Neurology Presentation:

MENINGOENCEPHALITIS

Presenter:
LATHISAH JOE (RPT1)
30/08/19
 Table of Content
• Introduction • Risk Factors
• Definition • Prognosis
• Anatomy and Physiology • Reference
• Etiology
• Pathophysiology
• Signs and Symptoms
• Epidemiology
• Diagnosis
• Management
 Medical
 Surgical
 Physiotherapy
• Complication
 Introduction
o Acute meningitis and acute encephalitis are some of the
public health problems world wide.
o Although bacteria cause meningitis, viruses can cause
both meningitis and encephalitis with equal frequency.
o It is often difficult to reliably differentiate meningitis and
encephalitis clinically.
o Therefore, the term Acute Meningo Encephalitis (AME) is
used to denote both conditions.
(Choudhury, Habibur Rasul, 2011)
 Introduction
o Meningitis is an inflammation of the meninges.
o Encephalitis is part of the spectrum of the inflammatory
disease of CNS followed by the manifestation of
inflammatory process involving the brain parenchyma
which is made up of the neurons and the glial cells.
 The time course of encephalitis may be acute (most viral
encephalitis), sub-acute, or chronic.
o Acute viral encephalitis is mostly associated with some
elements of meningitis (i.e meningoencephalitis).
 Definition
o Meningitis
Inflammation of brain and spinal cord
 CSF
 Meninges
o Encephalitis
 Inflammation of the brain itself
 Parenchyma
o Meningoencephalitis
More diffused inflammatory process
 More of the symptoms of meningitis and encephalitis
Anatomy and Physiology
Anatomy and Physiology
Neuroglia
 Etiology
1. Bacterial Meningitis
o Age Group Causes

Newborns Group B Streptococcus, Escherichia coli,

Listeria monocytogenes

Infants and Children Streptococcus phneumonia, Neisseria

meningitides, Haemophilus influenza
type b
Adolescents and Young Adults Neisseria meningitides, Streptococcus
phneumoniae

Older Adults Streptococcus phneumonia, neisseria

meningitides and listeria monocytogenes
 Etiology
2. Viral Meningitis
o Non-polio enteroviruses most common
Coxsackievirus A
Coxsackievirus B
Echoviruses
 Enterovirus D68 and
Other Enteroviruses
o HIV
o Mumps Virus
o Herpesviruses: HSV-2, VZV, CMV, EBV; Mollaret’s
o Measles virus
o Influenza
o Arboviruses: West Nile Virus
o Lymphocytic choriomeningitis virus
 Etiology
3. Fungal Meningitis
o Cryptococcal
o Coccidioidal
o Histoplasma
o Candida
o Aspergillus
4. Tuberculosis Meningitis
o Mycobacterium
 Etiology
5. Aseptic Meningitis
oOther Bacterial Diseases/Infections
Syphilis, leptospirosis, lyme disease, other tick-borne diseases,
mycoplasma
oParasites
T. gondii, T. solium, trichinella, N. fowleri
oAutoimmune
Sarcoidosis, Systemic lupus erythematosus (SLE), Behcet’s
oMalignancy
 lymphoma, leukemia, metastatic
oPost-infectious
oPost-vaccination (Dourado I, 2000)
 Etiology
Encephalitis

Non-Arbo viral Arbo-Viral (epidemic)

o Herpes viruses (sporadic) o Flaviviridae
 HSV-1, HSV-2  Japanese encephalitis
 Viricella zoster virus
 Cytomegalovirus St. Louis encephalitis
 Epstein-Barr virus
 Human herpes virus 6
o Togaviridae
 Eastern equine encephalitis
o Adenoviruses  Western equine encephalitis
o Influenza A
o Eteroviruses, poliovirus
o Mumps
o Rabies
 Meningoencephalitis
Pathophysiology
I. Inflammatory cells in the meninges.
II. Perivascular infiltrates with inflammatory cells.
III. Necrosis of brain parenchyma, with all cellular elements
affected, especially in the periventricular region, and
often associated with calcification.
IV. Reactive microglial and astroglial proliferation.
V. The occurrence of enlarged cells (neuronal and glial
elements) with intra-nuclear inclusions.
 Meningitis

Signs Symptoms
o Stiff Neck o Intense Headache
o Vomiting o Lethargy (tiredness)
o Altered Mental Function o Malaise
o Nuchal Rigidity o High Fever
o Brudzinski’s sign
o Kernig’s sign
o Cranial Nerve Palsy
o Seizures
 Encephalitis
Signs and Symptoms
o Fever
o Head ache
o Nausea
o Vomiting
o Lethargy
o Myalgias
 Meningoencephalitis
General Signs/Symptoms
• Infants:
high fever, bulging of forehead, poor feeding or constant
sleepiness.
• In children and adults are:
 fever, disorientation, or speech problem.
• At a later stage:
 headache, vomiting, fever, drowsiness, seizures, and
unconsciousness.
• Specific:
nuchal rigidity, blurred vision, hallucinations, purple rashes or
behavioural changes.
 Meningoencephalitis
Epidemiology
• According to a large epidemiological study conducted in USA, pt.s
more than 18≥ with ME collected from, Ninth Revision codes
available in the Premier Healthcare Database during 2011-2014
were analysed;
 Total: 26429 pt.s, median age - 43 and 56% female
o Etiologically:
 Enterovirus (13463 [51.6%])
 unknown (4944 [21.4%])
 bacterial meningitis (3692 [14.1%])
 herpes simplex virus (2184 [8.3%])
 noninfectious (921 [3.5%])
 fungal (720 [2.7%])
 arboviruses (291 [1.1%])
 other viruses (214 [0.8%])
 Meningoencephalitis
Epidemiology
• Another epidemiological study conducted in USA, with children ageing from
0-17 with ME collected from, Ninth Revision codes available in the Premier
Healthcare Database during 2011-2014 were analysed;
 Total: 6665 & majority male
 According to Age Range:
o 3030 (45.5%) younger than 1 year of age
o 295 (4.4%) 1–2 years of age
o 1460 (21.9%) 3–9 years of age
o 1880 (28.2%) 10–17 years of age
 Etiologically:
o Enterovirus (58.4%)
o Unknown (23.7%)
o Bacterial (13.0%)
o Noninfectious (3.1%)
o Herpes simplex virus (1.5%)
o Other viruses (0.7%)
o Arboviruses (0.5%)
o Fungal (0.04%).
 Diagnosis
• Medical Hx with:
Blood Cultures
 CT
MRI
 LP
• Physical Examination
 Kerning’s Test
 CN Examination
 Medical Management
• Antiviral therapy
Acyclovir
Ganciclovir
Foscarnet
 Pleconaril
• Corticosteroids
 Dexamethasone
Prednisone
Furosemide
Mannitol
 Surgical Management
• Surgical decompression is indicated for
impending uncal herniation or increased
intracranial pressure refractory to
medical management.
• PROCEDURE:
Part of the skull/bone flap is removed to
allow swollen room of the brain to expand
without being squeezed via
trephining/trepanning.
PHYSIOTHERAPY
 ASSESSMENTS AND
EXAMINATIONS
• METHODS:
SOAP
SMART
 Subjective Assessment
• GENERAL INFORMATION

Name Ref. Dr: Date of Referral:

 Age/Gender:  Ward/Dept:
 Village: IP/OP No:
 District: Physiotherapy Dxx:
 Residence:  Assessed by:
Contact Address: Review Date
 Medical Dxx:
 Subjective Assessment
• PC:  Underlying and other non-related
 Current problem that the pt. is conditions
experiencing/what you see that is  Hx of TB in the family
abnormal from the pt.  Previous surgical, medical and
 An infant/ a child’s developmental physiotherapy RX.
milestone. • Drug Hx:
 GCS: 1-10  Note and comprehend the medications
• HoPC: if a pt. is on drugs
 Progression of the Condition • F/S Hx:
 Date of Onset of Signs & Symptoms  Order in which a child was born
 Medical Management  Maritial Status
 Medical Observations  Occupation
 Other management  Involvement in any social activities
 Previous physiotherapy  Addiction:
 Results of Specific Investigations (X- o Drugs
rays, CT Scans, Blood Tests) o Cigarette
 Prenatal, antenatal and postnatal Hx o Alcohol
o Betel nut
• PMH:
 Objective Assessment
• Observation o Swelling
 General Palpation:
o General Health o Warmth
o Physique o Tenderness
o Posture o Bony alignment
o Gait o Swelling/edema:
 Pitying
o Attachment to body
 Non-pitying
o Skin color and texture
o Mm tone
Local
Flaccid
o Bony deformities
Spastic
o Mm bulk
o Scar
o Discoloration
Examination, Analysis and Management
at Acute Phase (2 days-2 wks)
• Vitals  CN Test – if GCS: E,S,4
 RR • Reflex Testing
 BP • Barthel Index Scale
 Pulse Analysis:
 Temp • Stable Vitals
 SPO2 • GCS: 8-15
• GCS • Problem Lists

Examination Management
• HMF • Chest Care – elevation of bed 35º-45º
 Orientation • 2hrly change of position to prevent
 Cognition pressure sore
 Memory • Monitor GCS and vitals
 Communication • Pt.’s advice and education to the guardians
• Special Tests • Outcome measures
 Kerning’s Test
 Brudzinski Test
Examination, Analysis and Management
at Sub-acute Phase (3-5 wks)
• Re-assessment Analysis:
• Recheck Vitals and GCS • Stable Vitals
• GCS: 8-15
Examination • Problem Lists
• HMF again  Aching mm
 Orientation  Stiff neck
 Cognition  ADLs
 Memory
• Note progression from acute-phase rehab and compare
 Communication
with outcome measure for sub-acute phase
• Redo Special Tests
 Kerning’s Test Management
 Brudzinski Test • Monitor GCS and vitals
 CN Test • Continue Chest Care – elevation of bed 35º - 45º
• Sensations: • Involve Deep Breathing Exercise
 Superficial
• 2hrly change of position to prevent pressure sore
o Light Touch
 Deep • PROM with respect to pain
o Pin Prick • Message on SCM mm
• Reflex Testing • Strengthening exercises on bilateral UL & LL on bed
• ROM Testing with resistance from the therapist
 AAROM • Sitting the pt. on bed for 5-30min with respect to the
• IRT Testing intensity of the pt.’s severe head ache
 mm Power • Pt.’s advice and education to the guardians
• Record 2nd Barthel Index Scale
Examination, Analysis and Management
at Post-acute Phase (6-10wks)
• 3rd Re-assessment  PROM
• IRT Testing
• Recheck Vitals and GCS  mm Power
Examination • Balance/Coordination Testing
• HMF again  Hill to Sheen
 Orientation  Finger to Nose
 Cognition  Romberg Testing
 Memory
 Communication • Record 2nd Barthel Index Scale
• Redo Special Tests • Hand Function
 Kerning’s Test • Posture
 Brudzinski Test • Gait
 CN Test • FIM:
• Sensations:  Self Care
 Superficial  Spincter Control
 Deep  Mobility
• Reflex Testing
• ROM Testing
 AROM
Examination, Analysis and Management
at Post-acute Phase (6-10wks) cont…
 Locomotion • Involve Deep Breathing Exercise
 Communication • 2hrly change of position to prevent pressure
 Social Adjustment sore
• System Review: • PROM with respect to pain
 Bowel and Bladder
• Message on SCM mm
Analysis: • Involve Thoracic Manipulation of the neck
• Stable Vitals • Strengthening exercises on bilateral UL & LL
• GCS: 8-15 with weights
• Problem Lists • Sitting the pt. on bed for 5-30min with respect to
 Aching mm the intensity of the pt.’s severe head ache if
 Stiff neck head ache still remains
 Photophobia • Tilt Bed Training
 ADLs • Kegel Training
• Note progression from acute-phase rehab and • Balance and Coordination Exercises
compare with outcome measure for sub-acute • Parallel Bar Gait Training
phase • Pt.’s advice and education to the guardians
Management
• Monitor GCS and vitals
• Continue Chest Care – elevation of bed 35º - 45º
Mostly;
• Physiotherapy should focus mainly on the
problems associated with the signs and
symptoms of the condition that requires
physical rehabilitation or from the problems
noted upon examination.
Else,
• Physiotherapy falls in acute-phase of
rehabilitation at ICU when dealing with
MENINGOENCEPHALITIS
 Complication
• Cerebral Venous Thrombosis
• Permanent Deafness/ Blindness
• Behavioral Changes
• Memory Loss
• Behavioral Changes
• Epilepsy/recurrent seizures
• Permanent Brain and Nerve Damage which can lead to
death
 Risk Factors
• Age
• Living in over populated areas
• Certain Medical Conditions:
• Travelling to sub-Saharan Africa
 Prognosis
• It has a high mortality and morbidity rate especially in
infants.
• However, prognosis depends mainly on the pathogen and
host immunologic state
• In severe cases, it is likely for the pt.s to die.
 reference
• Standards Unit, Microbiology Services, PHE. (2014, May 8). Retrieved from Standards Unit,
Microbiology Services, PHE Web site:
https://assets.publishing.service.gov.uk/government/uploads/system/.../S_5i1.pdf
• Hasbun R1, R. N.-L. (2017, August). NCBI PubMed National Library of Medicine National Institute
of Health. Retrieved from NCBI PubMed National Library of Medicine National Institute of Health
Web site: https://www.ncbi.nlm.nih.gov/pubmed/28419350
• Hasbun, R. M., Wootton, S. H., Rosenthal, N. M., Balada-Llasat, J. M., Chung, J. P., Duff, S.
M., . . . Ginocchio, C. C. (2019). Epidemiology of Meningitis and Encephalitis in Infants and
Children in the United States, 2011-2014. Paediatric Infectious Disease Journal, 37-41.
• Choudhury Habibur Rasul, F. M. (2011, April 14). Bioline Organisation. Retrieved from Bioline
Organisation Web site: www.bioline.org.br/pdf?mj12022
• https://www.teachmeanatomy.com
• https://www.anatomyEXPERT.com
• contributors, P. (n.d.). Physiopedia . Retrieved from Physiopedia Web site: https://www.physio-
pedia.com/index.php?title=Meningitis&oldid=209255
Any questions if you really didn’t
understand, you don’t know, you’re
lost or you cant recall?
PLUS your comments.
UNLESS YOU KNEW IT ALL ☺