INTRODUCTION

▰ Meningitis is a life-threatening infection of the

leptomeninges surrounding the brain and spinal cord,

with involvement of the subarachnoid space.

Essentials of Medical Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers

ACUTE
BACTERIAL
MENINGITIS 3
ACUTE BACTERIAL MENINGITIS

▰ Acute bacterial meningitis (also called as pyogenic

meningitis), is an acute purulent infection within the

subarachnoid space.

▰ Characterized by elevated polymorphonuclear cells in 4

CSF.
Essentials of Medical Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers
ACUTE BACTERIAL MENINGITIS
(Cont..)

▰ Agents - vary according to the age.

▰ Overall: Streptococcus pneumoniae - most common.

Other agents include meningococcus, Streptococcus

agalactiae, Listeria and Haemophilus influenzae. 5

Essentials of Medical Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers

AGENTS OF
PYOGENIC
MENINGITIS 6
Pneumococcal Meningitis
▰ Streptococcus pneumoniae (or pneumococcus) - leading
cause of meningitis in adults (>20 years of age),
▰ Also the most common agent of pneumonia.

▰ Present as commensals in human nasopharynx - spread

locally to cause otitis media or pneumonia – bloodstream
to distant sites - - bacteremia and meningitis 7

Essentials of Medical Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers

Pneumococcal Meningitis (Cont..)
▰ Principle virulence factors – capsular polysaccharide, C-carbohydrate
antigen, pneumolysin and autolysin.

▰ Risk factors: Underlying pneumococcal pneumonia (most important) or

otitis media, alcoholism, diabetes, splenectomy, complement deficiency,
hypogammaglobulinemia, and head trauma

Essentials of Medical Microbiology by Apurba S Sastry © Jaypee Brothers Medical Publishers

Q1. A 3-year old is diagnosed with bacterial meningitis.
Cerebrospinal fluid grows out gram positive cocci in
short chains & diplococci. This is most likely to be which
of the following?
a. Group B streptococcus
b. Salmonella
c. Staphylococcus aureus
d. Streptococcus pneumoniae

9
Ans 1. D. Streptococcus pneumoniae is the most

likely etiological agent. Gram positive diplococci

are also consistent with S.pneumoniae infection

MORPHOLOGY

Gram-stained smear of sputum containing

Gram-positive diplococci
 MORPHOLOGY

S.pneumoniae; India ink preparation to show

capsules

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 BIOCHEMICAL REACTIONS

• Catalase negative
• Oxidase negative
• Optochin sensitive
• Inulin fermentation
• Bile soluble

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 BILE SOLUBILITY TEST

Bile solubility test

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 OPTOCHIN SENSITIVITY

S.pneumoniae colonies sensitive to optochin

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Neisseria meningitidis
INTRODUCTION
Epidemic cerebrospinal fever is caused by
N.meningitis which are Gram negative diplococci
Learning objective
 Neisseria meningitis can be prevented by
1. Quadrivalent Conjugate vaccine
2. Chemoprophylaxis
Contents
History
Morphology
Culture
Biochemical reactions
Pathogenesis
Clinical Features
Lab Diagnosis
Treatment and Prophylaxis
A 7 year old boy presented to the Emergency
Department with high grade fever on the previous
day. He complained of headache, was disoriented
and had projectile vomiting. On examination, the
neck was found to be rigid and Kernig’s sign was
positive. A lumbar puncture was carried out along
with complete blood counts and serum biochemistry.
Cytology showed polymorphs at 1000/mm3, protein
250mg/dl (12-60mg/dl) and glucose 20mg/dl (40-
70mg/dl). Blood glucose were normal.
On Gram stain, Gram negative cocci were seen in
pairs, most of them inside polymorphs. Probable
diagnosis ?
a. Streptococcus pneumonia
b. Neisseria meningitidis
c. Haemophilus influenza
The latex agglutination was positive for
N.meningitidis antigen, confirming the diagnosis
of meningitis. The patient responded to treatment.
Vaccination was advised for patient’s siblings along
with chemoprophylaxis
Kernig’s sign
Kernig’s sign
Nuchal rigidity
History
1887: Weichselbaum isolated meningococcus from
CSF.
1896 &1901: Kiefer, Albreth & Gohn found carriers
1909: Dopter recognized serotypes
Glover noted that carrier rate in military recruit
camps rose with periods of crowding.
NEISSERIA
GRAM NEGATIVE DIPLOCOCCI WITH THEIR
ADJACENT SIDES FLATTENED
Readily undergo autolysis
AEROBIC, CO2 enriched humid atmosphere
STRONGLY OXIDASE POSITIVE
Polysaccharide capsule
TWO PATHOGENIC SPECIES OF THE
Genus Neisseria
1) N.meningitidis
2) N.gonorrhoeae
NEISSERIA MENINGITIDIS
MORPHOLOGY
CULTURE
-FASTIDIOUS ORGANISMS
ENRICHED MEDIA - TO NEUTRALISE INHIBITORY
SUBSTANCES IN MEDIA
 BA, CA, MUELLER HINTON AGAR
SELECTIVE MEDIA
a) MODIFIED THAYER MARTIN MEDIA WITH
ANTIBIOTICS – VANCOMYCIN, COLISTIN,
NYSTATIN, TRIMETHOPRIM
CHOCOLATE AGAR

BLOOD AGAR
STRICT AEROBES, 35- 36 C, MOIST ENVIRONMENT WITH
5-10% CO2
BIOCHEMICAL REACTIONS

STRONGLY OXIDASE POSITIVE

KOVAC’S METHOD

OXIDASE REAGENT – 1% TETRAMETHYL

PARAPHENYLENE DIAMINE HYDROCHLORIDE
OXIDASE TEST
FERMENT SUGARS, MALTOSE AND GLUCOSE, WITH PRODUCTION OF ACID, NO GAS
Antigenic structure
Capsular polysaccharide(Serogroups: A, B, C, D, X, Y,
Z, W, 29 E, H, I, K, L)
Non capsular cell wall Antigens
1. Pili
2. LOS (lipo-oligosaccharide)
3. Outer membrane proteins.(Serotypes)
Q2. The source of N. meningitidis is the
nasopharynx of human carriers who exhibit no
symptoms. The ability of this bacterium to colonize
the respiratory mucosa is associated with its ability
to synthesize which of the following?
a. Capsule
b. Collagenase
c. Hyaluronidase
d. Lipases
e. Pili
Ans 2. E. Both N.meninigitidis & N. gonorrhoea adhere
to to the mucous membrane by means of pilli. Coagulase
& lipase are products of staphylococci
MENINGOCOCCAL INFECTION

NATURAL HABITAT – HUMAN NASOPHARYNX

Epidemic Danger- Carrier rate >20%
TRANSMISSION IS BYRESPIRATORY DROPLETS
ESPECIALLY IN OVERCROWDED AREAS,
CLOSED COMMUNITIES
ROUTE OF SPREAD – DIRECT THROUGH
NEURAL SHEATH, CRIBRIFORM PLATE TO
SUBARACHNOID SPACE OR THROUGH
NASOPHARYNGEAL MUCOSA TO
BLOODSTREAM
Q 3. The two pathogenic Neisseria species,
N.meningitidis & N. gonorrheae, differ from
nonpathogenic Neisseria species in what way?
A. the former are less resistant to certain antibiotics than
the non-pathogenic species
B. The pathogenic species are oxidase positive
C. The pathogenic species grow well in enriched
chocolate agar
D. The pathogenic species do not grow well at room
temperature
Ans3. Both N.meningitidis & N.gonorrheae are true

human pathogens, surviving best in human host.

Normal flora (nonpathogenic) Neisseria will grow at

room temperature on simple medium

Clinical features
There can be 4 clinical situations
Bacteremia without sepsis
Meningococcemia without meningitis
Meningitis with or without meningococcemia
Meningoencephatic manifestations
Clinical features
At least two of Four symptoms in patients with
meningitis
1. Fever
2. Neck stiffness
3. Altered Mental status
4. Petechial rash
Critical need for diagnosis as early as possible
Petechial rash on oral mucosa and conjunctiva
Petechial rash on skin of hand
LABORATORY DIAGNOSIS

SPECIMENS
BLOOD (56%)
CSF (64%)
PETECHIAL LESIONS SPECIMENS (56%)
NASOPHARYNGEAL SWAB TO DETECT CARRIERS
CSF- BY LUMBAR PUNCTURE
 - UNDER PRESSURE
 - TURBID
 - DIVIDE CSF INTO TWO
PARTS
1. DEPOSIT – GRAM STAIN,
CULTURE
SUPENATANT:
AGGLUTINATION TEST
WITH SPECIFIC
ANTISERA.

2. INCUBATE OVERNIGHT IN
GLUCOSE BROTH
Gram stain of csf deposit
Lab Diagnosis
PCR (Sensitivity & Specificity (90%)
Advantages (SR)
1. Sensitivity not affected with prior antibiotic
administration.
2. Rapid
3. Rapidly type strains
4. Multiplex PCR can test simultaneously
meningococcal, pneumococcal & H.influenza.
 Disadvantages
 Cannot be used for antimicrobial sensitivity
Treatment and Prevention
Ceftriaxone 1g I/V q12h X 7days
If Penicillin & cephalosporin allergic:
Chloramphenicol
CHEMOPROPHYLAXIS

1. Ceftriaxone 250mg single IM dose.

2. Ciprofloxacin 500mg single dose
3. Rifampicin
Immuno-prophylaxis
Conjugated vaccine:
Given to young children. (2-6 years)

Single dose

Addition of a protein carrier (adjuvant) increases

the immunogenicity of the capsular vaccine.

Vaccine for Group B (MenB)
Vaccine contains four recombinant proteins:

Adhesin A, heparin binding antigen, factor H

binding protein and outer membrane vesicles
(OMV)
Schedule: Two doses, given IM route 1 month

apart
Indication: 16–25 years age.
Vaccine Recommendations
Routine vaccination not indicated (NTTAMM)
Persons residing or travelling to areas where
N.meningitidis is epidemic or hyperendemic
Terminal complement deficiency
Asplenia
Military recruits
Microbiologists
College freshman living in dormitories
REFERENCES
Ananthanarayan & Paniker’s Textbook of
Microbiology. 9th Edition
Mandell, Douglas and Bennet’s Principles and
Practices of infectious diseases. 6th Edition