A study of meningitis in adults and non-adult patients in iraq

Introduction:

Meninges are three connective tissue coverings that surround, protect, and suspend the brain and spinal
cord within the cranial cavity and vertebral canal. They consist of:

1. dura mater, which is the thickest and most external of the coverings;

2. arachnoid mater, which is against the internal surface of the dura mater;

3. pia mater, which is adherent to the brain and spinal cord(1)

Meningitis is a rare infection of the leptomeninges (the leptomeninges are a combination of the arachnoid
mater and the pia mater). Infection of the meninges typically occurs via a blood-borne route, though in
some cases it may be by direct spread (e.g., trauma) or from the nasal cavities through the cribriform plate
in the ethmoid bone.(2)

The typical history of meningitis is non-specific at first.

Types of meningitis:
Bacterial meningitis: a world-wide disease, has to be reviewed periodically because the specific
micro-organisms responsible for the infection vary with time ,age and geography the four most common
infecting organisms are Streptococcus pneumoniae, Neisseria meningitidis, Listeria monocytogenes, and
Haemophilus influenzae.1–6 The frequency of Gram-negative bacilli other than H. influenzae has increased
over time. In the developing countries, these micro-organisms are also common, but the relative
frequencies are unknown. Acute bactrial meningitis is most common neurological disease thar cause death
(3)

Viral meningitis: due to viral infection, group b coxsackievirus and echovirus). Other viral causes: mumps,
Parechovirus, Herpesviruses (including Epstein Barr virus, Herpes simplex virus, and Varicella-zoster
virus), measles, influenza, and arboviruses (West Nile, La Crosse, Powassan, Jamestown Canyon) In most
cases we collected, there is no specific treatment for viral meningitis. Most people who get mild viral
meningitis usually recover completely in 7 to 10 days without treatment. Antiviral medicine may help people
with meningitis caused by viruses such as herpesvirus and influenza(4)

Fungal meningitis: Fungi causing meningitis include Cryptococcus neoformans ,Coccidioides immitis

,Aspergillus ,Candida(5)

Parasitic Meningitis: like Amebic Meningitis

Symptoms of meningitis:
The patient may have a mild headache, fever, drowsiness, and nausea. As the infection progresses,
photophobia (light intolerance) and ecchymosis may ensue. Straight leg raising causes marked neck pain
and discomfort (Kernig’s sign) and an emergency hospital admission is warranted.(6)

Diagnosis of meningitis:
Meningitis is diagnosed through cerebrospinal fluid (CSF) analysis, which includes white blood cell count,
glucose, protein, culture, and in some cases, polymerase chain reaction (PCR). CSF is obtained via a
lumbar puncture (LP), and the opening pressure can be measured. The CSF findings expected in bacterial,
viral, and fungal meningitis are listed in the chart: Expected CSF findings in bacterial versus viral versus
fungal meningitis. Ideally, the CSF sample should be obtained before initiating antimicrobials. However,
when the diagnosis of bacterial meningitis is seriously considered, and the patient is severely ill, antibiotics
should be initiated before performing the LP.(7)

Treatment:
Treatment of viral meningitis: Most viruses causing meningitis have no specific treatment other than
supportive care.Fluid and electrolyte management and pain control are the mainstays of management of
viral meningitis. Patients should undergo observation for neurological and neuroendocrine complications,
including seizures, cerebral edema, and SIADH. Because of the difficulty in differentiating viral from
bacterial meningitis initially, empiric antibiotic therapy is usually indicated until bacterial meningitis is ruled
out.In patients aged one month and older, empiric therapy for bacterial meningitis can be provided with
vancomycin in combination with either ceftriaxone or cefotaxime while culture results are pending.If
encephalitis is suspected, empiric antiviral treatment with intravenous acyclovir should be a
consideration.[Acyclovir should be the choice for suspected or proven HSV or VZV infections, although it
has been shown to provide benefits in HSV encephalitis, not meningitis.(8)

Antibiotics that use with Bacterial meningitis:

Cefotaxime:this antibiotic is use for No bacteria on Gram stain,Neisseria meningitidis (Gram-negative cocci
on Gram stain exam) , Streptococcus pneumoniae (Gram-positive diplococcus on Gram stain
exam),Hemophilus influenzae (Gram-negative small bacilli on Gram stain exam, infant, toddlers)
,Escherichia coli (Gram-negative bacilli on Gram stain exam) it given intravenously .

Amoxicillin and Gentamicin: it use for the L.monocytogenes (Gram-positive bacilli on Gram stain exam),S.
agalactiae (Group B Streptococcus) (Gram-positive cocci on Gram stain exam in newborn or young infant)
also give intravenously.(9)

Risk factors of meningitis:

After 2004, the overall rate of severe sequelae following single-episode BM was 44% (917/2084), and
patients on average lost 11 years of healthy life due to BM (Tables S8 and S9). The risk of severe sequelae
was higher among adults (49%, 788/1602) than children (27%, 129/482) (OR 2.6, CI95% 2.1–3.3, p <
0.001), and higher in the post-neurosurgical setting (67%, 123/183) than in the non-neurosurgical setting
(42%, 794/1901) (OR 2.9, CI95% 2.1–3.9, p < 0.001) (Fig. 3, Table S8). The highest severe sequelae rates
were found among patients with staphylococcal (62%, 179/287), polymicrobial (50%, 5/10) and
pneumococcal (47%, 425/905) infections (Table S8). The rate of neurological sequelae was 36%(10)

Mortality:
Importantly, the overall mortality was 9%, and this decreased during the study period in the elderly and
unvaccinated adults, while it remained low in children (3%). At the beginning of the study period , the
all-cause 30-day mortality among adult patients with BM was 16% (126/780); towards the end of the study
period , it was 9% (85/910) (OR 0.5, CI95% 0.4–0.7; p < 0.001).(11)

Infection transformation of meningitis:

each type has it specific way to spread Fungal meningitis is usually caused by a type of fungus called
Cryptococcus. This rare type of meningitis is most likely to strike people with weak immune systems.
Fungal meningitis is not contagious. Parasitic meningitis is extremely rare and life-threatening. It’s caused
by a microscopic amoeba called Naegleria fowleri. This parasite enters the body through the nose, usually
in contaminated lakes and rivers. You can’t get it by drinking contaminated water and it isn’t contagious.In
case of viral meningitis The enteroviruses that cause meningitis can spread through direct contact with
saliva, nasal mucus, or feces. They easily spread through coughing and sneezing. Direct or indirect contact
with an infected person increases your risk of getting the same virus, and finally bactrial meningitis
Meningococcal bacteria can’t survive outside the body for long, so you’re unlikely to get it from being near
someone who has it. Prolonged close contact with an infected person may increase risk of transmission.
This is a concern in daycare centers, schools, and college dormitories.The bacteria can also spread
through:saliva,mucus,kissing,sharing,eating,utensils,coughing,sneezing,contaminated food. (12)

prevention:
Vaccines offer the best protection against common types of bacterial meningitis.

Vaccines can prevent meningitis caused by:

meningococcus

pneumococcus

haemophilus influenzae type b (Hib).Bacterial and viral meningitis can spread from person to person. If you
live with someone who has either type of meningitis, you should:Talk to your doctor or nurse about taking
antibiotics (in case of bacterial meningitis)Wash hands frequently, especially before eatingAvoid close
contact and sharing cups, utensils or toothbrushes.

1. Vaccination

Licensed vaccines against meningococcal, pneumococcal and Haemophilus influenzae disease have been
available for many years. These bacteria have several different strains (known as serotypes or serogroups)
and vaccines are designed to protect against the most harmful strains. No universal vaccine exists.In the
African meningitis belt, meningococcus serogroup A accounted for 80–85% of meningitis epidemics before
the introduction of a meningococcal A conjugate vaccine through mass preventive campaigns (since 2010)
and into routine immunization programmes (since 2016). Continuing introduction into routine immunization
programmes and maintaining high coverage is critical to avoid the resurgence of epidemics.

2. Antibiotics for prevention (chemoprophylaxis)

Antibiotics for close contacts of those with meningococcal disease, when given promptly, decreases the
risk of transmission. Outside the African meningitis belt, chemoprophylaxis is recommended for close
contacts within the household. Within the meningitis belt, chemoprophylaxis for close contacts is
recommended in non-epidemic situations. Ciprofloxacin is the antibiotic of choice, and ceftriaxone an
alternative.Identifying mothers whose babies are at risk of getting Group B streptococcal disease is
recommended in many countries. Mothers at risk are offered intravenous penicillin during labour to prevent
their babies developing Group B streptococcal infection.(13)

The incidence of meningitis worldwide is estimated to be 20 cases per 100,000 people; that is, about 1.2
million; the incidence and causes vary across geographic regions (5). Most outbreaks occur in sub-Saharan
Africa. The epidemic of meningococcal infections in Africa, New Zealand, and Singapore indicates that the
infection is still a major health problem or a global outbreak. Australia, Norway, the Netherlands, China,
Egypt, and Saudi Arabia are among the areas where the disease epidemic occurred14
Aims of study
1) To provide a general knowledge about the meeting and its types

2) To detect the period of meningitis treatment

3) To play a role in the prevention of this disease in our country

4) To get stronger background to deal with this disease as future doctors

Methods
We reviewed the charts of too many meningitis Patients in Nasiriyah Teaching Hospital from 2022 to 2023
to get the cases then we asked the meningitis patients about the disease and complications of it and how
they living with such danger condition then we asked the doctors about course of treatment .our study area
is whole iraq because the information we collected is not only from our governorate only but we use the
Polls we distributed it on the internet to collect patients information . we study patients of all ages from the
age of 2 monthes untill the age of 60 years and we collect about 60 samples of patients to include Thier
information in this study . We dont include the names of our patients and some of special data become one
of our carrier Professional ethics is to preserve patients secrets and the Statistical analysis is in simple way

Results:
The cases age:

About 57.5% of the cases we collected was an adult and 10% of them was Teenagers and the 32.5% was
childs and newborns

**We use the equation %=n÷m × 100

Where n is number of cases in particular age m is the total cases number (60 case)

Cases classification : the cases according to the types

 we collect 10 cases that were clearly said to have bacterial meningitis, two of them were dead and
the most treated cases was a childes and new born and they discovered early the treatment take 2
weeks .
 About viral meningitis we have 7 cases the viral type haven’t specific treatment they undrgo the
intensive care treatment and most of them was treated while 1 of them were dead

 We dont collect a cases about parasitic and fungal meningitis

 In one of the cases the patient was in chronic hypertension state so he was take laxis as treatment
after he developed meningitis he used gentamicin and after he returned to laxis he lost hearing

 One of cases was for a child who was playing in sun at 40c° after that he was sick and diagnosed
as meningitis then he treated with antibiotics

Type Bacterial Viral Other

Number of cases Clearly 10 cases Clearly 7 cases 2 case
Dead 2 cases 1 case ---
Treated 5 cases 6 cases Both of them

COMPLICATIONS:

Cysts of water in crainal cavity of patients who was treated we noticed it in two cases, the other
complications is that which include the defect in movement and it include paralysis ,seizures,stroke.

Growth retardation,athrophy of endocrine gland ,anemia, immune defect all of these we noticed in 3
years child treated from meningitis.

Hearing problem that we discovered are three all are associated with memory lose or defect it may
be lost of entire hearing or only when hear loud sounds one of them can understand our speech but
he cant response to us.

Sextual problem involve defect in erectation and infertility

Coma is the most common complication we found in 70% of the patients who delay discovered and
the death is Strong possibility in the comatose meningitis patient

We noticed that all this complications associated with the part of brain in the area of inflammation
and some of them are side effect to treatment as in the sextual problem

Transition of meningitis:
In addition to the information we listed in the introduction we observe that The meningitis may also
be transmitted by the carying person one of our cases his wife was dead in meningitis and he
married other wife after 4 monthes his new wife was diagnosed as she have meningitis
 Treatment periods viral meningitis treatment period is vary from 1 month to three
monthes while bacterial type period is different according to the type of bacteria we list the
periods we observed in the following table

Bacteriological targets Duration

S. pneumoniæ 10-14 days
H. influenzae b 7 dayes
N. meningitidis 5-7 days
L. monocytogenes 14-21 days
E.coli 21 days
S. agalactiae 14-21 days
Discussion:
In the first poient when we study the (ACUTE BACTERIAL MENINGITIS IN ADULTS,A Review of 493 Episodes

,MARLENE L. DURAND, M.D., STEPHEN B. CALDERWOOD, M.D., DAVID J. WEBER, M.D., M.P.H.,

SAMUEL I. MILLER, M.D., FREDERICK S. SOUTHWICK, M.D., VERNE S. CAVINESS, JR., M.D.,

AND MORTON N. SwARTZ, M.D) it said that S. Pneumoniæ was the most common cause of bacterial
meningitis while in our study cases it was the Neisseria meningitidis.

Other point is in (Antibiotic treatment of neuro-meningeal infections،Yves Gillet a,b, Emmanuel Grimprel b,c,d, Hervé Haas b,e,f,
Maria Yaghy a, François Dubos b,g, Robert Cohen b,h,i,⇑) said that Cefotaxime is the most common treated for N.
Meningitidis while the most used antibiotic to N. Meningitidis in cases we collected is Amoxicillin

Last point is in the(How Contagious Is Meningitis?Medically reviewed by Deborah Weatherspoon, Ph.D., MSNBy Ann Pietrangelo)

They not said that the meningitis can transition by a person without affect of the same person as we.

Conclsions:
The result show that the most common type of meningitis is the bactria and this bactria have

Two ways to cause it which ethier develop from other disease such as the tuberculosis or it

Apear at the injury or with the first years of life.

Recommendations
in a disease such as meningitis its treatment depends on the early discover of the disease so if we
increase the knowledge of people about it and how it spreads and increase the ability as a doctor to
prognosis of this disease it will greatly prevent. In case of viral meningitis its nessary to improve the
technologies in the intensive care rooms so we can deal more effectively with patients and incrase the
possibility of patients remission.

Our idea : the meningitis is a disease that can be sextually transmission

and this type of disease my be asymptomatic in the case of bacterial
meningitis which usually not Contagious but in our study we see one of
the cases was strongly Contagious that suggested its viral but at the
same time was asymptomatic here It is now understood that individuals
with very mild or no symptoms make up a large proportion of infected
individuals . We also now understand that an individual may become
infectious before developing symptoms, referred to as pre-symptomatic
infection . Progression can also be non-linear, with individuals moving
between symptomatic and asymptomatic phases over time. A classic
example is HIV, where an individual at their primary infection may
develop fever, fatigue and night sweats at which point they are more
infectious, live without symptoms for 10 years with limited infectiousness,
before progressing to symptoms of AIDS. So we think that some viruses
that causes meningitis have the same mechanism.
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