15.5.2 Meningitis

Question 1

Pathogenic organisms (common)

Answer 1

Child+adult
- Haemophilus influenzae (haemophilus)
- Streptococcus pneumoniae (pneumococcus)
- Neisseria meningitides (meningococcus)

<3months
- Group B haemolytic streptococcus
- Gram negative organisms: E.coli, Klebsiella etc

immunocompromised on new slide

Question 2

Pathogenic organisms (rare)

Answer 2

• Direct transmission CSF: – E.g. Streptococcus faecalis
• Immunocompromised: – HIV

Question 3

Pathogenesis

Answer 3

• know there are different routes
• common slide
• rare slide

Question 4

Pathophysiology

Answer 4

leave the white slide with the diagram

Question 5

Risk factors

Question 6

Clinical exam and history

Answer 6

Always suspect meningitis; it can present with alot of different symptoms
It is an medical emergency; start antibiotics immediately
Con with slides

Question 7

Clinical presentation of meningitis: Neonates

Answer 7

Signs are non-specific or absent. Therefore lumbar puncture is indicated.
• Irritability
• Restlessness
• Poor feeding
• Vomiting
• Apnoea, Bradycardia
• Temperature instability
• Hypotonia
• Fever
• Bulging fontanelle
• Jaundice
• Diarrhoea
• High pitched cry

Question 8

Clinical presentation of meningitis: older child

Answer 8

• Lethargy
• Vomiting
• Bulging fontanel
• Convulsions
• Rash
• Coma
• Fever
• Photophobia
• Headache
• Neck and backache
• Signs of meningism

Question 9

Clinical presentation: meningococcus

Answer 9

• Purpura
• Meningitis:
  ➡️Often severe brain oedema: LP risky
  ➡️Mannitol indicated
• Shock:
  ➡️Waterhouse-Friederichsen syndrome
  ➡️purpura fulminans: limb & digit loss

Give antibiotics immediately!
-> give antibiotics anybody close enough contact for droplet spread (even if vaccinated)

Question 10

Routine CSF findings in healthy and childhood meningitis

Answer 10

• neonate normal value
• changes
• septic
• aseptic
• TB (great mimicer)

Slide with table
Very NB!!

Question 11

Prevention of meningitis

Answer 11

• Immunization
  ➡️H.influenzae: Hibvaccine
  ➡️Pneumococccus: Polyvalent vaccine
• Chemoprophylaxis
  ➡️Meningococccus- rifampicin, ciprofloxaxin
  ➡️H. influenzae- rifampicin

Question 12

Key points to know

Answer 12

• types of organisms
• give antibiotics
• rash (antibiotic for everyone)
• TB meningitis is very NB!

Question 13

NB TBM epidemiology

Answer 13

• TB incidence South Africa
  ➡️1000/ 100,000 population
• TBM
  ➡️Most common bacterial meningitis W. Cape
  ➡️Most common reason for mortality in childhood TB
• Acid-fast bacilli
  ➡️Mycobacterium tuberculosis
• Age of presentation
  ➡️2-4 years

Question 14

TBM pathogenesis

Answer 14

• Results from primary TB- usually pulmonary
• Rich focus:
  ➡️granuloma in the brain that breaks through to the subarachnoid space → TBM
• Miliary TB
  ➡️25% of TBM

slide regarding the stats that 20% of TBM will die (especially the last bullet is very important) + slide after

Question 15

Pathology of TBM

Answer 15

Dense basal exudate
– CSF obstruction: hydrocephalus
– peri-arteritis: infarction
– peri-neuritis: cranial nerve palsies
– parenchymal: esp brainstem

Question 16

Clinical presentation: Stages of TBM

Answer 16

Stage 1:
- low-grade fever/ apathy and irritability
- Cough (daily for >2 weeks)/vomiting
- NB: weight crossing centiles on RTHB

Stage 2:
- neurological signs: neck stiffness, ⬆️ICP, hemiparesis
- 2a GCS 15
- 2b GCS 11-14 (refined MRC staging)

Stage 3:
- coma/ quadriparesis/ cranial nerve palsies/ possible brainstem dysfunction

Question 17

NB early diagnosis TBM

Answer 17

Stage I
➡️100% survival
➡️90% + neurologically normal

Stage 3
➡️30-40% mortality
➡️10% neurologically normal

Early diagnosis tips
- Always think of TBM
➡️esp low socio-economic setting
➡️Persistent symptoms (e.g. vomiting/coughing)
- Ask about TB contact: adults
- Road to Health Booklet
➡️80% poor weight gain months prior to TBM

Question 18

TB in children an puci-bacillary (cannot do only one test to test for TBM)