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Meningitis:Meningitis:The BasicsThe Basics
Steven M. Snodgrass M.D.Steven M. Snodgrass M.D.
What is meningitis ?What is meningitis ?
Inflammation of the Inflammation of the meninges/leptomeninges – the pia, meninges/leptomeninges – the pia, arachnoid, and dura mater.arachnoid, and dura mater.
Can have various causes – bacteria, Can have various causes – bacteria, viruses, fungus.viruses, fungus.
How it happensHow it happens
NP colonization of susceptible individual NP colonization of susceptible individual and invasion of respiratory tractand invasion of respiratory tract
Invasion of bloodstream (Bacteremia)Invasion of bloodstream (Bacteremia) Choroid plexitisChoroid plexitis Spread to meningesSpread to meninges Ventriculitis and increased intracranial Ventriculitis and increased intracranial
pressurepressure Recruitment of inflammatory mediators Recruitment of inflammatory mediators
How it happensHow it happens
Damage to blood-brain barrier leads Damage to blood-brain barrier leads to cerebral edemato cerebral edema
Endothelial cell damage, thrombosisEndothelial cell damage, thrombosis Increase in CSF protein, decrease in Increase in CSF protein, decrease in
glucose from hypoxia, decreased glucose from hypoxia, decreased aerobic metabolismaerobic metabolism
Infarction, Seizures, Abscess Infarction, Seizures, Abscess formationformation
Typical presentationsTypical presentations
You are seeing a 14 day old infant in You are seeing a 14 day old infant in the emergency room with a 2 day the emergency room with a 2 day history of congestion. Parents note history of congestion. Parents note infant to be increasingly irritable and infant to be increasingly irritable and lethargic, sleeping through feeds, lethargic, sleeping through feeds, multiple episodes of vomiting, difficult multiple episodes of vomiting, difficult to console. Fever of 103 rectal. Infant to console. Fever of 103 rectal. Infant looks pale and feels cool with HR of looks pale and feels cool with HR of 225. A spinal tap shows 5000 white 225. A spinal tap shows 5000 white blood cells and a gram stain reveals blood cells and a gram stain reveals gram negative rods. gram negative rods.
Typical presentationsTypical presentations
You are seeing a 15 yo high school You are seeing a 15 yo high school student in your office with a 24 hour student in your office with a 24 hour history of lethargy, repeated history of lethargy, repeated vomiting, and fever to 102. On exam vomiting, and fever to 102. On exam he is unable to touch his chin to his he is unable to touch his chin to his chest and resists full extension of his chest and resists full extension of his knee while lying flat. knee while lying flat.
Pathogens of Bacterial Pathogens of Bacterial MeningitisMeningitis
Neonates (<1mo) :Neonates (<1mo) :– Group B streptococcus, E. coli, ListeriaGroup B streptococcus, E. coli, Listeria
Infants (1-24 mos):Infants (1-24 mos):– Haemophilus influenzae type B, Haemophilus influenzae type B,
Streptococcus pneumoniae, Neisseria Streptococcus pneumoniae, Neisseria meningitidismeningitidis
Children (>2yo):Children (>2yo):– Neisseria (meningococcus), Strep Neisseria (meningococcus), Strep
pneumo (pneumococcus), H. flupneumo (pneumococcus), H. flu
Meningococcemia
Gram negative diplococciGram negative diplococci
DiagnosisDiagnosis
Must maintain a high index of Must maintain a high index of suspicion in many casessuspicion in many cases
Gold standard is positive culture in Gold standard is positive culture in CSF, may have CSF positive gram CSF, may have CSF positive gram stainstain
Lumbar puncture and CSF also show Lumbar puncture and CSF also show pleocytosis, increased protein, and pleocytosis, increased protein, and hypoglycorrheahypoglycorrhea
CSF findingsCSF findings
ComponenComponentt
NormalNormal BacterialBacterial
meningitimeningitiss
Viral Viral
meningitimeningitiss
HerpeticHerpetic
encephaliencephalitistis
SpirochetSpirochetalal
encephaliencephalitistis
GlucoseGlucose
mg/dLmg/dL40-8040-80 <30<30 >30>30 >30>30 40-11040-110
ProteinProtein
mg/dLmg/dL20-5020-50 >100>100 50-10050-100 >75>75 15-15015-150
WBCsWBCs 0-60-6 >1000>1000 100-500100-500 10-100010-1000 20-50020-500
NeutrophilNeutrophilss
00 >50 %>50 % <20 %<20 % <50 %<50 % <10 %<10 %
RBCsRBCs 0-20-2 0-100-10 0-20-2 100-500100-500 0-20-2
How much does it happenHow much does it happen11
Pittsburgh similar to US in generalPittsburgh similar to US in general– For 5-17 yo in 2006:For 5-17 yo in 2006:– Neisseria 0.4-0.5 cases per 100,000 with Neisseria 0.4-0.5 cases per 100,000 with
50% meningitis and 8% mortality50% meningitis and 8% mortality– Pneumococcus 3.3 cases per 100,000 with Pneumococcus 3.3 cases per 100,000 with
6% meningitis and 2.5 % mortality6% meningitis and 2.5 % mortality
– 237 total cases of pneumococcal meningitis237 total cases of pneumococcal meningitis– 68 total cases of meningococcal meningitis68 total cases of meningococcal meningitis
1. http://www.cdc.gov/ncidod/dbmd/abcs/survreports.htm
We’re luckyWe’re lucky
1.1 cases per 100,000 in US in 2004 1.1 cases per 100,000 in US in 2004 as compared to:as compared to:
Cases per 100,000:Cases per 100,000:– Pakistan 4.4Pakistan 4.4– Haiti 6.1Haiti 6.1– Iraq 5.9Iraq 5.9– China 7.7China 7.7– India 53.5India 53.5
TreatmentTreatment
Antibiotics – Penicillins, Vancomycin, Antibiotics – Penicillins, Vancomycin, CephalosporinsCephalosporins
? Steroids - Dexamethasone? Steroids - Dexamethasone Treat underlying hemodynamic Treat underlying hemodynamic
compromise (shock) and other compromise (shock) and other complicationscomplications
Monitor for and treat sequelaeMonitor for and treat sequelae
Complications and SequelaeComplications and Sequelae
Complications:Complications: Shock/SepsisShock/Sepsis Cerebral edemaCerebral edema Subdural empyemaSubdural empyema Subdural effusionSubdural effusion VentriculitisVentriculitis AbscessAbscess SeizuresSeizures
Sequelae:Sequelae: DeafnessDeafness Developmental Developmental
delay, cognitive delay, cognitive impairmentsimpairments
Chronic seizure Chronic seizure disorderdisorder
HydrocephalusHydrocephalus
Vaccines…Vaccines…
MenactraMenactra– Protects against four most common Protects against four most common
serogroups of Neisseria A, C, Y and W-serogroups of Neisseria A, C, Y and W-135135
– Most cases in infants due to serogroup BMost cases in infants due to serogroup B– Adolescents and adults aged 11-55 yoAdolescents and adults aged 11-55 yo– Give at entry to H.S., college dorm Give at entry to H.S., college dorm
residents, other at risk groupsresidents, other at risk groups– Conjugate vaccine as compared to MPSVConjugate vaccine as compared to MPSV
ProphylaxisProphylaxis
Most often for meningococcal Most often for meningococcal meningitis and Haemophilus meningitis and Haemophilus influenzaeinfluenzae
Close contactsClose contacts Rifampin or CiprofloxacinRifampin or Ciprofloxacin
Steve SnodgrassSteve Snodgrass Children’s Hospital of Pittsburgh of Children’s Hospital of Pittsburgh of
UPMCUPMC [email protected]@chp.edu Please e-mail with questions or Please e-mail with questions or
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