.

: : : : : ,

 ,
1-23 : Streptococcus pneumoniae and Neisseria meningitidis
2-5 : Haemophilus influenzae type b. 5-18 : N. meningitidis 18-60 : S. pneumoniae, N. meningitis > 60 : S. pneumoniae, L. monocytogenes

 -
S. pneumoniae N. meningitidis H. influenzae Listeria species Streptococci Staphylococci 30-50% 10-35% 5-10% 5% 5% 5-15%

 -1
,

 -2
Nuchal rigidity
Passive or active flexion of the neck will usually result in an inability to touch the chin to the chest

Tests to illustrate nuchal rigidity

The Brudzinski sign refers to spontaneous flexion of the hips during attempted passive flexion of the neck The Kernig sign refers to the inability or reluctance to allow full extension of the knee when the hip is flexed 90 degrees

 -3
Other findings
Some infectious agents, particularly N. meningitidis, can also cause characteristic skin manifestations, petechiae and palpable purpura

If meningitis is the sequela of an infection elsewhere in the body, there may be features of that infection still present at the time of diagnosis of meningitis eg, otitis or sinusitis


/ /


Viral Fungal Tuberculous Spirochete Collagen Vascular Disease Parameningeal infection: brain abscess, epidural abscess Subarachnoid hemorrhage Neuroleptic Malignant Syndrome

 -1
Most often the WBC count is elevated with a shift toward immature forms Platelets may be reduced if disseminated intravascular coagulation is present or in the face of meningococcal bacteremia Blood cultures are often positive, and can be very useful in the event that CSF cannot be obtained before the administration of antimicrobials
At least one-half of patients with bacterial meningitis have positive blood cultures, with the lowest yield being obtained with meningococcus

 -2
CSF analysis The CSF can be diagnostic, and every patient with meningitis should have CSF obtained unless the procedure is contraindicated Chemistry and cytologic findings highly suggestive of bacterial meningitis include a CSF glucose concentration below 45 mg/dL, a protein concentration above 500 mg/dL, and a white blood cell count above 1000/mm3 A Gram stain should also be obtained The Gram stain is positive in up to 10 percent of patients with negative CSF cultures and in up to 80 percent of those with positive cultures


() CT : ICP

DX Viral

Color Normal

Opening Pressure Normal or elevated Normal or elevated Elevated

RBC 0

WBC 1001000 mostly monos 1001000 mostly monos 1001000 mostly monos

Gluc 45-85

Prot Normal or elevated > 50

Smear Neg

Cx Neg

Funga l

Normal or cloudy Normal or cloudy

< 45

Fungal smear positive AFB positive

+/-

TB

< 45

> 50

+/-


Suspected bacterial meningitis is a medical emergency The mortality rate of untreated bacterial meningitis approaches 100 percent Empiric treatment should be begun as soon as the diagnosis is suspected using bactericidal agent(s) that achieve significant levels in the CSF

Choice of agent
Third generation cephalosporins such as cefotaxime and ceftriaxone, have emerged as the beta-lactams of choice in the empiric treatment of meningitis These drugs have potent activity against the major pathogens of bacterial meningitis with the notable exception of listeria Ceftazidime, another third generation cephalosporin, is much less active against penicillin-resistant pneumococci than cefotaxime and ceftriaxone

Treatment - Empiric
Ceftriaxone 2 gm IV q12h or

Cefotaxime 2 gm IV q4-6h
plus Vancomycin 15 mg/kg q6h If > 50 years, also add Ampicillin 2 gm IV q4h (for Listeria)

Haemophilus influenzae
A third generation cephalosporin is the drug of choice for H. influenzae meningitis Patients with H. influenzae meningitis should be treated for five to seven days For adults, a dose of 2 g every six hours of cefotaxime and 2 g every 12 hours of ceftriaxone is more than adequate therapy Pharyngeal colonization persists after curative therapy and may require a short course of rifampin if there are other children in the household at risk for invasive Haemophilus infection The recommended dose is 20 mg/kg per day (to a maximum of 600 mg/day) for four days

Neisseria meningitidis
This infection is best treated with penicillin Although there are scattered case reports of N. meningitidis resistant to penicillin, such strains are still very rare A third-generation cephalosporin is an effective alternative to penicillin for meningococcal meningitis A five day duration of therapy is adequate However, when penicillin is used, there may still be pharyngeal colonization with the infecting strain. As a result, the index patient may need to take rifampin, a fluoroquinolone, or a cephalosporin

Listeria monocytogenes
Listeria has been traditionally treated with ampicillin and gentamicin, as resistance to these drugs is quite rare Ampicillin is given in typical meningitis doses (2 g intravenously every four to six hours in adults) and gentamicin is used for synergy An alternative in penicillin-allergic patients is trimethoprim-sulfamethoxazole (dose of 10/50 mg/kg per day in two or three divided doses) The usual duration of therapy is at least three weeks

PREVENTION OF MENINGITIS Vaccines

A spectacular reduction in H. influenzae meningitis has been associated with the near universal use of a vaccine against this organism in developed countries since 1987 There has been a 94 percent reduction in H. influenzae meningitis between 1987 and 1995 Pneumococcal vaccine administered to the chronically ill and elderly is probably useful in reducing the overall incidence of pneumococcal infections. However, its role in the prevention of meningitis is as yet undetermined

Vaccines
Meningococcal vaccines are active against many strains of N. meningitidis However, the majority of meningococcal infections in the United States are caused by type b meningococcus for which there is no vaccine Vaccines for other types (notably type a) are recommended for travelers and American military personnel to countries with epidemic meningitis Immunization against meningococci is not warranted as postexposure prophylaxis

Chemoprophylaxis
There is a role for chemoprophylaxis to prevent spread of meningococcal and haemophilus meningitis but not for pneumococcal disease The use of antimicrobial therapy to eradicate pharyngeal carriage of meningococci is widely accepted to prevent development of disease in close contacts and to eradicate pharyngeal carriage Rifampin 600 mg PO every 12 h for a total of four doses is recommended Ciprofloxacin, in a single dose of 500 mg PO, is equally effective and can be used in patients over the age of 18

Role Of Steroids
The addition of antiinflammatory agents has been attempted as an adjuvant in the treatment of meningitis Early administration of corticosteroids such as dexamethasone for pediatric meningitis has shown no survival advantage, but there is a reduction in the incidence of severe neurologic complications and deafness A meta-analysis of five such studies in children showed a relative risk of bilateral deafness of 4.1 and of late neurological sequelae of 3.9 in controls compared to children treated with steroids

 A second meta-analysis of trials of meningitis in children evaluated the findings according to organism For H. influenzae type b meningitis, dexamethasone therapy was associated with a significant reduction in deafness For pneumococcal meningitis, dexamethasone was effective only if given early ; in this setting, there was a significant reduction in hearing loss Two days of therapy was as effective and less toxic than longer courses of steroid administration
Dexamethasone as adjunctive therapy in bacterial meningitis. A meta-analysis of randomized clinical trials since 1988. JAMA 1997; 278:925

 There is no consensus regarding the utility of corticosteroid therapy in adults The Infectious Disease Society of America considers adjuvant corticosteroids for meningitis to be unsupported for routine use in adults but supports them for H. influenzae infections in children Guidelines for the use of systemic glucocorticoids in the management of selected infections. J Infect Dis 1992; 165:1

 Complications are more common in adults A series of 86 adults with meningitis, for example, showed a mortality rate of 18.6 percent with a complication rate of 50 percent The most common problems were:
Cerebrovascular involvement 15.1 percent. Cerebral edema 14 percent. Hydrocephalus 11.6 percent. Septic shock 11.6 percent. Disseminated intravascular coagulation 8.1 percent. Acute respiratory distress syndrome 3.5 percent.

 A second review of bacterial meningitis in adults from 1962 to 1988 found a mortality rate of 25 percent that did not vary during the 26 years of the study As in children, there was a higher rate of death due to S. pneumoniae (37 percent) as compared to N. meningitidis (13 percent) and listeria (10 percent)
Acute bacterial meningitis in adults. N Engl J Med 1993; 328:21.

 (HSV-)
3 100,000
spread of the virus from a previously infected ganglion ( ) ()

 -
: , , , . HSV-1 ENY PCR

 -MRI

 -MRI.2

 -
, 10 mg/kg 2-3 70% 19% 50% ( )


> /


India InK, + , Ag Meningitis Cryptococcus coccidioides candida Aspergillus Zygomycetes


. . . . VDRL 1:4-1:28 AIMA VDRL 1:15-1:512

AIDS

AIDS


JC papovavirus

 ( prions, JCD)
DNA RNA , , ,