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Global Issue
• Meningitis kills or disables around 1.2 million people worldwide each year.
• Bacterial meningitis, which is the most severe and common form of meningitis, causes around 120,000 deaths globally every year.
Definition“Meningitis is a disease caused by the inflammation of the protective membranes covering the brain and spinal cord known as the meninges.”
Facts Of Meningitis• Meningitis may develop in response to a number of causes,
usually bacteria or viruses but meningitis can also be caused by physical injury, cancer or certain drugs.
• Viral meningitis is often less severe than bacterial meningitis and usually resolves without specific treatment.
• Those surviving meningitis can have their lives devastated as a result of long-term effects, such as deafness, brain damage, learning difficulties, seizures, difficulties with physical activities and when septicemia is involved loss of limbs.
• Meningitis can be hard to recognize in the early stages. Symptoms can be similar to those of the common flu, including: fever, vomiting, headache, stiff neck, sensitivity to light, drowsiness, muscle and leg pain.
Nasopharyngeal colonization
Local invasion
Bacteremia
Meningeal invasion
Bacterial replication in the subarachnoid space
Release of bacterial components (cell wall, LOS)
Cerebral micro vascular endothelium
Macrophages, neutrophils, other CNS Cells
Cytokines
Subarachnoid space inflammationCerebral vasculitisIncreased CSF outflow resistance
Hydrocephalus
Interstitial edema
Increased intracranial pressure
Decreased cerebral blood flow and loss of cerebro vascular auto regulation
Cytotoxic edema
Cerebral infarction
Increased BBB permeability
Vasogenic edema
Classification of MeningitisBased on duration:• Acute: symptoms present within a period of 0-24 hours.• Sub acute: symptoms lasting from 1-7 days.• Chronic: symptoms lasting over 7 days.Based on etiology:• Bacterial meningitis • Viral Meningitis• Fungal Meningitis• Parasitic Meningitis• Non infectious Meningitis Trauma, cancer or certain drugs
Bacterial Meningitis Causative agents varies
according to age:• Newborn to 3 months: Escherichia Coli, Group B Streptococci, Listeria Monocytogenes, Streptococcus
Pneumoniae, Haemophilus Influenzae type b, Neisseria Meningitides.
• Age 3 months to Adolescence: Neisseria meningitis, Streptococcus
Pneumoniae, Haemophilus Influenzae type b.
Mycobacterium Tuberculosis is most common in young children of any age.
• Adolescence to Young adults: Neisseria Meningitides, Streptococcus
Pneumoniae
• Older Adults: Streptococcus Pneumoniae, Neisseria Meningitides, Listeria Monocytogenes• Streptococcus Pneumoniae is the
most common type of Meningitis. Approximately 6,000 cases/yr
• Haemophilus Meningitis incidence has declined about 95% due to the introduction of Haemophilus Influenza b vaccine
Viral MeningitisCausative agents:• Enteroviruses• Adenovirus• Herpes Simplex Virus• Varicella-Zoster Virus• Mumps Virus• Measles Virus• Viral Meningitis is often less severe than Bacterial Meningitis.• Duration of illness approx 7 to 10 days.• Viral Meningitis occurs mostly in children younger than age 5.• There are certain diseases and medications that may weaken the immune
system and increase risk of Meningitis. For example, Chemotherapy and recent organ or Bone Marrow Transplant.
Fungal MeningitisCausative agents:• Cryptococcus Neoformans • Coccidioides Immitis • Histoplasma Capsulatum• Aspergillus Fumigatus • Candida Albicans (Yeast)
Occurrence: Rare
Mode of Transmission: • Fungal Meningitis is not contagious, usually
the result of spread of a fungus through blood to the spinal cord and also potentially contaminated medication injected into the body..
• Fungal Meningitis, people with weakened immune systems, like those with HIV infection or Cancer are at higher risk.
Treatment: Fungal Meningitis is treated with long
courses of high dose Anti-Fungal medications.
Parasitic Meningitis
Causative pathogens• Angiostrongylus Cantonensis• Cystic Echinococcosis• Naegleria FowlerOccurrence: Very rareTransmission: Spread through Warm Freshwater ( Lake, River &
Swimming Pool )
Non Infectious Meningitis
Causes:• Cancers• Systemic Lupus Erythematosus (Lupus)• Certain Drugs• Head Injury• Brain SurgeryMode of Transmission:• This type of Meningitis is not spread from person to person. Non-
Infectious Meningitis can be caused by Cancers, Systemic Lupus Erythematosus (Lupus), Certain Drugs, Head Injury and Brain Surgery.
Clinical Presentation Young Infants <3 months:• Fever or Hypothermia• Bulging Fontanel• Convulsion/Seizures• High-pitched cry and Irritability• Lethargy and Altered Mental
State• Apnea• Poor Feeding and Vomiting
Children >3 months to Adolescent:• Fever (50% of patients)• Headache, Photophobia, Stiff
Neck, Irritability, Lethargy, Vomiting and Altered Level of Consciousness
• Papilledema
Physical ExaminationKerning's Sign• It is an assessed with patient lying in Supine Position
with Hip Joint and Knee Joint flexed to 90 degree. In a patient with Positive kerning's sign pain limits passive Extension of the Knee.
Physical ExaminationBrudzinski`s Sign• A Positive Brudzinski`s sign occurs when flexion of
the Neck causes involuntary flexion of the Knee and Hip Joints.
Physical Examination
Skin Findings:• Non Specific Erythmatous,
Macular, Papular rash to a
Petechial or Purpuric rash.• TUMBLER TEST is Positive
Investigations
• Lumber Puncture (LP)• CSF Culture• Polymerase Chain
Reaction (PCR)• Blood Counts• Blood Culture• X-ray Chest• CT Scan
• Latex Agglutination• Gram Staining
CSF Normal Bacterial Meningitis
Viral Meningitis Fungal Meningitis Parasitic Meningitis
Appearance Clear Opale-scant to Purulent
Clear Normal or Cloudy Normal
Glucose(mg/ dL) 40-85mg/ dL
Normal to Marked Decrease. <40 mg/ dL
Normal (> 40 mg/dL.)
<40 mg/dL (Low) Normal or Minimal Low
Protein(mg/ dL) 15-45mg/dL
(Marked Increase) > 250 mg/dL.
<100 mg/dL (Moderate Increase)
(Moderate to Marked Increase) 25 -500 mg/ dL
Slightly Elevated
WBCs(cells/ µL) 0–5/µL (Adults / Children); 30/µL(Newborn)
>500 (Usually > 1000). Early: May be < 100.
< 100 cells/µL Variable (10 -1000 cells/µL) <500cells/µL
Increased no. of Esinophils
CSF Culture Sterile Positive Negative Positive Mostly NegativeGram`s/ZN Staining Not Seen Gram +ve Cocci
(Pneumococcai),Gram –ve Cocci(Meningococci),Gram –ve Bacilli(H.Influenzae)
No organisms are seen
No organisms are seen
No organisms are seen
Detection of Micro Organism
Negative Latex Agglutination Test, Blood Culture
CSF for PCR is the Diagnostic procedure of choice
Blood Culture Blood Culture
Management
• Monitor vital sign hourly (B.P,R/R, Pulse rate, temperature)
• Monitor input and output• Give treatment as prescribed• Keep proper ventilation• Turn patient at every 2 hours• Monitor the child's state of
consciousness and pupil size at every after hours during the first 24 hours ( thereafter every 6 hours)
• Assess for increased ICP (Intra cranial pressure)
• Measure and records the head circumference of infants
• Document the characteristics of seizure activity and duration
• On discharge ,assess all children for neurological problems, especially hearing loss
Treatment: AntibioticsAmpicillin In neanate:100-200mg/kg/day, every 6
hours
In children:200-400mg/kg/day, every 6 hours
Cefotaxime In neonate: 100-150 mg/kg/day, every 6-8 hours
In children 200mg/kg/day, every 6-8 hours
Ceftriaxone 100mg/kg, every after 12 hours or 24 hours
Gentamicin In neonate:5 mg/kg/day, every 8 hours
In children:60mg/kg/day, every 6 hours
Vancomycin In neonate:45mg/kg/day, every 8 hours
Benzyl penicillin In neonate: 100,000 units/kg/day, every 6-12 hours according to age
In children: 400,000 units/kg/day every 4 to 6 hours
Chlor-amphenicol 100mg/kg/day I/V every 6 hours (max dose 4 g/day)
Supportive Treatment
• Give Paracetamol 15mg/kg 6-8 hourly for fever (>38.5 M).• IV fluids: isotonic fluids at maintenance rate(250 ml/24hrs).• Feeding according to age requirement (75-100 kcal/kg/day).• Give anticonvulsant if convulsing.• Correct hypoglycemia if present.• NGT for feeding.• Physiotherapy.
Complication
• Increased intracranial pressure(ICP)
• Cranial nerve palsy• Seizures• Stroke• Ataxia• Inappropriate ADH secretion• Rapidly increasing head
circumference• Subdural Effusions
• Blindness• Cerebral Infarcts• Anemia• Cerebral or Crebeller Herniation• Deafness• Spasticity• Visual Handicap or Squint• Epilepsy
Meningitis According to Tibb (Unani Medicine)
MENINGIES• Dura matter (Supportive and as an
infrastructure)• Arachanoid matter(Bilious)• Pia matter(Atrabilious)• Brain( Phlegmatic)
Pia Matter Arachanoid Matter Brain
Atrabilious (Cold & Dry) Bilious (Hot & Dry) Phlegmatic (Cold & Moist)
Fever Pale eyes Papilledema
Nausea Vomiting Nausea & Vomiting
Neck Stiffness Bitter Taste Chills and Rigors
Seizures Seizures Nasal Discharge
Headache Headache Headache
Perspiration Photophobia Vertigo & Lethargy
Irritability
Rod shape Cocci shape Spiral shape
Emollient, Atrabilious Concoctive & Purgative
Exhilarant, Sedative & Hypnotics, Brain Tonic, Bilious Purgative
Phlegmatic Purgative, Emollient
Khisanda-e- Astokhuddoos, Jawarish-e-Anareen & Jawarish-e- Ood-e-tursh
Luab bahidana, sharbat- e-neelofer, mufarah-e- barid
Aab anar-e-Tursh
Sharbat-e-Badyan,Roghan-e-Kafoor
Sharbat-e-Deenar,Roghan-e-Khashkhash
Sharbat-Allu-Bukhara, Sikanjbeen-e-Sadah & Roghan-e-Gul
DIFFERENTIAL DIAGNOSIS ACCORDING TO TIBB (Unani medicine)
Sign & Symptoms
Herbal treatment
Causative pathogens
Prognosis
• It depends on patient`s age and disease severity.Mortality rate • 5% Neisseria Meningitis• 8% in Haemophillus Influenza • 25% in Streptococcal Pneumoniae• 35% of survivors have permanent deficit e.g. Deafness, Learning
Disabilities, Blindness, Seizures and Hydrocephalous.
PREVENTION
• Haemophilus vaccine (Hib vaccine) in children.• The pneumococcal conjugate vaccine is now a routine childhood
immunization and is very effective at preventing pneumococcal meningitis.
• Household members and other in close contact with people who have meningococcal meningitis should receive preventive antibiotics.
REFERENCES
• www.slideshare.net• News health(2010) management
of acute bacterial meningitis in infants and children clinical practice guidelines.
• Who (2005) pocket book of hospital care for children guidelines for the management of common illnesses with limited resources.
• www.cdc.gov• Basis of pediatrics( 8th Edition)• Tarteeb ul Adwiya