Meningitis

Symptoms:
1. Fever
2. headache
3. photophobia
4. Nuchal rigidity
• Nuchal rigidity = hurts to move back of neck

Diagnosis:
1. Kernig sign
• Thigh bent at hip with knee at 90 degrees
• Subsequent extension of knee is painful (resistance)

2. Brudzinski sign
• Lie patient at
• Lift head o table
• Involuntary lifting of legs

Signs are seen in:

• Usually meningitis
• Also subarachnoid hemorrhage

3. Spinal tap / lumber puncture:

• The spinal cord end at L1 or L2 so do spinal tap below it to avoid
never damage
• Right location L4/5

4. Opening pressure
• Measuring the pressure of uid in the spinal canal
• Patient position: to to lie on their side ( sitting will elevate the
pressure, gravity )
• Normal pressure up to 250mm H20
• Elevated pressure (>250):
• Bacterial
• Fungal/TB
• Rarely viral
• Elevated pressure in hydrocephalus

Pseudotumor cerebri and cryptococcal meningitis are treated by

draining some of the ICP as a therapeutic maneuver

Complications of Meningitis
• Death
• Hydrocephalus: due to scarring damage arachnoid villi
causing decrease absorption of CSF
• Hearing loss
• Seizures
• Most from bacterial meningitis ( more severe form )
Treatment:
Antibiotics depending on the age, co-
morbidities, spinal uid type until we get the
culture

Normal CSF
• Clear
• 0-5 lymphocytes
• <45mg/dl protein
• >45mg/dl glucose
• About 2/3 of blood glucose (80-120)
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 Shape Symptoms Transmission Risk

Neisseria Meningitidis Gram negative cocci in • bacteremia can
pairs (diplococci) complicate meningitis
called:
Polysaccharide Meningococcemia
capsule prevents Bacteria + meningitis =
phagocytosis meningococcemia
• Sepsis: fevers, chills,
Lipooligosaccharide
tachycardia
(LOS) outer membrane
similar to • Purpuric rash
lipopolysaccharide on • DIC / disseminated
gram negative rods intravascular
It’s endotoxin and coagulation
activate severe
in ammatory response • Waterhouse-
Friderichsen
syndrome: Adrenal
destruction from
meningococcemia =
cause hypotension and
the patient need
cortisol to maintain BP
= life threatening
usually reason why
young healthy patient
die
Transmitted by • Can cause
respiratory droplets outbreaks: Dorms,
• Enters pharynx then barracks
bloodstream then CSF • Can infect young,
• Many asymptomatic healthy people: College
carriers students in dorms
• Infected patients need
droplet precautions
( wear mask )
• Close contracts
receive prophylaxis:
Rifampin ( also used
to treat tuberculosis
(TB) )
Most of the patient to
like using it because it
turn tears, saliva color
to reddish- orange so
mostly replaced by
Ceftriaxone or
Cipro oxacin
• Vaccine available
Contains capsular
polysaccharides→anti-
capsule antibodies for
high risk group

Haemophilus Small, gram negative Used to be so common Enters pharynx then • H. Flu meningitis
In uenzae rod (coccobacillus) before the vaccines lymphatics then CSF almost always occurs in
( doesn’t cause the u, Hib conjugate vaccines unimmunized children
u caused by virus not given in infancy • May immigrate from
bacteria ) other countries without
vaccination

Listeria Gram positive rod • Undercooked meat, A ects people with

Facultative intracellular unwashed vegetables poor cell mediated
organism • Unpasteurized immunity so it tends to
“ tumbling motility “: cheese/milk a ect newborns and
unique way of • In neonates, also the elderly
movement transplacental or
vaginal transmission Multiplies in cells with
poor cell-mediated
immunity
Neonates, HIV, organ
transplant

Group B Strep Also called Strep May not have classic Most common cause
Agalactiae symptoms because meningitis in newborns
• Gram positive cocci they are babies they will • Transmitted when
in chains not complain of baby passes through
• Catalase negative photophobia, headache birth canal
• Beta hemolytic , unchallenged rigidity • Ampicillin during
bacteria • Hypotonia, labor can prevent
• CAMP test positive weaksucking re ex
( speci c ndings) • Bulging fontanels,
sunken eyes
• Poor feeding
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 Shape Disease Risk

Streptococcus Lancet-shaped, gram Can follow strep respiratory • Asplenic patients:

Pneumoniae positive cocci in pairs infection ( cold, pneumonia ) because we need the
spleen to destroy
otitis media (kids)
encapsulated organism
pneumonia
• Sickle cell: also called
sinusitis
functionally asplenic they
have a sleep but it’s not
working well
• Alcoholics

Shape Risk Agar

E. Coli Motile, gram-negative bacillus (rod) 2nd most common • Blood agar ( sheep blood
• Some strains have K-1 capsular antigen meningitis cause neonates )
which: • MacConkey agar:
• Inhibits complements, other immune selective gram negative
response bacteria if something
• Allows bacteria to evade host immunity grows on macconkey agar
then it’s an interrogate
bacteria from the GI tract
• Eosin methylene blue
agar

CSF Diagnosis

TB Meningitis CSF lymphocytes 1. Culture: Need multiple CSF samples

High protein, low glucose
Nucleic acid ampli cation tests (NAATs)
used
for culture because it hard to culture TB
2. Acid-fast bacilli ( AFB ): sometimes
seen in CSF quick way to test TB but
often negative
3. Nucleic acid ampli cation tests
(NAATs): used ( Use polymerase chain
reaction (PCR) techniques )

Types Transmission Treatment Diagnosis

Viral Meningitis / Old Usually enteroviruses Fecal-oral transmission • Self-limited Usually no speci c
name: “aseptic” • Coxsackievirus, • Supportive care – no virus testing only
echovirus, poliovirus speci c treatment exception:
• All single stranded 1. If HIV suspected
RNA viruses • Blood testing for HIV
• Rare causes RNA and HIV
• HSV antibody
• HIV 2. If you suspect HSV
• West Nile virus and anti-viral can be
• Varicella Zoster virus given

Herpes Simplex Virus

Features Treatment

HSV-1 • Oral herpes acyclovir, valacyclovir, famciclovi

• Eye infections (keratoconjunctivitis)
• Encephalitis-Loves to infect the TEMPORAL lobe

HSV-2 • Genital herpes acyclovir, valacyclovir, famciclovi

• 13 to 36% primary genital herpes pts have clinical
ndings of
meningitis (headache, photophobia and meningismus)
• Genital lesions in 85% patients with HSV-2 meningitis
HSV-2 and meningitis they kind go together
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 Meningitis Encephalitis

Symptoms 1. Fever 1. Altered mental status

2. headache 2. Motor or sensory de cits
3. photophobia 3. Altered behavior and personality changes
4. Nuchal rigidity 4. Speech/movementdisorders
• Nuchal rigidity = hurts to move
back of neck

Etiologies 1. HSV-1 is common

2. Varicella-zoster (chickenpox, shingles)
3. Mosquito viruses
• St. Louis encephalitis virus
• Eastern/western equine
• West Nile
• California encephalitis
4. Lassa fever encephalitis cause in ammation of
Lung, GI tract, heart, eyes
• Spread by mice ( kind similar to ebola )
• Hemorrhagic virus like Ebola (many other symptoms)
5. Measles rare due to vaccination and they survive measles but 5
to 10 years they develop subacute sclerosing panencephalitis
( which is in ammation of the whole brain = fatal )
6. Naegleria fowleri (protozoa)
It’s an amoeba found in freshwater lakes the bug get into your nose
then go to the brain = called brain eating amoeba
Freshwater lakes + fever + mental status changes + encephalitis
7. HIV encephalitis with very low CD4 count usually under < 200
hallmark multinucleated giant cells in brain + brain atrophy

Location of In ammation of meningis Encephalitis = brain in ammation

in ammation
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 All antibiotics used have good CSF penetration

Etiology gram

Gram positive Gram negative

1. Streptococcus pneumonia: + cocci 1. Neisseria meningitis: - cocci in pairs ( diplococci )
2. Group B strep / strep agalactiae: + cocci in 2. Haemophilus in uenza: - rod ( coccobacillus )
chain NOT in pairs 3. E.coli: - bacillus rod
3. Listeria: + rod
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