy should be considered with appropriate test. 8. Cerebral oedema & inflammation: Corticostewids- Dexamethasone 0.15mg/kg/dose given every 6 hours for 2 days; Or, 0.4mg/kg/dose every 12 hours for 2 days. Corticosteroids appear to have maximum benefit if given 1-2 hours before antibiotics are initiated and also may be effective if given concurrently with or soon after the 1st dose of antibiotics.13 Mannitol is usually used to reduce cerebral oedema. 9. Acute increase of intracranial pressure- may be helped by using mannitol. 10. Internal hydrocephalus (arrested hydrocephalus) ventriculo- atrial (brain) or caval shunt or to peritoneal cavity after neuroradiological evaluation of the venticular system. 11. Fluid & electrolyte homeostasis- adequate amount of fluid & electrolyte should be administered, if the child is unconcious by i.v infusion. 12. Hypo tension- fall in B.P should be corrected by i.v. infusion of fluid vasopressor. C. Supportive care & diet- 1. Initially - nothing by mouth, to reduce the risk of aspiration since vomiting may occur. 2. In the initial days of Rx delivery of all the fluid i.v. to ensure greater accuracy in measurement of intake/output. 3. Oral cavity should be kept clean & moist to prevent putrefaction. 4. The sphincter function should be observed. 5. If constipation for more than 2-3 days - liquid paraffin, or glycerene suppository or other laxative may be used. 6. Retention of urine- - Managed by gentle pressure on the suprapubic region as this may initiate voiding. - Hot water bottle may be kept on lower abdomen. - In severe case catheterization & aseptic meas-ure may be necessary. 7. Bed sore- may be prevented by- - Repeated change in posture - Application of methylated spirit on the skin. - Skin kept dry & talcum powder is aplied - Soft foam rubber matress or aircushion - used to prevent pressure on the bony points. 8. Diet- should be rich in protein, calorie & vitamins unconscious, and young infant may be fed through N.G tube. D. Follow up & rehabilitation-Mi cases of meningitis should be followed up for early detection of the residual neurological deficits or mental retardation, if present. Children with neurological handicaps should be rehabilitated by appropriate physiotherapy & occupational therapy. Treatment of Viral meningitis : Treatment mainly symptomatic & supportive. 1. Hospitalization. 2. Symptomatic treatment-Fever: Antipyretic usually paracetamol, (aspirin should not be given because it is associated with Reye syndrome). Headache & hyperesthesia: Rest, analgesic reduction in room light, noise & visitors Photophobia: Reduction in light. Vomiting: Antiemetic can be given. 3. A prophylactic antibiotic should be given to prevent secondary bacterial infection. 4. Hydration- should be maintained by fluid therapy. 5. Nursing care & adequate nutrition. 6. Regular monitoring of vital signs neurological examinations. 7. Treatment of complications-same as bacterial meningitis. 8. Acyclovir is indicated for herpes simplex virus (HSV) encephalitis. Treatment of T. B meningitis: Intensive phase (2 months) - (H R Z) S; and Continuation phase (4 months) - (RH). (H- Isoniazide, R- Rifampicin, Z- Pyrazinamide, S- Streptomycin) Recommended daily dose: Isoniazide (INK) = 5 (4-6)mg/kg/day. Rifampicin = 10 (8-12)mg/kg/day. Pyrazinamide = 25 (20-30)mg/kg/day. Streptomycin - 15 (12-18)mg/kg/day. Ethambutol - 20 (15-25)mg/kg/day. Prednisolone - As a corticosteroid prednisolone is advised in the early stages because of its anti-inflammatory nature; it may reduce the development of arachnoiditis, fibrosis and spiral block. Dose: 2mg/kg/day (max. 60mg daily) for 4 weeks. The dose should be gradually tapered over 1-2 weeks before stopping. Note: 1. Pyridoxine 20mg daily should be given to prevent the INH-induced neuropathy. 2. All medications should be given before breakfast & in a single dose, if possible in order to achieve a single combined peak concentration for maximum effect on bacilli. |
| Introduction | |
| History | |
| Etiology | Etiology & Classification : Meningitis may be classified etiologically as- Common- 1. Bacterial (or pyogenic). 2. Viral (or aseptic). 3. Tuberculous. Rare- 4. Mycotic (torulosis, nocardiosis, histoplasm-osis). 5. Syphilitic. 6. Protozoal (malaria, toxoplasmosis). Bacterial meningitis:2'13 Newborn to 2-3 months: Common Less common 1. Gram-negative bacilli 1. Listeria monocytogenes. (E. coli, Proteus). 2. Group B Streptococci. 3. Klebsiella erugenes. 4. Pseudomonas eruginosa. 5. Staphylococci. Note: E. coli & streptococci cause about 50-75% of infections. Children 3 months to pre-school age: Common Less common 1. H. Influenze. 1.Mycobacterium tuberculosis 2. Neisseria meningitidis (Meningococcus). 3. Streptococcus pneumonie Older children & adult: Common Less common 1. Neisseria meningitidis 1. Listeria monocytogenes. (Meningococcus). 2. Mycobacterium tuberculosis 2. Streptococcus pneumonie 3. Staphylococcus aureus (Pneumococcus) 4. H. Influenze. Viral (or aseptic) meningitis: 1. Enteroviruses- 85% (Cox-sackie, Echovirus) 2. Arbovirus- 5% (Pol virus- non paralytic) 3. Mumps virus- 2% 4. Herpes simplex 1% (type 1 & 2)- Other viruses, each causing <1% infection such as, E. B virus, measles virus, Influenza vims, live virus vaccine et |
| Clinical Features | Clinical features: New born Older children 1. Vacant stare 1. Irritability 2. Drowsiness/irritability 2. Headache (bursting) 3. Vomiting/Circulatory 3. Vomiting- may be projectile collapse 4. Fever/hypothermia 4. Fever 5. Reluctant to feed 5. Anorexia 6. Poor tone & poor cry. 6. Restlessness/crying 7. Tremors/convulions 7. Photophobia, coma, convulsions. 8. Neurological deficits 8. Drowsiness/Blurring of consciousness 9. Bulging of ant. fontanelle 9. Fontanelle may bulge (if not closed). 10. Kernig’s sign (±) 10. Kernig’s sign (+ ve) 11. Neck rigidity- usually 11. Neck rigidity & absent Brudzinski’s sign may be (+ve) |
| Preventions | Prevention. Keeping up to date with recommended vaccines is the best protection against meningococcal disease. Maintaining healthy habits, like getting plenty of rest and not having close contact with people who are sick, also helps |
| Treatment | Antibiotics given directly into a vein. fluids given directly into a vein to prevent dehydration. oxygen through a face mask if there are any breathing difficulties. steroid medication to help reduce any swelling around the brain, in some cases. |
| Complications | Complications Acute- 1. Sock. 7. Siezures 2. Dehydration. 8. T Intracranial pressure 3. Cerebral oedema. 9. Cranial nerve palsy 4. Acidosis 10. Stroke 5. Hypoglycemia. 11. Cerebral/Cerebellar herniation 6. Coagulopathy (viz. DIC).12. Thrombosis of venous sinuses Delayed Complications- 1. SIADH (secretion of 7. Mental retardation inappropriate ADH). 2. Extrameningeal infection. 8. Delay in acquisition 3. Subdural effusions or of language empyema 4. Epilepsy 9. Visual impairment 5. Cerebral palsy 10. Behavioral problems 6. Hydrocephalus. 11. Ataxia |
| Prognosis | Some people with the infection die and death can occur in as little as a few hours. However, most people recover from bacterial meningitis. Those who do recover can have permanent disabilities, such as brain damage, hearing loss, and learning disabilities |
| Types | Bacterial Meningitis. Meningitis caused by bacteria can be deadly and requires immediate medical attention. ... Viral Meningitis. Meningitis caused by viruses is serious but often is less severe than bacterial meningitis. ... Fungal Meningitis. ... Parasitic Meningitis. ... Amebic Meningitis. ... Non-Infectious Meningitis. |
| Classification | 3 subtypes: acute septic and aseptic, recurrent, and chronic meningitis. Meningitis may also be classified according to the causative organism into 5 subtypes: bacterial, viral, fungal, parasitic, and non-infectious meningitis |
| Observation | |
| Pathology |
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