Transcript MENINGITIS+Mala..

MENINGITIS
OUTCOME  VARIABLE
Acute Benign Form of Viral
TO
Rapidly Fatal Bacterial Meningitis
WITH
Local Progressive mental
deterioration and death
Meningitis – inflammation of the
meninges
 Encephalitis – infection of the brain
parenchyma
 Meningoencephalitis –
inflammation of brain + meninges
 Aseptic meningitis – inflammation
of meninges with sterile CSF
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Introduction
Meningitis: inflammation of the pia
mater and the arachnoid mater, with
suppuration of the cerebrospinal fluid
Symptoms of meningitis
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Fever
Altered consciousness, irritability,
photophobia
Vomiting, poor appetite
Seizures 20 - 30%
Bulging fontanel 30%
Stiff neck or nuchal rigidity
Meningismus (stiff neck + Brudzinski +
Kernig signs)
 Contraindications:
– ICP reported to increase risk
of herniation
–Cellulitis at area of tap
–Bleeding disorder
WHAT DETERMINE THE
OUTCOME?
1. Etiological organism
2. Speed and appropriation of the
therapy.
MORTALITY
Bacterial Meningitis : 40 %
CAUSES OF MENINGITIS
INFECTIOUS
Viral
NON-INFECTIOUS
Aseptic Meningitis
Bacteria
Malignancy
Mycobacterial
Sarcoid
Brucella
behcet disease
Fungal
SLE
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Viral Meningitis
Generally benign, rarely fatal
Enterovirus: around 80% of cases
Other viruses: mumps, Epstein-Barr virus,
Rare but serious forms: Herpes group viruses
No specific preventive or curative treatment for
most except Herpes viruses
Clears up on its own with no treatment in 3
to 8 days
Bacterial meningitis Organisms
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Neonates
– Most caused by Group B Streptococci
– E coli, enterococci, Klebsiella,
Enterobacter, Samonella, Serratia,
Listeria
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Older infants and children
– Neisseria meningitidis, S. pneumoniae,
tuberculosis, H. influenzae
Causes of bacterial meningitis
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Strep pneumonia………….37
Neisseria meningitides…..13
Listeria monocytogenes….10
Other strept.species……….7
Gram negative……………….4
Haemophillus influenza……4
No pathogens………………37
Review of 493 cases of adult meningits
(Durand NEJM 1993 )
APPROACH
TO PATIENT
WITH POSSIBLE MENINGITIS
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I) Maintain diagnostic VIGILANCE
a.)
Suspect the diseases
b.)
Look for classical features
1) Headache
2) meningeal irritation….HOW?
3) Obtundation
c.) Confirm or exclude the diagnosis
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II) INITIATE RAPID TRATMENT
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b.
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c.
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I.V.
Large and sufficient
dose
Effective choice
INITIAL MANAGEMENT
APPROACH
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Recognition of the meningitis
syndrome.
Rapid diagnostic evaluation.
Emergent antimicrobial &
adjunctive therapy.
III.
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CONSIDER CHANGING
EPIDEMIOLOGY
A.) Global emergence and Prevalence of
Penicillin- Resistant Strain of Strep.
pneumonia.
B.) Dramatic Reduction in invasive H.
influenza disease secondary to use of
conjugate Haemophillus Type B- vaccine.
C.) Group B – Streptococci 
Now  > 50 also.
Neonate
IV.
COMPLEXITIESOF
EMPIRIC MANAGEMENT
I F Focal Sign
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Pappiledema
OR Focal Neurological
deficit (often >VI N)
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? Brain abscess
Chr. Meningitis
DON’T Delay Administration
of Antibiotics
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Bacterial Meningitis Treatment
Neonatal (<3 mo)
Ampicillin (covers Listeria)
+
 Cefotaxime
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– High CSF levels
– Less toxicity than aminoglycosides
– No drug levels to follow
Management Algorithm for Adults
Suspicion of bacterial meningitis
YES
new onset seizure, papilledema, altered level of consciousness, or focal neurological deficit or delay in
performance of diagnostic L.P
NO
YES
Blood c/s & Lumbar puncture
Dexamethasone + empirical Abx
CSF is abnormal
B/C stat
Dexamethasone + empirical Abx
-ve CT-scan of the head
YES
+ve CSF gram stain
NO
Dexamethasone +
empirical Abx
Perform L.P
YES
Dexamethasone +
targeted Abx
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CASE I
A 12 year old Nigerian boy who
has arrived to Riyadh 2 days prior to
presentation - C/O severe headache
& Photophobia?
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How do you approach & manage
him?
Presence of fever & neck
stiffness.
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Neurological deficit & Fundus.
Skin  RASH
CSF examination:
Opening pressure: 260 mm H20
& cloudy
WBC: 1500/ ml. 96%
segmented
Glucose:
24mg / dl
Protein: 200 mg.
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MOST
– 1.
– 2.
– 3.
– 4.
LIKELY DIAGNOSIS:
Neisseria m.
Strep. Pneumonia
H. influenza
Listeria monocytogen
EPIDEMIOLOGICAL FEATURES
OF MENINGOCOCCAL MENINGITIS
1. Affect children + young adult
 2 – 20 years
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2. Epidemic usually sero group A & C
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3. Nasopharyngeal Acquisition
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4. Predisposing in those with
Terminal Complement
deficiencies ( Cs ----- C9 )
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5. SKIN RASH
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a. Fulminate meningococcemia
with purpura
b. Meningitis with RASH (Petechiae)
c. Meningitis without RASH.
6. Mortality 3 - 10 %.
7. D. O. Choice  Penicillin I.V.
 CASE
2
A 26 YEAR OLD Saudi female who
has been C / O unwell & fever &
cough and headache for the last 3
days. Examination revealed ill –
looking women with sign of
consolidation R Lung base.
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DIAGNOSIS:
Bacteria Pneumonia.
Organism?
Six (6) hours after admission, her
headache became worse and she
became obstunded.
 DIAGNOSIS:
? MENINGITIS
 CSF:
WBC: 3000 99%
DML
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Sugar: Zero
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Protein:
260 mg/dl.
 Gram Stain:
Gram +
 DIAGNOSIS:
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Bacterial…..?
Epidemiological Features of
Pneumococcal meningitis
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The most common.
Cause
The most killing. 20 - 30 %
DEATH
May be associated with other
Focus:
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a. Pneumonia
25%
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b.Otitis Media
30%
c. Sinusitis
15 %
d. Head Trauma & CSF Leak 10%.
E. splenectoy and SS disease..
Global emergence of Penicillin –
Resistant.
Case presentation
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30 years old sudanese male who was
to the ER in confusional state for few
hours befor presentation ..history
revealed presence of two attacks of
seizures in the same day with high
fever…
EXAMINATION:
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Looks unwell 
Neck Stiffness 
Funds
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Possible diagnosis:
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1. Meningitis
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2. Brain abscess
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3. Subarachnoid.
Hemorrhage…
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Temp. 39°C
absent
Bilateral
papilledema
MENINGITIS
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1.
2.
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Viral Meningitis
Bacterial Meningitis
Brucella & Tuberculosis
PREVENTION :
CHEMOPROPHYLAXIS
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Neiseria meningitidis
Eradication of nasopharyngeal
carriage
..(post exposure ) for :
1)house hold contact
2)Treating doctor who has
examined patient very closely
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What drugs are recommonded:
Rifampicin 600 X 2 d
Ciprofloxacin 500X1
Ceftriaxon 125mg I.M X1
VACCINE TO
 1. Hib Type B vaccine 
1.Protection
2. Eliminate
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2. Meningococcal vaccine: A, C, Y,
W135
- Up to 3 years adult
Does not affect N. ph. Carriage 
…Does not provide herd immunity.
Viral meningitis Treatment
Supportive
 No antibiotics
 Analgesia
 Fever control
 Often feel better after LP
 No isolation - Standard
precautions
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Caes
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56 years saudi women presented to the
infectious disease clinic c/o low grade
fever and night sweating for the last 6
wks…on detailed inquires she admitted to
have headache for 4 wks improving on
analgesics..
EXAMINATION:
T: 38.2..Fully conscious
Neck stiffnes..bilateral papillodema
LABORATORY RESULTS..
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CSF:…xanthocromic
wbc 340 L: 85 %
protein 1.5g sugar 25 mg
WHAT IS YOUR ANYLASIS OF THIS
CSF………..
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1)
2)
3)
4)
5)
Partially treated bacterial meningitis
Aseptic meningitis
Bruclla meningitis
Tubercoulus meningitis
OTHERS……..
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TREATMENT:
A. Principles of Therapy:
1.
Multiple drugs. ( INH& Rif.)
2.
Educate the patient  Long
therapy  6/12
3. Tell about Potential side effects
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a.
Orange sweat & tears with
Rifampicin.
b.
Hepatitis
with
INH.
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4.
Follow patient closely.
B. Commonly Used Drugs:
1. INH
(Isonized)
a. Bactericidal  inhibit
DNA
synthesis
b. Excellent tissue and
CNS penetration.
c. Acetylated with liver
 Renal.
d. Toxicity :
Hepatitis /
P.
Neuropathy.
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2. Rifampicin
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a.
b.
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c.
d.
Bactericidal  inhibit
RNA synthesis
Excellent tissue & CNS
penetration
Hepatic excretion
Toxicity : Hepatitis / RASH
/ Drugs interaction
Malaria&Travel Medicine
MALARIA
Febrile illness caused by
Plasmodium.
200 – 300,000,000 cases.
700,000---2.7,000,000 death/year
more in rural area..
more during rainy season
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Human ---- ----- Another
Mosquito
Transmission
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BITE OF FEMALE ANOPHELES
BETWEEN DUSK AND DAWN
BLOOD TRANSFUSION
CONTAMINATED NEEDLES
CONGENITAL.
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ETIOLOGY
Four species.
Death is mostly due to ..?
SYPMTOMS
--- Non-specific
Headache & fatigue &
muscle pain
Fever
DX:  Viral infection..?
Clinical Features:
 Symptoms:
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7 – 10 days 
Paroxysms.
Cold 
Hot
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Malaria
Chills & Rigor & cold skin
Fever, warm skin
3-6
hours
deverevescence  Marked sweating
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Between Paroxyms  Well DX ?
SIGNS
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Spleen Enlargement
Jaundice
Fever
Anemia
Clinical example:
An 18 years old Saudi pregnant
young women originally from Jazan
came C/O Fever and headache.
Exam: Pale, jaundiced,
Temp. - 39°C
Spleen enlarged NEXT?
CBC:
WBC - 8000
Hb - 9.0
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Platelets: 90
CXR:
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MCU : 98
Normal
DIAGNOSIS
1. Index of suspicion
Travel hist.
Incubation Period
2 WKS
Prophylaxis - Longer
2. ? Malaria
3. Blood smear :Thin & thick
4. Special Drug
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COMPLICATION:
1. Cerebral Malaria
 encephalopathy
 Seizure
 Death 20%
2. Black. Water Fever

non immune
 High degree
of F.M.
 Hemolysis
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Malaria & Pregnancy:
1.
2.
Risk of low birth & abortion.
Risk of glucose , pulm. oedema
TREATMENT
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1.
2.
3.
History
Smear
Species
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4.
Severity
5.
Drugs:
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CBC
Hib
Coagulation
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TREATMENT
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1.
Uncontrolled airway
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2.
I.V . infusion
Blood glucose test,
parasitemia, Hct.
Antimalaria.
a.
Chloroquine p.o.
b.
Mefloquine
C.
Quinine AND DOXYCYCLINE
D. ARTEMISININS
E . ATOVAQUONE PLUS PROGUANEL
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4.
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5.
Fluid balance

P. Edema

Dehydration & Shock
6. Convulsion 
Diazepam
7.
Blood C/ S……8) LP
DRUG TOXICITY
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MEFLOQUINE : neuropsychiatric
symptoms : mood changes
.encephalopathy…transient
QUININE : Bitter taste , GIT upset ,
cinchonism ( nausea, vomiting ,
tinnitus , high tone deafness )
Doxycycline ..GIT upset, vaginal
candidiasis..( use antifungal )
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PREVENTION
Avoid mosquito
Wear long sleeved clothing
Sleep in well – screened rooms
Use mosquito netting
Use insect repellents (e.g. DEET)
Chemoprophylaxis..
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1) CHLOROQUINE
ONE TABLET EVERY WK..
DAILY WILL LEED TO RETINOPATHY
Consider resistant plasmodium
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Chloroquine-sensitive areas
Drug of choice
Chloroquine 500 mg (300 mg base) : once/wk
Atovaquone/ proguanil (Malarone) : 1 tab/d
( 250 mg atovaquone /100 mg proguanil)
Mefloquine 250 mg once/wk
Doxycycline 100 mg daily
Alternatives
Primaquine 30 mg base daily
Chloroquine plus proguanil 500 mg (300 mg
base) once / wk + 200 mg