MENINGITIS

o The brain and spinal cord are covered by

connective tissue layers collectively called the
meninges which form the blood-brain barrier.
1-the pia mater (closest to the CNS)
2-the arachnoid mater
3-the dura mater (farthest from the CNS).
The meninges contain cerebrospinal fluid (CSF).
Meningitis is an inflammation of the meninges, which,
if severe, may become encephalitis, an
inflammation of the brain.


ETIOLOGY
-Bacterial Infections
-Viral Infections
-Fungal Infections
(Cryptococcus neoformans
Coccidiodes immitus)
-Inflammatory diseases
(SLE)
Cancer
-Trauma to head or spine.

Bacterial meningitis
Etiological Agents:
Pneumococcal, Streptococcus pneumoniae (38%)

Meningococcal, Neisseria meningitidis (14%)

Haemophilus influenzae (4%)

Staphylococcal, Staphylococcus aureus (5%)

Tuberculous, Mycobacterium tuberculosis


Bacterial Meningitis
Potentially life threatening disease.
One million cases per year world wide. 200,000 die annually.
Can affect all age groups but some are at higher risk.
Treatment available : antibiotics as per causative organism
Humans are the reservoir .
Pneumococcal meningitis is the most common type.
Approximately 6,000 cases/yr
Haemophilus meningitis: Since 1985 Incidence has declined by
95% due to the introduction of Haemophilus influenza b
vaccine.
Other bacterial meningitis caused by E-Coli K-1, Klebsiella species
and Enterobacter species are less common overall, but may be
more prevalent in newborns, pregnant women, the elderly
and immunocompromised hosts.

Meningococcal disease

Etiological Agent: Neisseria meningitidis
Clinical Features: sudden onset. F,H,N,V
Reservoir: Humans only. 5-15% healthy carriers
Mode of transmission: direct contact with patients oral or nasal
secretions. Saliva.
Incubation period: 1-10 days. Usually 2-4 days
Infectious period: as long as meningococci are present in oral secretions
or until 24 hrs of effective antibiotic therapy
Epidemiology:
Sporadic cases worldwide.
Meningitis belt sub-Saharan Africa into India/Nepal.
In US most cases seen during late winter and early spring.
Children under five and adolescent most susceptible. Overcrowding e.g.
dormitories and military training camps predispose to spread of
infection.

Aseptic Meningitis
Definition: A syndrome characterized by acute onset of
meningeal symptoms, fever, and cerebrospinal fluid
pleocytosis, with bacteriologically sterile cultures.

Laboratory criteria for diagnosis:
CSF showing 5 WBC/cu mm
No evidence of bacterial or fungal meningitis.

Case classification
Confirmed: a clinically compatible illness diagnosed by a
physician as aseptic meningitis, with no laboratory
evidence of bacterial or fungal meningitis

Comment
Aseptic meningitis is a syndrome of multiple etiologies, but
most cases are caused by a viral agent
Viral Meningitis
Etiological Agents:
Enteroviruses (Coxsackie's and echovirus): most common.
-Adenovirus
-Arbovirus
-Measles virus
-Herpes Simplex Virus
-Varicella
Reservoirs:
-Humans for Enteroviruses, Adenovirus, Measles, Herpes Simplex,
and Varicella
-Natural reservoir for arbovirus birds, rodents etc.
Modes of transmission:
-Primarily person to person and arthopod vectors for Arboviruses
Incubation Period:
-Variable. For enteroviruses 3-6 days, for arboviruses 2-15 days
Treatment: No specific treatment available.
Most patients recover completely on their own.
Non Polio Enteroviruses
Types:62 different types known:

-23 Coxsackie A viruses,
-6 Coxsackie B viruses,
-28 echoviruses, and 5 other

How common?
-90% of all viral meningitis is caused by Enteroviruses
-Second only to "common cold" viruses, the rhinoviruses.
-Estimated 10-15 million/ more symptomatic infections/yr in US

Who is at risk? Everyone.

How does infection spread?
Virus present in the respiratory secretions & stool of a patient.
Direct contact with secretions from an infected person.
Parents, teachers, and child care center workers may also become
infected by contamination of the hands with stool.


The difference between Meningitis and Septicaemia

When bacteria cause disease i.e. meningococcal
disease the body can be affected in different ways:
Meningitis - bacteria enter the blood stream and
travel to the meninges and cause inflammation.
Septicaemia - when bacteria are present in the
blood stream they can multiply rapidly and release
toxins that poison the blood. (The rash associated
with meningitis is due to septicaemia.)
Meningitis and septicaemia often occur together.



Symptoms of Meningitis and Septicemia


Meningitis and meningococcal septicaemia may not
always be easy to detect, in early stages the
symptoms can be similar to flu. They may develop
over one or two days, but sometimes develop in a
matter of hours.

It is important to remember that symptoms do not
appear in any particular order and some may not
appear at all.


Symptoms for meningitis and meningococcal septicaemia:

:Babies and Young Children
-High temperature, fever, possibly with cold hands and feet
-Vomiting or refusing feeds
-High pitched moaning, whimpering cry
-Blank, staring expression
-Pale, blotchy complexion
-Stiff neck
-Arched back
-Baby may be floppy, may dislike being handled, be fretful
-Difficult to wake or lethargic
-The fontanelle (soft spot on babies heads) may be tense or
bulging.


Older Children and Adults

-High temperature, fever, possibly with cold hands and
feet.
-Vomiting, sometimes diarrhoea.
-Severe headache.
-Joint or muscle pains, sometimes stomach cramps.
-Neck stiffness (unable to touch the chin to the chest)
-Dislike of bright lights.
-Drowsiness.
The patient may be confused or disorientated. Fitting may
also be seen.
A rash may develop.


One of the physically
demonstrable
symptoms of meningitis
is Kernig's sign. Severe
stiffness of the
hamstrings causes an
inability to straighten
the leg when the hip is
flexed to 90 degrees.
Another physically
demonstrable
symptoms of meningitis
is Brudzinski's sign.
Severe neck stiffness
causes a patient's hips
and knees to flex when
the neck is flexed.




In the early stages, signs and symptoms
can be similar to many other more
common illnesses, foe example flu.
Early symptoms can include fever,
headache, nausea (feeling sick),
vomiting and general tiredness.
The common signs and symptoms of
meningitis and septicaemia are
shown above. Others can include
rapid breathing, diarrhoea and
stomach cramps. In babies, check if
the soft spot (fontanelle) on the top
of the head is tense or bulging.

One sign of meningococcal septicaemia is a rash that
does not fade under pressure (see Glass test)
-This rash is caused by blood leaking under the skin. It
starts anywhere on the body. It can spread quickly to
look like fresh bruises.
-This rash is more difficult to see on darker skin. Look
on the paler areas of the skin and under the eyelids.


Glass Test


A rash that does not fade
under pressure will still be
visible when the side of a
clear drinking glass is
pressed firmly against the
skin.
If someone is ill or obviously
getting worse, do not wait
for a rash. It may appear
late or not at all.
A fever with a rash that does
not fade under pressure is
a medical emergency.
Differential Diagnoses
The diseases most frequently confused with
meningitis are brain abscess, meningeal
carcinomatosis, CNS vasculitis, stroke, encephalitis.

Treatment
1. bacterial meningitis
Empiric antibiotics must be started immediately, even before the
results of the lumbar puncture and CSF analysis are known. The choice
of initial treatment depends largely on the kind of bacteria that cause
meningitis in a particular place.
2. Viral meningitis typically requires supportive therapy only; most
viruses responsible for causing meningitis are not amenable to specific
treatment. Viral meningitis tends to run a more benign course than
bacterial meningitis.
3. Fungal meningitis, such as cryptococcal meningitis, is treated with
long courses of highly dosed antifungals , such as amphotericin B and
flucytosine . Raised intracranial pressure is common in fungal
meningitis, and frequent (ideally daily) lumbar punctures to relieve the
pressure are recommended, or alternatively a lumbar drain.
Prognosis

Patients with viral meningitis usually have a good
prognosis for recovery.
The prognosis is worse for patients at the
extremes of age (ie, <2 y, >60 y) and those with
significant comorbidities and underlying
immunodeficiency.
Patients presenting with an impaired level of
consciousness are at increased risk for developing
neurologic sequelae or dying.
A seizure during an episode of meningitis also is a
risk factor for mortality or neurologic sequelae.