Coccidiodes
Histoplasmosis
Mucormycosis
Aspergilosis
Candidasis
Toxoplamosis
Hydatid
Amoeba
Malaria
Cysticercosis
Organisms Causing Meningitis
Rickettsial
Rocky mountain spotted fever
Organisms Causing Meningitis
Others
Tuberculosis
Borrelia burgdorferi
Treponema pallidum
Mycoplasma pneumoniae
brucella
Chlamydia
Organisms Causing Meningitis
viral meningitis
fairly common disease but rarely fatal
lymphocytic predominance ie mononuclear
cells (but may see neutrophils if CSF
sampled early in course - up to 48hrs
glucose not reduced
Organisms Causing Meningitis
may follow Temporary, flu-like symptoms with
running nose sneezing etc., headache, low grade
fever and stiff neck.
Goes away on its own usually within three to 10
days
Bed rest, paracetamol
Enteroviruses, the most common type of viral
meningitis
Strict isolation is not necessary
Organisms Causing Meningitis
Since most cases are due to enteroviruses
that may be passed in the stool, people
diagnosed with viral meningitis should be
instructed to thoroughly wash their hands
after using the toilet.
Organisms Causing Meningitis
The incidence of viral meningitis drops with age.
Neonates are at greatest risk and have the most
significant risk of morbidity and mortality.
Low
power
view
showing
many
neutrophi
ls.
CSF-Gram stain:
High
power
shows
clusters of
bacteria.
Neutrophil
s
CSF-Gram stain:
High
power
shows
clusters of
bacteria.
Neutrophil
CSF-Gram stain:
High
power
shows
clusters of
bacteria.
Neutrophil
CSF-Gram stain:
Observe
Paired
rounded
bacteria –
(diplococci)
staining
pink (gram
negative)
Pathogenesis of Meningitis
The virus or bacteria replicates in the initial
organ system (ie, respiratory or
gastrointestinal mucosa) and gains access to
the bloodstream. Primary viremia or
bacteremia introduces the virus or bacteria
to the reticuloendothelial organs (liver,
spleen, and lymph nodes.)
Pathogenesis of Meningitis
If the replication persists despite
immunologic defenses, secondary
bacteremia or viremia occurs, which is
thought to be responsible for seeding of the
CNS. Rapid viral replication likely plays a
major role in overcoming the host defenses.
Pathogenesis of Meningitis
There occurs local immune response to
bacteria or virus
Increased vascular permeability
oozing of fluid exudate,inflammatory cells
Neutrophils migrate from capillaries and
release toxins
TNF-a and IL-B1 produced by activated
macrophages and endothelial cells
Pathogenesis of Meningitis
Ensuing inflammatory response increases
blood-brain permeability
Cerebral edema
Increased ICP
Pathogenesis of Meningitis
cellular damage and loss of cellular homeostasis
and worsen cerebral edema
damage to vessels lead to vasculitis and bleed or
thrombose leading to infaraction or haemorrahage
Headache
--Nuchal rigidity
Lethargy
Irritability
Restlessness
Poor feeding
Back pain
Opisthotonos
Focal neurologic signs
Hypertension
Irregular
respiration
Severe headache
herniation
vomitting
Meningococcemia - Petechiae
Signs & symptoms of Meningitis
Is due to small skin bleed
All parts of the body are affeced
The rashes do not fade under pressure
Pathogenesis:
a. Septicemia
b. wide spread endothelial damage
c. activation of coagulation
d. thrombosis and platelets aggregation
Signs & symptoms of Meningitis
e. reduction of platelets (cosumption )
f. BLEEDING 1.skin rashes
2.adrenal hemorrhage
Arenal hemorrhage is called Waterhouse-
Friderichsen Syndrome.It cause acute
adrenal insufficiency and is uaually fatal
Meningococcemia - Purpura
fulminans
Signs & symptoms of Meningitis
May also look like bruises,echymosis .
Complications and Outcome of
Meningitis
Infection can spreading to
Dura – pachymeningitis
Leptomeninges - leptomeningitis
Brain – encephalitis
Spinal cord – myelitis
Ventricles - ventriculitis
Complications and Outcome of
Meningitis
Disseminated intravascular coagulation (DIC)
Cerebral edema
May be age-specific
Complications and Outcome of
Meningitis
Tiredness
Recurring headaches
Memory loss, which may be severe
Difficulties in concentration
Anger outbursts
Clumsiness
Differential Diagnosis of
Meningitis
Brain abscess
Encephalitis
Tumor like
ASTROCYTOMAS,OLIGODENDROGLIOMAS
,EPENDYMOMAS
MIXED GLIOMAS
Metastatic tumor
Subdural and epidural empyema
subdural
subarachnoid
Differential Diagnosis of
Meningitis
Chemical meningitis: Rupture of tumor
intracranial haemorrage like
Epidural
subdural
Subarachnoid
intraparenchymal
Differential Diagnosis of
Meningitis
metabolic encephalopathy
hyperglycaemic coma
uremia
hepatic encephalopathy
vit B deficiencies
vascular diseases (amyloid angiopathy,
vasculitis, berry aneurysms, A-V
malformations
CSF & LUMBER PUNCTURE
It is produced in the brain by modified ependymal
cells in the choroid plexus (approx. 50-70%), and
the remainder is formed around blood vessels and
along ventricular walls. It circulates from the
choroid plexus through the interventricular
foramina (foramen of Monro) into the third
ventricle, and then through the cerebral aqueduct
(aqueduct of Sylvius) into the fourth ventricle,
where it exits through two lateral apertures
(foramina of Luschka) and one median aperture
(foramen of Magendie).
CSF & LUMBER PUNCTURE
It then flows through the
cerebellomedullary cistern down the spinal
cord and over the cerebral hemispheres.
CSF & LUMBER PUNCTURE
The cerebrospinal fluid is produced at a rate
of 500 ml/day. Since the brain can only
contain from 135-150 ml, large amounts are
drained primarily into the blood through
arachnoid granulations in the superior
sagittal sinus. Thus the CSF turns over
about 3.7 times a day.
CSF & LUMBER PUNCTURE
Direct cranial measurement of ICP.
1. Diagnostic aid
2. Therapy for idiopathic intracranial
hypertension
3. Infusion of anaesthetic (“spinal”),
chemotherapy, or contrast agents
(myelography)
CSF & LUMBER PUNCTURE
Contraindications
- INR > 1.4 or other coagulopathy
- platelets < 50
- infection at desired puncture site
- obstructive / non-communicating hydrocephalus
- intracranial mass
- high intracranial pressure (ICP) / papilloedema
CSF & LUMBER PUNCTURE
An LP may safely be performed without
first doing a CT head in a young previously
healthy patient with no history of seizures, a
normal level of consciousness and a normal
neurological exam.
CSF & LUMBER PUNCTURE
Anatomy
INCORRECT CORRECT
CSF & LUMBER PUNCTURE
6.Put on mask and sterile gloves.
7.Sterilize the field using the sterilizing
solution and sponges provided. Clean a 6
inch area around the desired entry site,
proceeding outward in concentric circles.
Do this 3 separate times. Place sterile drape
over the field.
Skin Preparation
Overlying skin cleaned
with povidone-iodine
fungal culture
viral culture
normally 14 mg/dl
in bacterial meningitis is usually <25 mg/dl
PCR for microbial DNA may become
sensitive and specific method for bacterial
identification
CSF & LUMBER PUNCTURE
CT Scanning sould be done and preferred choice
before Lumbar Puncture in Suspected Meningitis
>50 (2.2
Normal <5 , lymphocytes mainly 5-45 mmol to 4
mmol/l)
Bacterial, 100-500 or <2.2 m
>1000K PMN’s
acute >1.5gm/l mol/l
Viral Low to
<1000 increased
normal
TB <500 increased decreased
Fungal < 500 increased decreased
CSF Diagnosis
WBC Glucose Protein
Normal <5 2/3rd of serum 15 to 45
(lymphocytes) glucose mg/dl
Bacterial >1000 PMN’s Low Elevated
Meningitis predominate (>100 mg)