BACTERIAL

MENINGITIS
- MARIA CHRISTMA B. UMBAÑA
 FLOW OF THE STUDY

Pathology of Pathophysiology Sign and

the disease of the disease Symptoms

Laboratory
Treatment
Findings
 OUR CASE:

• A 7 YEAR OLD GIRL WAS BROUGHT IN BY HER MOTHER WITH A THREE DAY
HISTORY OF HEADACHE, PAIN IN THE LEFT EAR, FEVER AND VOMITING. HER
MOTHER WAS CONCERNED BECAUSE THE LAST TIME SHE HAD BEEN SICK LIKE
THIS SHE HAD TO BE ADMITTED TO HOSPITAL.
 PAST MEDICAL HISTORY:
Child has had six previous hospital admissions for
Streptococcus pneumoniae meningitis starting from age
3 years and occurring at approximately six monthly
intervals, with the most recent admission having been
eight months prior to this presentation.

On each admission Streptococcus pneumoniae was

isolated from cerebrospinal fluid (CSF) sensitive to
ceftriaxone. Serotype testing was not available.

The child was treated with 10 days of IV ceftriaxone and

on each occasion CSF was cleared of infection.
 PAST MEDICAL HISTORY:

At discharge on all admissions CSF was clear with

resolution of meningitis.

On her third admission at age four she was

found to be HIV positive and started on HAART.

No history of seizures, head trauma or loss of

consciousness
 FAMILY HISTORY:

One sibling aged

Mother is HIV
Father died two 18 months, HIV
positive and has
years previously of negative as tested
been on HAART for
pneumonia by PCR and is
the last 12 months
currently well.
 PATHOLOGY OF THE DISEASE:
Bacterial Bacterial meningitis is contagious and caused by infection from
certain bacteria. It’s fatal if left untreated.
Meningitis:

Bacterial meningitis is the infection of the arachnoid membrane,

subarachnoid space, and cerebrospinal fluid by bacteria. The
infection may spread to the meninges from an adjacent infected
area such as sinusitis, otitis media, and mastoiditisor from the
environment through a penetrating injury or congenital defect

A meningitis infection may produce bacteria in the bloodstream.

These bacteria multiply and some release toxins. That can cause
blood vessel damage and leaking of blood into the skin and organs.
A serious form of this blood infection can be life-threatening
THE MOST COMMON TYPES OF BACTERIA
THAT CAUSE BACTERIAL MENINGITIS ARE:
Streptococcus pneumoniae
• which is typically found in the respiratory tract, sinuses, and nasal cavity and can cause
what’s called “pneumococcal meningitis

Neisseria meningitidis
• which is spread through saliva and other respiratory fluids and causes what’s called
“meningococcal meningitis

Haemophilus influenza,
• which can cause not only meningitis but infection of the blood, inflammation of the
windpipe, cellulitis, and infectious arthritis

Listeria monocytogenes
 which are foodborne bacteria

Staphylococcus aureus
• which is typically found on the skin and in the respiratory tract, and causes
“staphylococcal meningitis
COMPROMISED IMMUNITY

• PEOPLE WITH AN IMMUNE DEFICIENCY ARE MORE VULNERABLE TO INFECTIONS. THIS INCLUDES
THE INFECTIONS THAT CAUSE MENINGITIS. CERTAIN DISORDERS AND TREATMENTS CAN WEAKEN
YOUR IMMUNE SYSTEM. THESE INCLUDE:

• HIV/AIDS
• AUTOIMMUNE DISORDERS

• CHEMOTHERAPY

• ORGAN OR BONE MARROW TRANSPLANTS

PATHOGENESIS:
The organisms that cause bacterial meningitis colonize the nasopharynx
and, from there, they get into the blood stream. They enter the
subarachnoid space by passing through endothelial cells (transcytosis),
getting across the porous choroid plexus capillaries, or being carried by
granulocytes. The CSF is an ideal medium for the spread of bacteria
because it provides enough nutrients for their multiplication and has few
phagocytic cells, and low levels of antibodies and complement. Initially,
bacteria multiply uninhibited and can be identified in smears, cultures, or by
ELISA detection of their antigens before there is any inflammation.

Infection may spread to the subdural space from air sinuses or from the middle
ear.
• CEREBROSPINAL
FLUID (CSF) IS A CLEAR,
COLORLESS
BODY FLUID FOUND IN
THE BRAIN
AND SPINAL CORD. IT IS
PRODUCED BY THE
SPECIALISED EPENDYMAL
CELLS IN THE CHOROID
PLEXUSES OF THE
VENTRICLES OF THE
BRAIN, AND ABSORBED IN
THE ARACHNOID
GRANULATIONS.
PATHOPHYSIOLOGY OF THE DISEASE: Additional Info:

• THE GIRL WAS DIAGNOSED WITH STREPTOCOCCUS

PNEUMONIAE (PNEUMOCOCCUS) INFECTION. In developing countries,
including South Africa,
S. PNEUMONIAE IS A GRAM-POSITIVE, ENCAPSULATED
pneumococcus remains the
most common and
BACTERIUM, AND AN IMPORTANT AND COMMONLY ENCOUNTERED important disease-causing
BACTERIAL PATHOGEN IN HUMANS. IT IS OFTEN FOUND AS A organism in infants. Although
NORMAL COMMENSAL IN THE NASOPHARYNX OF HEALTHY ADULTS exact numbers are difficult
AND CHILDREN. IT DOES HOWEVER HAVE THE POTENTIAL TO to obtain, it is estimated that
pneumococcal infection is
BECOME PATHOGENIC.
responsible for more than
one million of the 2.6 million
annual deaths due to acute
THE BACTERIUM DOES SO BY ESCAPING LOCAL HOST DEFENSES respiratory infection in
AND PHAGOCYTIC MECHANISMS, AND PENETRATES THE CSF children younger than 5
EITHER THROUGH CHOROID PLEXUS/SUBARACHNOID SPACE years. Case fatality rates
associated with invasive
SEEDING FROM BACTERAEMIA OR THROUGH DIRECT EXTENSION
disease vary widely but can
FROM SINUSITIS, OTITIS MEDIA OR MASTOIDITIS.
PRESENTLY, IT IS THE approach 50% and are
MOST COMMON BACTERIAL CAUSE OF MENINGITIS, ACCOUNTING greatest in patients who
FOR 47% OF CASES. develop meningitis.
• PNEUMOCOCCUS IS A COMMENSAL BACTERIUM THAT
IS TRANSMITTED BETWEEN HUMANS VIA AEROSOLS. IN
THIS WAY THE BACTERIA COLONISE THE
NASOPHARYNX, AND TYPICALLY DO NOT CAUSE ANY
DISEASE IN HEALTHY INDIVIDUALS. HOWEVER,
AMONGST CHILDREN YOUNGER THEN 5 YEARS, THE
ELDERLY AND IMMUNOCOMPROMISED INDIVIDUALS,
ESPECIALLY THOSE WHO ARE HIV-INFECTED,
ASPLENIC, HAVE COMPLEMENT DEFICIENCIES,
HUMORAL IMMUNITY DEFECTS OR NEUTROPHIL
DYSFUNCTION, THEY ARE ALL AT A GREATER RISK OF
DISEASE RESULTING IN INFECTIONS AT MORE DISTANT
SITES SUCH AS PNEUMONIA, OTITIS MEDIA, MENINGITIS,
ENCEPHALITIS AND SYSTEMIC BACTERAEMIA.
THESE COMPLICATIONS ARE TYPICALLY
ASSOCIATED WITH MENINGITIS:
• SEIZURES

• HEARING LOSS
• VISION LOSS

• MEMORY PROBLEMS

• ARTHRITIS
• MIGRAINE HEADACHES

• BRAIN DAMAGE

• HYDROCEPHALUS
• A SUBDURAL EMPYEMA, OR A BUILDUP OF FLUID BETWEEN THE BRAIN AND THE SKULL
SYMPTOMS OF BACTERIAL MENINGITIS IN CHILDREN. THESE INCLUDE:

• SUDDEN FEVER

• BODY AND NECK ACHES

• CONFUSION OR DISORIENTATION

• NAUSEA

• VOMITING

• TIREDNESS OR FATIGUE

Bacterial meningitis symptoms develop suddenly. They SIGNS AND

may include:
• altered mental status SYMPTOMS
• nausea
• vomiting
• sensitivity to light
• irritability
• headache
• fever
• chills
• stiff neck
• purple areas of skin that resemble bruises
• sleepiness
• lethargy
LABORATORY FINDINGS:
The initial symptoms of meningitis are fever, severe headache, and stiff
neck. The inflamed spinal structures are sensitive to stretch, and pain
can be elicited by maneuvers that stretch the spine, such as bending
the leg with an outstretched knee (Kernig sign) or bending the neck
(Brudzinski sign). As the disease progresses, confusion, coma, and
seizures develop. In people with meningitis, the CSF often shows a low
sugar (glucose) level along with an increased white blood cell count
and increased protein.

LABORATORY TESTS:
Blood is drawn to check the white and red blood cell counts. A chest
X-ray film may be obtained to look for signs of pneumonia or fluid in
the lungs. Other tests may be performed to look for other sources of
infection. Spinal tap: A spinal tap, or lumbar puncture, is necessary to
diagnose meningitis.
 TREATMENT:
IN OUR CLINICAL CASE, ON ALL HER ADMISSIONS A LUMBAR PUNCTURE WAS PERFORMED AND
STREPTOCOCCUS PNEUMONIAE WAS ISOLATED. ON EACH OCCASION THE BACTERIA WERE FOUND TO BE
SENSITIVE TO CEFTRIAXONE A THIRD GENERATION CEPHALOSPORIN. THE PATIENT WAS TREATED WITH
INTRAVENOUS CEFTRIAXONE UNTIL THE INFECTION WAS CLEARED FROM THE CSF. THIS USUALLY REQUIRED 10
DAYS OF TREATMENT BUT THE MOST RECENT ADMISSION REQUIRED 21 DAYS OF IV THERAPY BEFORE THE
INFECTION WAS CLEARED.

ON THIS CURRENT ADMISSION THE CHILD HAS AGAIN BEEN TREATED WITH IV CEFTRIAXONE. IN ADDITION
EXTENSIVE IMAGING OF THE SINUSES, MASTOIDS, CRANIUM AND BRAIN WERE CONDUCTED. THE IMAGING
ESPECIALLY CT OF THE MASTOIDS SHOWED INFECTION IN THE LEFT MASTOID, THE USUALLY AIRFILLED
HONEYCOMB LIKE APPEARANCE OF THE CAVITIES WERE OBLITERATED. BASED ON THESE FINDINGS AND THE
PATIENTS HISTORY OF RECURRENT MENINGITS THE CHILD WAS SCHEDULED FOR A LEFT SIDED MASTOIDECTOMY
AS THIS WAS BELIEVED TO BE THE SOURCE OF DIRECT INOCULATION OF STREPTOCOCCUS PNEUMONIAE INTO
THE CSF.
 PROPHYLACTIC ANTIBIOTICS WERE PRESCRIBED UNTIL THE TIME OF SURGERY TO PREVENT ANY
FURTHER RECURRENT INFECTIONS.

IT WAS DECIDED THAT ALTHOUGH THE CHILD HAD NOT RECEIVED THE HEPTAVALENT
PNEUMOCOCCAL CONJUGATE VACCINE (PCV7 VACCINE) BECAUSE IT WAS NOT PART OF THE
VACCINATION SCHEDULE WHEN SHE WAS AN INFANT AND TODDLER, THERE WOULD BE NO
ADDITIONAL BENEFIT IN GIVING IT TO HER AT THIS STAGE. THE REASON FOR THIS IS THAT HER
IMMUNE SYSTEM IS CURRENTLY FUNCTIONING WELL WHICH MEANS THAT SHE HAS ALREADY
FORMED ANTIBODIES TO STREPTOCOCCUS PNEUMONIAE. THE REASON FOR HER RECURRENCE OF
INFECTION WAS NOT DUE TO A POOR IMMUNE RESPONSE BUT RATHER TO A DIRECT INOCULATION
OF BACTERIA INTO THE CSF VIA OTITIS MEDIA AND MASTOIDITIS.
THANK
YOU