NERVOUS SYSTEMNERVOUS SYSTEMINFECTIONSINFECTIONS

MENINGITISMENINGITIS

Acute infection of the meninges Acute infection of the meninges presents with the characteristic presents with the characteristic combination:combination:

pyrexia Headache Meningism

CAUSES OF MENINGITISCAUSES OF MENINGITIS

InfectiveInfective

Bacteria Bacteria Viruses: Enteroviruse,Mumps,Viruses: Enteroviruse,Mumps,

Influenza Herpes simplexInfluenza Herpes simplex

Protozoa & parasites:ToxoplasmaProtozoa & parasites:Toxoplasma

AmoebaAmoeba

Fungi:Cryptococcus neoformans, Fungi:Cryptococcus neoformans, candida candida

Fever,Headache,Nuchal Fever,Headache,Nuchal rigidityrigidity

Altered mental statusAltered mental status

Yes NoYes No

Encephalitis,ADEM,Abscess MeningitisEncephalitis,ADEM,Abscess Meningitis

Imaging,CT or MRI. CSFImaging,CT or MRI. CSFBrain imaging CSF

Bacterial causes of Bacterial causes of meningitismeningitis

•Age of onsetAge of onset•CommonCommon•Less commonLess common

• NeonateNeonate•G-negative G-negative bacillia,Group Bbacillia,Group B

•streptococcistreptococci

•Listeria Listeria monocytogenesmonocytogenes

•Pre-school Pre-school childchild

•H-influenzaeH-influenzae

•N-meningitidisN-meningitidis

•St-pneumoniaSt-pneumonia

•MycobacteriuMycobacteriumm

•tuberculosistuberculosis

•Older childOlder child

•And adultAnd adult•N-MeningitidisN-Meningitidis

•St-pneumoniaSt-pneumonia•L –L –m,T.B,Cryptom,T.B,Crypto

Neonate

G-negative bacilli Group B streptococci

Pre-school child

Haemophillus ifluenza

Neisseria meningitidis

Streptococcus pneumonia

Older child &adult

Neisseriameningitidis

Streptococcuspneumoniae

Listeriamonocytogenes

CSF INDICES IN MENINGITISCSF INDICES IN MENINGITISConditConditionion

CELlCELl

TypeType CELLCELL

CountCount GlucosGlucosee

proteinproteinGG - -

stainstain

NormaNormall

LymLympp

0-40-4 >60% >60%

B-GB-G

NormalNormal--

ViralViralLymLympp

10-200010-2000 normalnormal

normalnormal--

BacterBacterialial

PolyPoly 10001000

50005000

LowLowNN//

IncreaseIncrease++

TBTBL/L/P,MP,M

50-500050-5000 LowLowIncreaseIncreaseofteoftenn

CHEMOTHERAPY OF BACTERIAL CHEMOTHERAPY OF BACTERIAL MENINGGITIS MENINGGITIS

N-meningitidis BenzylpenicillinN-meningitidis Benzylpenicillin Strep.pneumoniae CefotaximeStrep.pneumoniae CefotaximeSensitive to B-lactams CeftriaxoneSensitive to B-lactams Ceftriaxone

Resistant +VancomycinResistant +VancomycinH.Influenzae CefotaximeH.Influenzae Cefotaxime CeftriaxoneCeftriaxoneListeria monoctogenes Ampicillin $ Listeria monoctogenes Ampicillin $ gentamicinegentamicine

Treatment of Treatment of pyogenicmeningitis of pyogenicmeningitis of

unknown cause unknown cause1-patients with a typical meningococcal rash1-patients with a typical meningococcal rash Benzylpenicillin 2.4 gIV.6-hourlyBenzylpenicillin 2.4 gIV.6-hourly2-Adult aged 18-50 years without meningococcal rash2-Adult aged 18-50 years without meningococcal rash Cefotaxime 2 g IV.6-hourlyCefotaxime 2 g IV.6-hourly Ceftriaxone 2g IV.12-hourlyCeftriaxone 2g IV.12-hourly3-Patient in whome pencillin-resistant pneumococcal infection 3-Patient in whome pencillin-resistant pneumococcal infection

is suspectedis suspected As 2 but add-Vancomycin 1g Iv,12-hourly or Rifampicin 600 As 2 but add-Vancomycin 1g Iv,12-hourly or Rifampicin 600

mgmg IV.12-hourlyIV.12-hourly4-Adult aged over 50 years and those in whome Listeria 4-Adult aged over 50 years and those in whome Listeria

monocytogees infection is suspectedmonocytogees infection is suspected As for 2 but add Ampicillin 2g IV.4-jourly or Co-trimoxazoleAs for 2 but add Ampicillin 2g IV.4-jourly or Co-trimoxazole5-Patients with a clear history of anaphylaxis to B-lactams5-Patients with a clear history of anaphylaxis to B-lactams Chloramphenicol 25 mg/kg IV.6-hourly plus Vancomycin 1g Chloramphenicol 25 mg/kg IV.6-hourly plus Vancomycin 1g

IV.12-hourly IV.12-hourly

Recommendations for Empirical Recommendations for Empirical antimicrobial therapy in adult with antimicrobial therapy in adult with

community-acquiredcommunity-acquired meningitismeningitis Predisposing factor pathogen DrugsPredisposing factor pathogen Drugs16-50 yr N-St-pn Vancomycin 16-50 yr N-St-pn Vancomycin

++ 33rdrd cephalosporin cephalosporin>50 yr>50 yr ٍ ٍ St-pn, N, List Van+3St-pn, N, List Van+3rdrd Ceph+ Ceph+ AmpicillinAmpicillinPresence of a risk St-pn, list, Van+3Presence of a risk St-pn, list, Van+3rdrd ceph+ ceph+ H-infuenzae AmpicillinH-infuenzae Ampicillin

www.NEJM.ORGwww.NEJM.ORG ,N ENGL ,Jan-2006 ,N ENGL ,Jan-2006

Chemoprophylaxis for meningococcal Chemoprophylaxis for meningococcal infection infection

DoseDose it reduce the incidence of clinical it reduce the incidence of clinical disease among contact?disease among contact?

Observational dataObservational data suggest that antibiotic suggest that antibiotic reduce the risk of disease reduce the risk of disease

In adults a single dose of In adults a single dose of 500 mg 500 mg ciprofloxacinciprofloxacin or oral or oral rifampicin rifampicin 600mg(12-hourly)600mg(12-hourly) for 2 days. for 2 days.

VaccinesVaccines for groups A&C but not B for groups A&C but not B menigococci.menigococci.

COMPLICATIONS COMPLICATIONS OF MININGOCOCCAL OF MININGOCOCCAL SEPTICEMIASEPTICEMIA• MenigitisMenigitis

• RashRash

• ShockShock

• Intravascular Intravascular coagulationcoagulation

• Renal failureRenal failure

• GangreneGangrene

• ArthritisArthritis

• PericarditisPericarditis

Major intracranial Major intracranial complications in Bacterial complications in Bacterial meningitis in adultmeningitis in adult----------------------------------------------------------------------------------1-Transtentorial herniation1-Transtentorial herniation2-Hydrocephalus2-Hydrocephalus3-Infarction3-Infarction4-Seizures4-Seizures

CLINICAL FEATURES OF TB CLINICAL FEATURES OF TB

MENINGITISMENINGITIS

•VomitingVomiting

•Low-grade Low-grade feverfever

•lassitudelassitude

•DepressionDepression

•ConfusionConfusion

•Behavior Behavior changeschanges

SignsSigns

Meningism (may be Meningism (may be absent)absent)

Ocular palsiesOcular palsies

PapilloedemaPapilloedema

Depression of conscious Depression of conscious levellevel

Focal hemispher signsFocal hemispher signs

Meningism (may be Meningism (may be absent)absent)

Ocular palsiesOcular palsies

PapilloedemaPapilloedema

Depression of conscious Depression of conscious levellevel

Focal hemispher signsFocal hemispher signs

Viruses causing acute Viruses causing acute encephalitisencephalitis

CommonCommon ArbovirusesArbovirusesEnterovirsusesEnterovirsusesHSV HSV Less commonLess commonCMVCMVEBVEBVHIVHIVMumpsMumps

Viruses causing acute Viruses causing acute meningitismeningitis

Enterviruses =75-90Enterviruses =75-90

Echo 30% Coxsa-A 10% Coxsac-B Echo 30% Coxsa-A 10% Coxsac-B 40%40%

Mumpsvirus 15%Mumpsvirus 15%

Practical pointsPractical points

• The typical profile is lymphocytic The typical profile is lymphocytic pleocytosis(25-500 cells/uL.)pleocytosis(25-500 cells/uL.)

• A normal or slightly elevated proteinA normal or slightly elevated protein• A normal glucose concentration. A normal glucose concentration. • PMN pleocytosis should always promt PMN pleocytosis should always promt

an alternative diagnosisan alternative diagnosis• In both enterovirus &HSV,PCR is the In both enterovirus &HSV,PCR is the

diagnostic procedure of choicediagnostic procedure of choice

Differential diagnosisDifferential diagnosis

Bacterial menigitis: Bacterial menigitis:

Mycoplasma,lasteria,brucella Mycoplasma,lasteria,brucella

Parameningeal infectionParameningeal infection

Partially treated bacterial meningitisPartially treated bacterial meningitis

Tb,fungal, parasitic, Syphilitic diseaseTb,fungal, parasitic, Syphilitic disease

Neoplastic meningitisNeoplastic meningitis

Sarcoid, Behcets diseaseSarcoid, Behcets disease

Bacterial menigitis: Bacterial menigitis:

Mycoplasma,lasteria,brucella Mycoplasma,lasteria,brucella

Parameningeal infectionParameningeal infection

Partially treated bacterial meningitisPartially treated bacterial meningitis

Tb,fungal, parasitic, Syphilitic diseaseTb,fungal, parasitic, Syphilitic disease

Neoplastic meningitisNeoplastic meningitis

Sarcoid, Behcets diseaseSarcoid, Behcets disease

Chronic & recurrent Chronic & recurrent meningitismeningitis

Characteristic neurological syndrome Characteristic neurological syndrome for>4weeksfor>4weeks

&&Persistent inflammation in CSF (WBC>5/Ul)Persistent inflammation in CSF (WBC>5/Ul)

Causes:1-Meningeal infectionCauses:1-Meningeal infection 2-Malignancy2-Malignancy 3-Noninfectious inflammatory disorder3-Noninfectious inflammatory disorder 4-Chemical meningitis4-Chemical meningitis 5-Parameningeal infections5-Parameningeal infections

Symptoms & signs of chronic Symptoms & signs of chronic meningitis meningitis

SymptomSymptom Sign Sign

Chronic headache Sign of Meningeal irritation Chronic headache Sign of Meningeal irritation

Change in personality Altered mental statusChange in personality Altered mental status

Facial weakness Crainal nerve palsyFacial weakness Crainal nerve palsy

Double visions Papilledema,optic atrophyDouble visions Papilledema,optic atrophy

Weakness Myelopathy,radiculopathyWeakness Myelopathy,radiculopathy

Sensory symptoms Frontal lobe dysfunctionSensory symptoms Frontal lobe dysfunction

Sphincter dysfunction AtaxiaSphincter dysfunction Ataxia