Oleh : Dr.

Budi Wahyono, SpS

Piamater Arakhnoid Duramater

Masa Inkubasi Gejala prodromal Masa infeksi abortif Bakteriemi Septikemi Gejala lokalisatorik

Invasi hematogen
Dapat berasal dari nasofaring, paru, jantung

Perkontinuitatum dari jaringan di sekitarnya Pembuluh darah meningeal yang kecil dan sedang mengalami hiperemi sel PMN ke ruang subarakhnoid eksudat (2 lapisan; lapisan PMN dan fibrin, makrofag)

Inflamasi pada selaput otak Manifestasi klinis nya adalah tanda meningeal ; nyeri kepala, kaku kuduk dan fotofobia Menurut lamanya gejala, terbagi atas 2 ; akut (beberapa minggu-1 bulan) dan kronis (>4 minggu)

Risk and/or Predisposing Factor Age 3 months to 18 years N meningitidis S pneumoniae H influenzae S pneumoniae N meningitidis H influenzae

Bacterial Pathogen

Age 18-50 years

Age older than 50 years

S pneumoniae N meningitidis L monocytogenes Aerobic gram-negative bacilli S pneumoniae N meningitidis L monocytogenes Aerobic gram-negative bacilli Staphylococcus aureus Coagulase-negative staphylococci Aerobic gram-negative bacilli, including Pseudomonas aeruginosa S pneumoniae H influenzae Group A streptococci

Immunocompromised state

Intracranial manipulation, including neurosurgery

Basilar skull fracture

CSF shunts

Coagulase-negative staphylococci S aureus Aerobic gram-negative bacilli

Virus
Enterovirus ; Polio, Echovirus, Coxsackie Herpes ; HSV

Paramyxovirus ; Mumps, measles

Togavirus ; Rubella Flavivirus ; Japanese ensefalitis Retrovirus ; HIV

Radang pada selaput otak disebabkan oleh Mycobacterium tuberculosa Cairan otak jernih
Riwayat kontak TB Pengguna obat kortikosteroid lama Belum pernah di vaksin BCG

Tanda rangsang meningeal

Agent Bacterial meningitis

Opening Pressure 200-300

WBC count per L 100-5000; >80% PMNs*

Glucose (mg/dL) <40

Protein (mg/dL) >100

Microbiology Specific pathogen demonstrated in 60% of Gram stains and 80% of cultures

Viral meningitis

90-200

10-300; lymphocytes

Normal, reduced in LCM and mumps

Normal but may be slightly elevated

Viral isolation, PCR assays

Tuberculous meningitis

180-300

100-500; lymphocytes

Reduced, <40

Elevated, >100

Acid-fast bacillus stain, culture, PCR

Cryptococcal meningitis

180-300

10-200; lymphocytes

Reduced

50-200

India ink, cryptococcal antigen, culture

Aseptic meningitis

90-200

10-300; lymphocytes

Normal

Normal but may be slightly elevated

Negative findings on workup

Normal values

80-200

0-5; lymphocytes

50-75

15-40

Negative findings on workup

Tirah baring Pantau respirasi Pemilihan antibiotik yang tepat dan cepat
Penisilin G 1-2 juta unit setiap 2 jam Kloramfenikol 4x1 gram /24 jam Ampisilin 4x3 gram /24 jam Gentamisin

Pada meningitis TB 2HRZE-7RH 2 bulan pertama

7-12 bulan berikutnya

INH: 300 mg/hari, oral Rifampisin: 10 mg/kgBB per hari, oral Pirazinamid: 30 mg/kgBB/hari, oral Streptomisin: 15 mg/kg/hari, oral Etambutol: 15-20 mg/kg/hari, oral

INH: 300 mg/hari, oral Rifampisin: 10 mg/kgBB/hari, oral

Steroid
Dexametasone 10 mg bolus intravena, kemudian

4 kali 5 mg intravena selama 2-3 minggu selanjutnya turunkan perlahan selama 1 bulan.

Inflamasi pada parenkim otak disertai dengan kelainan neurologis difus maupun fokal Ensefalitis akut banyak terjadi karena infeksi virus

Virus penyebab ensefalitis dapat dibagi menjadi dua kelompok

Virus RNA adalah enterovirus (polio, coxsakie

grup A dan B, echo), arbovirus, flavivirus (Japan B, yellow fever, dengue). Virus DNA adalah virus herpes, pox, retrovirus (AIDS).

demam tinggi yang akut tanda-tanda rangsang meningeal (nyeri kepala, demam dan kaku kuduk) kelainan fokal neurologi (kejang, penurunan kesadaran dari lethargy hingga koma) gejala-gejala spesifik lainnya yang disebabkan oleh virusnya.

Perubahan status mental Kelainan fokal (hemiparese, kejang fokal, gangguan otonom) Ataksia Kelainan saraf kranialis

CSF Finding (Normal)

Pressure (5-15 cm H2O) Cell counts, mononuclear cells/mm3 Preterm (0-25) Term (0-22) 6 mo+ (0-5)

Bacterial Meningitis
Increased No cell count excludes bacterial meningitis Typically thousands of polymorphonuclear cells, but counts may not change dramatically or even be normal (classically in very early meningococcal meningitis or in extremely ill neonates) Lymphocytosis with normal CSF chemistry results observed in 1525% of patients, especially if counts <1000 or if patient is partially treated About <90% of patients with ventriculoperitoneal shunts and CSF WBC count >100 cells/mm3 are infected; CSF glucose level usually normal, and these patients' pathogens are less pathogenic than others' Cell count and chemistry levels normalize slowly (days) with antibiotics

Viral Meningitis*
Normal or mildly increased Usually <500, nearly 100% mononuclear <48 hours, clinically significant polymorphonuclear pleocytosis may be indistinguishable from early bacterial meningitis, particularly with EEE Nontraumatic RBCs in 80% of patients with HSV meningoencephalitis, though 10% have normal CSF results

Microorganisms (none)

Gram stain 80% effective Inadequate decolorization may causeHaemophilus influenzae to be mistaken for gram-positive cocci Pretreatment with antibiotics may affect stain uptake, causing gram-positive species to appear to be gram-negative and decrease culture yield by an average of 20 Decreased

No organism

Glucose Euglycemia (>50% serum) Hyperglycemia (>30% serum) Protein Preterm (65-150 mg/dL) Term (20-170 mg/dL 6 mo+ (15-45 mg/dL)

Normal

Usually >150 mg/dL May be >1000 mg/dL

Mildly increased

CT Scan

Tirah baring Pemberian nutrisi parenteral e/ virus :

Asiklovir diberikan dengan dosis 10 mg/kgBB setiap 8 jam selama 10 hari atau peroral 200 mg/kgBB 5-6 kali sehari. Kadar Hemoglobin harus terus dipantau, bila Hb turun sampai 9 g/dl maka dosis diturunkan menjadi 200 mg setiap 8 jam. Jika Hb turun sampai 7 g/dl maka pengobatan dihentikan sementara waktu dan diberikan lagi setelah kadar Hb normal kembali. Antibiotik ; Ampisilin 4 x 3-4 gram Kloramfenikol 4x1 gram

e/ bakteri :

Steroid (dexamethasone)

Enterovirus Fecal oral transmission

Non Paralitik Poliomyelitis Paralitik Poliomyelitis Paralitik Poliomyelitis dengan kerusakan bulbar

Fisioterapi Intervensi Pembedahan Vaksin pencegahan