Meningitis
Dr E. O. Adeyemi, FWACP
Consultant Paediatrician
Federal Teaching Hospital, Ido-Ekiti.
Introduction
• Pyogenic vs aseptic meningitis
• Meningitis implies an inflammation of the leptomeninges
• It is a potentially fatal infection that can affect any age group
• It is associated with significant morbidity and mortality.
Common causes of bacterial meningitis (0-2
months)
Gram negative Gram positive
• E. coli • Group B streptococci
• Kleb. Pneumoniae • Staphylococcus species
• Pseudomonas aeruginosa • Listeria monocytogenes
• Proteus species
• Aerobacter aerogenes
Common causes of bacterial meningitis
(2months -12yrs)
Gram negative Gram positive
• Haemophilus influenzae • The streptococci sp
• N. meningitidis • Pneumococcal sp
• Salmonella sp. • Staphylococci sp
• Shigella sp. • Listeria monocytogenes
• Others as for newborn-2 month
age group
Some Risk factors for bacterial meningitis
• Anatomic defects e.g. caused by congenital anomalies, trauma, otitis
media
• In neonates: maternal infections, Chorioamnionitis, Spina bifida, LBW
babies
• Defective opsonization e.g. SCA, splenectomy
• Immunocompromised states e.g. HIV/AIDS, malignancies, severe
burns
• Iatrogenic e.g shunts, catheters
• Overcrowding
• Male gender
Pathogenesis
• Usually results from haematogenous spread
• May also follow direct inoculation
• Capsules help resist phagocytosis
• Inflammatory response occurs with production of cytokines
and subsequent alteration of BBB
• Reduced concentration of complement and antibodies in CSF
encourages proliferation
Pathology/Pathophysiology
• Purulent exudate within the meninges which may spread to
the ventricles
• Cerebral infarction may be due to vascular occlusion
• Inflammation of spinal and cranial nerves
• Raised ICP due to a combination of vasogenic, cytotoxic and
interstitial oedema, SIADH maybe a contributing factor.
Pathophysiology contd.
• Raised CSF protein due to increased vascular
permeability
• Hypoglychorrachia due to decreased glucose transport
by cerebral tissues
Clinical manifestation
• High index of suspicion needed particularly for
neonates and younger children
• There are no specific sign or symptoms attributable to
meningitis in neonates
• Up to a 3rd of patients < 2yrs don’t show typical signs
and symptoms
• May be insidious or fulminant in presentation
Clinical features of meningitis (symptoms)
• Fever
• Vomiting
• Irritability
• Headache and general body aches
• Poor feeding
• Photophobia
• Body rash
• Lethargy /weakness
• Drowsiness
• Unconsciousness
• Seizures
Clinical features of meningitis (signs)
• Pyrexia
• Purpura
• Altered consciousness
• Shock
• Raised intracranial pressure
• Papilloedema
• Bulging anterior fontanelle
• Neck stiffness
• Positive Kernig’s sign
• Positive Brudzinski’s sign
Investigations
• LP for CSF specimen for analysis – (macroscopic/macrosopic,
chemistry, culture).
• Blood – culture, FBC, glucose, E/U, Cr, gases
• Rapid antigen tests for meningitis organisms (CIE, LAT, ELISA)
• PCR
• CT scans / MRI –(subdural effusion, intracranial abscess)
• Trans-fontanel ultrasonography in infants
The normal csf picture
Newborn Older children
• Clear, colourless • Clear, colourless
• Protein: <150 FT or <170 preterm • Protein: 15-45 mg/dl
(mg/dl)
• Glucose: > 50% of blood glucose • Glucose: > 66% of blood glucose
Cells /uL: Cells /uL:
• Lymphocytes (0-30) • Lymphocytes (0-4)
• Polymorphs (0-3) • Polymorphs (0)
• RBCs (20-50) • RBCs (0)
CSF in bacterial meningitis
Pyogenic (Untreated) Partially treated
• Turbid • Clear or cloudy
• Protein markedly elevated • Protein elevated
• Glucose decreased • Glucose normal or decreased
• Cells: markedly increased and • Cells: increased and mostly
predominantly PMNs. PMNs
• Yield on Gram stain, culture and • Yield poor on gram stain and
bacterial antigen tests. culture but bacterial Ag tests
usually positive
Indications for a repeat LP
• Patients with gram negative bacillary meningitis
• Clinical evidence of improvement is lacking after 48-
72 h of therapy
• Slower than anticipated rate of response
Contraindications to lumbar puncture
• Raised intracranial pressure
• Very ill patient (almost moribund)
• Focal neurologic signs
• Local infection at proposed LP site.
• Cardio-respiratory instability
• Coagulopathy
• Thrombocytopaenia
Principles of Drug treatment
• No delay to commencement of IV antibiotics in the upper
tolerable and non-toxic doses
• Choice of antibiotics should be guided by the antibiotic
sensitivity pattern of the agents causing meningitis in the
local environment.
• Generally, a third generation cephalosporin e.g ceftriaxone
(alone or in combination with other antibiotics) should cover
for the most common bacteria causing meningitis
Drug options
• Age 1-2months: ampicillin (200mg/kg/day in 4 doses) and cefotaxime
(200mg/kg/day in 4 doses)
• Older infants and children:
1. Cefotaxime (200mg/kg/day in 4 doses) or ceftriazone
(100mg/kg/day in single dose).
2. Ampicillin (dose as above) and chloramphenicol (75-100mg/kg/day
in 4 doses)
3. Benzylpenicillin 400,000 units /kg/day in 4 doses
Steroid
• A short course of steroids (dexamethasone) may be beneficial in
containing inflammatory response…. 0.6 mg/kg/24h in 4 dd IV given
6 hly for the first 4 days of antibiotic therapy
• Role of corticosteroids: decreased duration o fever, CSF protein,
frequency of seizures, and frequency of hemiparesis and hearing
deficits.
Supportive care
• Regular monitoring of the vital signs
• Control of seizures
• Fluid restriction
• Treatment of raised intracranial pressure
• Treatment of shock, DIC, seizures and other
complications as appropriate
Complications
• Cerebral palsy and mental retardation
• Cranial nerve palsies – II, III, VI, VII, VIII, others
• Hydrocephalus
• Epilepsy
• Subdural effusion
• Intracranial abscess
• Shock / DIC
Differential diagnoses
• Aseptic meningitis (Viral)
• Tuberculous meningitis
• Fungal meningitis
• Encephalitis
• Cerebral malaria
Principles of prevention
• Routine immunization
• Mass vaccination during epidemics of meningococcal meningitis
• Chemoprophylaxis of contacts e.g use of rifampicin for contacts of
cases of meningococcal of H.Flu meningitis.
• Vaccination of special risk groups e.g. polyvalent pneumococcal or
meningococcal vaccines for SCA, asplenic patients.
Poor prognostic factors
• Delayed treatment
• Young age
• Coma at presentation
• Immunocompromised status
• Seizures
Viral encephalitis
• Also often referred to as aseptic meningitis.
• Clinical course is usually self-limited, with complete recovery in 7-10
days.
• When the viral pathogen causes a more involved meningoencephalitis
or meningomyelitis, the course can be significantly more protracted.
• many viruses are capable of causing meningitis
• as many as one third of cases, no causative agents are identified
Some implicated viruses
• Enteroviruses- coxsackievirus and echovirus
• Herpes simplex virus (HSV)-1, HSV-2, varicella-zoster virus (VZV),
Ebstein-Barr virus (EBV), cytomegalovirus (CMV), and human
herpesvirus-6
• Mumps
• Adenovirus
• Measles
• HIV
• Lymphocytic choriomeningitis virus
Presentation
• Poor feeding and irritability in neonate
• Bulging fontanelles
• Fever, headache, irritability, nausea, vomiting, stiff neck, rash.
• Seizures
• Constitutional symptoms of vomiting, diarrhea, cough, and myalgias
Investigations
• CSF culture remains the criterion standard in discerning bacterial or
pyogenic from aseptic meningitis
• viral serology and cultures
• PCR
• RVS
• Mantoux skintest
Treatment
• Treatment for viral meningitis is mostly supportive.
• Bed rest, hydration, antipyretics.
• Intravenous antibiotics should be administered promptly if bacterial
meningitis is suspected.
• Patients with signs and symptoms of meningoencephalitis should
receive acyclovir early to possibly curtail HSV encephalitis
• Ganciclovir for CMV-related infections
Complications
• Seizure disorders
• Hydrocephalus
• Sensorineural hearing loss
• Weakness
• Paralysis
• Cranial nerve palsy
• Learning disabilities
• Blindness
• Behavior disorders
• Speech delay
Prognosis
• The prognosis for viral meningitis is usually excellent as most cases
resolving in 7-10 days.
• Exception falls with the neonatal patients, in whom viral meningitis
can be fatal or associated with significant morbidity.
• Concomitant encephalitis adds significant potential for adverse
outcomes.
• Concurrent systemic manifestations, such as pericarditis and hepatitis,
are other indicators of poor prognosis.
Prevention
• Pregnant women should avoid exposure to rodents, rats, and house
mice
• Neonates should be kept away from exposure to mosquitoes
• Vaccination remains the most potent means of combating infections
• Strict hand-washing is effective in controlling the spread
Thank you
