Transcript Nurs870_AcuteCondition_Presentationx

MENINGITIS
Sarah Guillard
Nurs 870 Pennsylvania State University
Definition
Meningitis is an inflammation of the brain or spinal cord. It can
be bacterial, viral, fungal, parasitic or due to toxins. It can also
be idiopathic.
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(McCance, Huether, Brashers, & Rote, 2014).
Pathophysiology
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Bacterial meningitis occurs at a rate of about 1.2 million cases per year
nationwide
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Affects the pia mater, arachnoid villi, the subarachnoid space, the ventricular
system and CSF.
The most common bacteria types are neisseria meningitides and streptococcus
pneumoniae.
Secondary to systemic or localized infection
Bacteria enters the CNS through the choroid plexus or another area with altered
blood/brain barrier permeability.
Bacteria reproduces in the subarachnoid space and inflames the meninges which
increases their permeability. Neutrophils enter the subarachnoid space and
produce exudate which interferes with the normal CSF flow, causing further
inflammation.
The meninges becomes edematous further increasing ICP. Inflammation of the
blood vessels causes them to be engorged, disrupting blood flow, and possibly
leading to thrombosis
(McCance, Huether, Brashers, & Rote, 2014); (Tunkel, 2015).
Pathophysiology
Aseptic meningitis covers all other meningitis that does
not have a positive routine bacterial culture after
lumbar puncture including viral, fungal, and tubercular
infections.
(Johnson, 2012).
Pathophysiology
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Viral Meningitis
Generally limited to the meninges.
 The most common cause is enterovirus such as coxsackievirus,
non-polio enterovirus or echovirus.
 Other common viruses involved are nonparalytic
poliomyelitis, arbovirus, and herpes simplex 2.
 Viral meningitis is blood borne and enters the brain either
directly or indirectly through infected migrating leukocytes
which then infect the vascular endothelial cells.
 The blood-brain barrier becomes permeable as
inflammatory cytokines are released in response
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(Johnson, 2012); (McCance, Huether, Brashers, & Rote, 2014).
Pathophysiology
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Other Types of Meningitis:
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Fungal - usually immunocompromised person such as an HIV patient. More
insidious development over days to weeks. Most common source is cryptococcus.
A granuloma or gelatinous mass is formed in the meninges with resulting fibrosis
and often cranial nerve dysfunction due to compression.
Tubercular – also found in immunocompromised patients. A tuberculin nodule
forms that erodes the pia mater allowing mycobacteria to enter the CSF and
inflaming the meninges, cerebrum and spinal nerves.
Spirochetes - Lyme disease and syphilis. Other tick borne illnesses such as Rocky
Mountain spotted fever and erlichosis can also be considered as differentials in
aseptic meningitis.
Drugs can also induce aseptic meningitis such as NSAIDs, immunoglobulins,
rofecoxib, antiepileptic drugs, and OKT3 antibodies.
(McCance, Huether, Brashers, & Rote, 2014) (Johnson, 2012).
History
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Common symptoms for bacterial meningitis
 Classic
triad – mental status change, fever, nuchal
rigidity
 Headache
 Hypothermia
 Seizure
 photobobia
(Tunkel, 2015)
History
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Common symptoms for viral meningitis
 Nausea
 Vomiting
 Fever
 Headache
 Nuchal
rigidity
(Johnson, 2012)
History
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Those with acute meningitis generally seek help within
around 24 hours.
Subacute bacterial and viral meningitis occur over 1-7 days,
while fungal and tubercular meningitis may have a more
chronic presentation over more than 7 days.
Acute HIV meningitis may present similarly to mononucleosis
with sore throat, lymphadenopathy, fever, rash, and malaise.
Be sure to screen for HIV risk factors when these symptoms
are present with symptoms of meningitis such as seizure,
confusion, headache, or cranial nerve palsies.
(Hasbun, R. 2016); (Tunkel, 2015).
History
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Besides screening for the common symptoms listed above,
other patient history questions to ask include:
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Travel to area of the world where meningococcal meningitis is
endemic
Living situation
Recent antibiotic use or drug allergies
Recent IV drug use
Exposure to other sick persons
Recent infections or illness
Recent rash, petechiae, or ecchymosis
Recent or remote head trauma
Otorrhea or rhinorrhea
Any immunocompromising conditions
(Johnson, 2012)
Physical Assessment
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General: Bacterial meningitis patients appear very ill, and bacterial or aseptic meningitis may cause
lethargy.
HEENT: Perform optholmoscopic exam to assess for papilledema. Perform otoscopic and upper respiratory
system exam as bacterial meningitis may be secondary to another infection such as sinusitis or otitis media).
Viral meningitis may present with upper respiratory symptoms. Hearing loss is a late complication of
bacterial meningitis. Assess for enlarged lymph nodes that may indicate acute HIV infection.
Skin: 11-25% of patients with bacterial meningitis will have a rash, palpable purpura or petechiae and it is
more common with meningococcal meningitis.
Chest/Lungs: Bacterial or viral meningitis may be secondary infections. Primary infection may originate in
the lungs so they should be assessed for signs of bacterial pneumonia or viral infection.
GI: Assess for nausea and or vomiting which is common especially with viral meningitis
GU: 85% of patients with HSV-2 meningitis will have genital lesions that precede it by about seven days.
Musculoskeletal: Assess for stiffness or pain in the joints as many patients with bacterial meningitis will have
arthritis. The Brudzinski and Kernig maneuvers and assessment of nuchal rigidity were not shown to be
particularly useful for identification of bacterial meningitis in a prospective study of 297 adults. Brudzinski’s
and Kernig’s signs were shown to have a 5% sensitivity and nuchal rigidity had a 30% sensitivity.
Neurological: Assess for photophobia, a common symptom in both aseptic and bacterial meningitis. Assess
for focal neurologic deficits and cranial nerve palsies which may occur early or late in the infection for
bacterial meningitis. Assess for change in mental status such as lethargy or confusion
(Johnson, 2012); (Thomas, Hasbun, Jekel, & Quagliarello, 2002); (Tunkel, 2015).
Labs and Diagnostics
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Immediate blood cultures and lumbar puncture
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Normal CSF values are less than 50 mg/dL of protein, a CSF-to-serum glucose ratio
greater than 0.6, less than 5 white blood cells/microL, and a lactate concentration less
than 3.5 mEq/L”
If there are no signs of bacterial infection, lumbar puncture should be repeated 1224 hours later and possibly screened with PCR for enterovirus. Seventy five percent
of patients who are negative for bacterial meningitis will have a positive PCR for
enterovirus
CBC - For bacterial meningitis, the white count may be elevated with a left shift.
Leukopenia and thrombocytopenia may be present and are indicators of poorer
prognosis.
BNP
Coagulation studies may be consistent with DIC
Procalcitonin and serum lactate will help to rule out sepsis.
(Tunkel, 2015); (Johnson, 2012)
Differentials
Bacterial vs. Aseptic Meningitis
 Viral gastroenteritis or other acute viral infection
Red Flags:
 Sepsis
 Neoplasm
 Bacterial meningitis
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(Wong &Wu, 2016); (Neviere, R, 2016); (Tunkel, 2015).
Treatment
Treatment
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Adults younger than 50 - vancomycin 15-20 mg/kg IV q12h and a third generation
cephalosporin such as cefotaxime or ceftriaxone IV 2g q6h and 2g q12h
respectively, as the most common infectious agents are N. meningitides and S.
pneumoniae.
Over 50 years old - ampicillin 2g IV q12h should be added as well to cover L.
monocytogenes and aerobic gram-negative bacilli.
The gram stain results may require revising the antibiotic therapy to target the
infecting microbe.
Antibiotic therapy lasts for 7-21 days depending on the bacteria involved.
All adult patients with suspected or confirmed pneumococcal meningitis should also
receive dexamethasone 0.15 mg/kg IV q6h for 2-4 days to mitigate the
inflammatory process.
(Tunkel, 2015)
Treatment
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Treatment for viral meningitis is supportive with most cases
resolving in 7-10 days.
HSV meningitis has no consensus treatment but the
recommendation is to treat it with acyclovir 10mg/kg every
8 hours IV and then switched to po, for a total of 10-14
days, to be taken outpatient
Treatment for tuberculosis meningitis is isoniazid 5 mg/
kg/day, rifampin 10 mg/ kg/day, pyrazinamide 15 to 30
mg/kg/day, and ethambutol 15 to 25/ kg/day.
Cryptococcus, the most common cause of fungal meningitis is
treated with amphotericin B IV 0.7 to 1.0 mg/ kg/day plus
flucytosine Ancobon 25 mg/kg every six hours orally
(McCance, Huether, Brashers, & Rote, 2014); (Johnson, 2012); (Bamberger, 2010)
Patient Teaching
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Family and friends in close contact with those diagnosed
with bacterial meningitis will need to be treated with
antibiotics.
The patient will likely follow with infectious disease
after their course in the hospital and may need
rehabilitation if they are elderly or had an extended
course resulting in deconditioning.
Those with viral meningitis will need teaching on the
difference between viral and bacterial meningitis and
why it is not treated with antibiotics. Like other viral
illness, they should get fluids and rest and return to the
primary care office if their symptoms worsen
(UpToDate,2016)
Outcomes
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Mortality due to bacterial meningitis increases with age.
In one study, patients 18-34 had a case fatality rate of 8.9% while those
over 65 had a case fatality rate of 22.7%.
Nosocomial infection has a higher mortality rate than community acquired.
Mortality is highest in those with S. pneumoniae and L. monocytogenes and
lowest with N. meningitides.
Twenty eight percent of community acquired bacterial meningitis has
neurologic complications. Lasting complications include sensorineural hearing
loss, intellectual impairment, residual deficits due to meningitis induced CVA,
and hydrocephalus.
Aseptic meningitis has varying outcomes depending on etiology, but
generally viral meningitis has good outcomes without residual effects and
can often be treated at home after it has been established that it is
nonbacterial in origin.
(Tunkel, 2015); (Sexton, 2015); (Johnson, 2012)
Questions and Discussion
References
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Bamberger, D. (2010) Diagnosis, Initial Management and Prevention of Meningitis. American Family Physician. 82(12):1491-1498
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Goroll, A., Mulley, A. (2014). Primary Care Medicine: Office Evaluation And Management Of The Adult Patient (7th ed.). Philadelphia: Wolters Kluwer Health
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Hasbun, R. (2016) Meningitis Clinical Presentation. Medscape. Retrieved from: http://emedicine.medscape.com/article/232915-clinical
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Hasbun, R., Abrahams, J., Jekel, J., Quagliarello, V. (2001) Computed Tomography Of
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The Head Before Lumbar Puncture In Adults With Suspected Meningitis. New England Journal of Medicine. 345(24): 1727-33.
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Johnson, R. (2012) Aseptic Meningitis in Adults. UpToDate. Retrieved from: http://www.uptodate.com/contents/aseptic-meningitis-inadults?source=search_result&search=meningitis&selectedTitle=6~150
McCance, K., Huether, S., Brashers, V., Rote, N. (2014) Pathophysiology: the Biologic Basis For Disease In Adults and Children (7th ed.). St. Louis, MO: Elsevier Mosby
Neviere, R. (2016). Sepsis Syndromes in Adults: Epidemiology, Definitions, Clinical Presentation, Diagnosis, and Prognosis. UpToDate. Retrieved from:
http://www.uptodate.com/contents/sepsis-syndromes-in-adults-epidemiology-definitions-clinical-presentation-diagnosis-andprognosis?source=search_result&search=sepsis&selectedTitle=1~150
Sexton, D. (2015) Neurologic Complications of Bacterial Meningitis. UpToDate. Retrieved from: http://www.uptodate.com/contents/neurologic-complications-ofbacterial-meningitis-in-adults?source=see_link
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Thomas, K., Hasbun, R., Jekel, J., Quagliarello, V. (2002). The Diagnostic Accuracy of Kernig's
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Sign, Brudzinski's Sign, and Nuchal Rigidity in Adults with Suspected Meningitis. Clinical Infectious Disease. 35(1): 46-52
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Tunkel, A. (2015). Clinical Features And Diagnosis Of Acute Bacterial Meningitis In Adults. UpToDate. Retrieved from: http://www.uptodate.com/contents/clinicalfeatures-and-diagnosis-of-acute-bacterial-meningitis-in-adults?source=machineLearning&search=meningitis&selectedTitle=1~150&sectionRank=1&anchor=H3#H3
Tunkel, A., Hartman, B., Kaplan, S., Kaufman, B., Roos, K., Scheld, W., Whitley, R. (2004) Practice Guidelines For The Management Of Bacterial Meningitis. Clinical Infectious
Disease. 39(9):1267-84
Tunkel, A. (2015) Initial Therapy And Prognosis Of Bacterial Meningitis In Adults. UpToDate. Retrieved from: http://www.uptodate.com/contents/initial-therapy-and-prognosis-of-bacterialmeningitis-in-adults
UpToDate. (2016) Patient Information: Viral Meningitis (The Basics). Retrieved from: http://www.uptodate.com/contents/viral-meningitis-the-basics?source=see_link
UpToDate (2016) Patient Information: Bacterial Meningitis (The Basics) Retrieved from: http://www.uptodate.com/contents/bacterial-meningitis-thebasics?source=search_result&search=patient+teaching+meningitis&selectedTitle=2~150
Wong, E., Wu, J. (2016) Clinical Presentation and Diagnosis of Brain Tumors. UpToDate. Retrieved from: http://www.uptodate.com/contents/clinical-presentation-and-diagnosis-of-braintumors?source=machineLearning&search=brain+neoplasm&selectedTitle=1~150&sectionRank=1&anchor=H2#H2