PBL 03

My Baby’s Neck is Stiff

1. Differentiate between normal CSF and CSF in meningitis (bacterial, tuberculosis and viral) on
the basis of clinical and CSF findings.

Meningitis is an inflammatory process involving leptomeninges. If infection spreads into the

underlying brain it is termed as meningoencephalitis.
The brain and its covering or any part can be sites of infection. Some have predilection
(RABIES) or part of systemic infection (S.AUREUS). Also due to direct injury of neuron and glial
cells toxins, or as a consequence of host innate or adaptive immune response.
Signs in newborns

Newborns and infants may show these signs:

● High fever
● Constant crying
● Excessive sleepiness or irritability
● Difficulty waking from sleep
● Inactivity or sluggishness
● Not waking to eat
● Poor feeding
● Vomiting
● A bulge in the soft spot on top of a baby's head (fontanel)
● Stiffness in the body and neck
● Infants with meningitis may be difficult to comfort, and may even cry harder when held.
BACTERIAL (pyogenic) MENINGITIS:

VIRAL (aseptic) MENINGITIS:

TUBERCULOUS (chronic) MENINGITIS:

2. Describe mechanism of action, clinical uses and adverse effects of cell wall synthesis
inhibitors.
3. Describe pharmacokinetics, clinical uses and side effects of drugs which modulate
histaminergic (H1) systems.

LGs:
nuchal rigidity
Nuchal is Base of neck
the sign used to diagnose meningitis is called nuchal rigidity. Nuchal rigidity is an inability to flex
the neck forward due to rigidity of the neck muscles.

No rash was seen on the body

Meningococcal bacteria reproduce in the bloodstream and release poisons (septicemia). As the
infection progresses, blood vessels can become damaged. This can cause a faint skin rash that
looks like tiny pinpricks. The spots may be pink, red, or purple.
In the early stages, there may not be a rash, or the rash may fade on pressure. The rash usually
occurs in the later stages of meningitis

Babinski: Positive
The Babinski reflex occurs after the sole of the foot has been firmly stroked. The big toe then
moves upward or toward the top surface of the foot. The other toes fan out.
This reflex is normal in children up to 2 years old. It disappears as the child gets older. It may
disappear as early as 12 months.
When the Babinski reflex is present in a child older than 2 years or in an adult, it is often a sign
of a central nervous system disorder.

Discuss the contra- indications of L/P

Contraindications
As with any procedure, there are times when it is not safe to proceed with lumbar puncture.
These contraindications are:
* Skin infection near the site of the lumbar puncture
* Suspicion of increased intracranial pressure due to a cerebral mass
* Uncorrected coagulopathy
* Acute spinal cord trauma
The presence of skin infection near the site of the LP increases the risk of carrying the infection
into the CSF with the LP needle.

Which bacteria is responsible for meningitis in different age groups?

INDICATION OF MENINGITIS IN ADULTS

Meningitis is a serious infection of the meninges, the membranes covering the brain and spinal
cord. It is a devastating disease and remains a major public health challenge. The disease can
be caused by many different pathogens including bacteria, fungi or viruses, but the highest
global burden is seen with bacterial meningitis.
Several different bacteria can cause meningitis. Streptococcus pneumoniae, Haemophilus
influenzae, Neisseria meningitidis are the most frequent ones.
The swelling from meningitis typically triggers signs and symptoms such as headache, fever
and a stiff neck.

Possible signs and symptoms in anyone older than the age of 2 include:

● Sudden high fever

● Stiff neck
● Severe headache that seems different from normal
● Headache with nausea or vomiting
● Confusion or difficulty concentrating
● Seizures
● Sleepiness or difficulty waking
● Sensitivity to light
● No appetite or thirst
● Skin rash (sometimes, such as in meningococcal meningitis)

Transmission
The bacteria that cause meningitis are transmitted from person-to-person through droplets of
respiratory or throat secretions from carriers. Close and prolonged contact – such as kissing,
sneezing or coughing on someone, or living in close quarters with an infected person, facilitates
the spread of the disease. The average incubation period is 4 days but can range between 2
and 10 days.

Neisseria meningitidis only infects humans. The bacteria can be carried in the throat and can
sometimes overwhelm the body's defences allowing infection to spread through the
bloodstream to the brain. A significant proportion of the population (between 5 and 10%) carries
Neisseria meningitidis in their throat at any given time

Risk factors for meningitis include:

Skipping vaccinations. Risk rises for anyone who hasn't completed the recommended childhood
or adult vaccination schedule.

Age. Most cases of viral meningitis occur in children younger than age 5. Bacterial meningitis is
common in those under age 20.

Living in a community setting. College students living in dormitories, personnel on military

bases, and children in boarding schools and child care facilities are at greater risk of
meningococcal meningitis. This is probably because the bacterium is spread through the
respiratory route, and spreads quickly through large groups.

Pregnancy. Pregnancy increases the risk of listeriosis — an infection caused by listeria bacteria,
which may also cause meningitis. Listeriosis increases the risk of miscarriage, stillbirth and
premature delivery.

Compromised immune system. AIDS, alcoholism, diabetes, use of immunosuppressant drugs

and other factors that affect your immune system also make you more susceptible to meningitis.
Having your spleen removed also increases your risk, and anyone without a spleen should get
vaccinated to minimize that risk.

Complications
Meningitis complications can be severe. The longer you or your child has the disease without
treatment, the greater the risk of seizures and permanent neurological damage, including:

● Hearing loss
● Memory difficulty
● Learning disabilities
● Brain damage
● Gait problems
● Seizures
● Kidney failure
● Shock
● Death
Cell wall synthesis inhibitors:
A number of drugs inhibit cell wall synthesis. Most important are vancomycin, which targets
monomer polymerization; and the β-lactams, e.g., penicillins and cephalosporins, which block
polymer cross-linking. β-lactam antibacterial agents also activate autolysins. Autolysins punch holes
in bacterial cell wall and disrupt its integrity. Transpeptidase antagonism and autolysis prevent
bacterial self-maintenance, i.e., remodeling and repair; and replication.

Vancomycin:
Vancomycin is bactericidal in susceptible organisms. It is primarily effective against
aerobic gram-positive cocci and bacilli. It does have activity against some anaerobic gram-positive,
but not against gram-negative bacilli. Since facultative and anaerobic gram-positive and gram-
negative cocci and bacilli predominate in all types of odontogenic infections, Vancomycin does not
have the requisite spectrum to be considered an empirical option in treating odontogenic infections.

It works by killing bacteria or preventing their growth. Vancomycin will not work
for colds, flu, or other virus infections. Vancomycin injection is also used to treat
serious infections for which other medicines may not work.
Mechanism of Action: Inhibits cell wall synthesis by binding to the D-Ala-D-Ala
terminal of the growing peptide chain during cell wall synthesis, resulting in inhibition of
the transpeptidase, which prevents further elongation and cross-linking of the
peptidoglycan matrix (see glycopeptide pharm).

CLINICAL USES:
Bacterial infections
skin infections
bloodstream infections
endocarditis
bone and joint infection
meningitis

SIDE EFFECTS:
low blood pressure accompanied by flushing
bitter taste
chills
vomiting
drug fever
eosinophilia

Penicillins:
 They are group of antibiotics originally obtained from penicillium moulds.
Most penicillins in clinical use are chemically synthesized from naturally produced
penicillins.
Mechanism of action:
Inhibits bacterial cell wall synthesis by binding and inactivating proteins
(penicillin binding proteins) present in the bacterial cell wall. Penicillins inhibit the
transpeptidation reaction and block cross-linking of the cell wall.

CLINICAL USES:
pneumonia
strep throat
meningitis
syphilis
gonorrhoae
respiratory tract infections
scarlet fever
ear, skin, mouth and throat infections

SIDE EFFECTS:

nausea
vomiting
epigastric distress
diarrhea
black hairy tongue

Cephalosporins:
Cephalosporins are a large group of antibiotics derived from the mold
Acremonium (previously called Cephalosporium). Cephalosporins are bactericidal (kill
bacteria) and work in a similar way to penicillins.

Mechanism of action:
Initially derived from the fungus Cephalosporium sp., cephalosporins are a large group
of bactericidal antimicrobials that work via their beta-lactam rings. The beta-lactam rings
bind to the penicillin-binding protein and inhibit its normal activity.

CLINICAL USES:
skin or soft tissue infections
urinary tract infections
respiratory tract infections
 SIDE EFFECTS:
stomach upset
nausea
dizziness
vomiting
diarrhea
yeast infection or oral thrush

h1 antaGonist:
They are also called H1 blockers, are a class of medications that block the action
of histamine at the H1 receptor, helping to relieve allergic reactions.

Mechanism of action:
The primary mechanism of antihistamine action in the treatment of
allergic diseases is believed to be competitive antagonism of histamine binding to
cellular receptors (specifically, the H1-receptors), which are present on nerve endings,
smooth muscles, and glandular cells.
CLINICAL USES:
allergic rhinitis
urticaria
allergic conjunctivitis
diarrhea
angioedema
pruritis

SIDE EFFECTS:
dizziness
tinnitus
blurred vision
euphoria
anxiety
insomnia
tremor
vomiting
Dimenhydrinate:
Dimenhydrinate is an antihistamine that reduces the effects of natural
chemical histamine in the body. Dimenhydrinate is used to treat or prevent nausea,
vomiting, and dizziness associated with motion sickness. Dimenhydrinate may also be
used for purposes not listed in this medication guide.
Dimenhydrinate is used to prevent and treat nausea, vomiting, and
dizziness caused by motion sickness. Dimenhydrinate is in a class of medications
called antihistamines. It works by preventing problems with body balance.
Mechanism of action:
Dimenhydrinate competitively blocks H1 receptors, thereby preventing
the actions of histamine on bronchial smooth muscle, capillaries and gastrointestinal
(GI) smooth muscle. This prevents histamine-induced bronchoconstriction, vasodilation,
increased capillary permeability, GI smooth muscle spasm.
Side effects:
drowsiness
ringing in the ear
dry mouth, nose or throat
blurred vision
problems with coordination
headache
excitement or hyperactivity

REFERENCE:
1. https://www.who.int/health-topics/meningitis#tab=tab_1
2. https://www.mayoclinic.org/diseases-conditions/meningitis/symptoms-causes/syc-
20350508
3. ROBINS BASIC PATHOLOGY
4. KATZUNG