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Infection > Meningitis > Flashcards

Meningitis Flashcards

1
Q

What is meningitis

A

Infection and inflammation of the meninges

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2
Q

What is meningism

A

Thunderclap headache
Photophobia
Vomiting
Neck stiffness due to spasm on flexion

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3
Q

What can cause meningism

A

Meningitis
SAH
Migraine
Sinusitis

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4
Q

What should you beware of

A 
Fever
Vomiting
Lethargy
Confusion 
Even in absence of headache / photophobia
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5
Q

What are bacteria causes

A

Neisseria meningitides
S.pneumonia
H.influenza - more in young-18

Neonate
E.coli
GBS
Listeria monocytogene - also in >50

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6
Q

What are viral causes

A 
HSV and VZV = most common 
Enterovirus
Mumps 
EBV 
HIV
CMV - immunocompromised
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7
Q

What causes shunt associated meningitis (VA / VP)

A

Coag -ve staph - S.epiderdimis
S.aureus
Coliforms

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8
Q

What do you do for shunt associated

A

Refer to neurosurgeon

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9
Q

What are non-infective causes

A 
Drugs
SLE
Sarcoid
Malignancy
Treat as infective 1st then look for these if no infection
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10
Q

What does CSF show in non-infective

A

No organism

Excessive WCC / protein

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11
Q

What are RF for meningitis

A 
Alcohol 
Immunocompromised - HIV / DM / congenital 
ENT condition
Surgery 
Splenectomy 
Skull trauma
FH / contact
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12
Q

How is meningitis transmitted

A 
Close contact
Vertical from mother to baby - group B strep 
Adjacent infection - sinusitis
Neurosurgery 
Head injury / trauma
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13
Q

How do you Dx meningitis

A

Blood culture before Ax if possible
Blood PCR
LP = definite if no CI
Always do CT prior to LP to ensure no mass

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14
Q

What do you send CSF for

A 
Gram stain and culture - bacteria
PCR - viral
AAFB on ZN for TB
Cell count
Antigen detection
Glucose
Protein
WCC
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15
Q

What other tests do you do

A 
Bedside obs 
NPA and throat swab to isolate 
Bloods- FBC, U+E, LFT, clotting, CRP
Blood glucose
ABG or VBG 
CXR as part of sepsis screen
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16
Q

What are CI to LP

A 
Focal neuro suggesting mass
- Papilloedema
- Seizure 
Chairi malformation
Raised ICP
Unstable patient
Bleeding disorder / DIC
Immunocompromised 
Infection over LP site
Meningococcal septicaemia as thrombocytopenia
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17
Q

What are complications of LP

A 
Spinal headache
Nerve root trauma
Cyst 
Infection
Brain herniation if raised ICP
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18
Q

How does spinal headache present

A

Bilateral

Improves when supine

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19
Q

How do you Rx

A

Fluid
Caffeine
Epidural blood patch

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20
Q

What are symptoms of nerve root trauma

A

Electric shock
Back pain
Altered mental
CN abnormalities

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21
Q

How do you Rx and Dx if nerve been injured

A

Raise head
Mannitol
Steroid
Intubate

Nerve conduction studies

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22
Q

What empirical therapy do you give for meningitis

A 
BenPen in community 
Amox +cefaxime if <3 months or >60
Cefotaxime if >3 months
Chloroamphenicol if allergic
Aciclovir if any signs of encephalitis 
Steroid if >3 months and not meningococcus
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23
Q

What does CSF show in bacterial meningitis

A 
Turbid colour 
Increased opening pressure
Elevated WCC
Neutrophils predominate >50%
Reduce glucose 
Increased protein
Increased lactate
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24
Q

What does CSF show in viral meningitis

A 
Clear colour 
Increased opening pressure can be normal 
Elevated WCC (lymphocytes) 
Neutrophils <10%
Normal glucose
Normal or raised protein
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25
Q

What does CSF show in TB

A 
Cloudy 
Increased  pressure 
Increased WCC
Reduced glucose 
Increased protein 
Mixed cell / lymphocytes
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26
Q

When may opening pressure be normal

A

Viral
TB
FUngal

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27
Q

What do you do if organism killed by Ax before LP

A

Look at protein / glucose

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28
Q

What should you never do

A

Delay Rx if life-threatening

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29
Q

What causes meningococcal

A

Neisseria meningitdes

Gram -ve

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30
Q

How does meningococcal present

A 
Meningism 
Rapid deterioration in mental
Systemic upset - flu / fever
Seizures
Irritable 
Skin rash - petechial / maculopapular (20%) 
Petechiae conjunctiva
SEPTIC SIGNS
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31
Q

What should you never wait for

A

Skin rash to appear

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32
Q

How do you assess

A 
A - can't maintain if unconscious 
B - increased RR / O2
C - shock 
D - AVPU / pupils / GCS / papilloedema / focal neuro 
E - rash / temp /
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33
Q

What is Kernig sign

A

Can’t extend knee joint when hip joint flexed

Signs of meningeal irritation

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34
Q

What is Bruzinski sign

A

Hip and knees flex when neck flexed

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35
Q

When do you do a CT

A

Most people get a CT just to make sure
Rule out abscess
Make sure safe to do LP

Indication
Immunocompromised
Hx CNS - stroke
Seizure within one week of feeling unwell
Swollen optic disc 
Low GCS
Focal
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36
Q

When may you not need LP

A

Confident Dx with typical rash

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37
Q

Do you still do LP if Ax given

A

Yes as changes in CSF can stay for 48 hours

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38
Q

How do you treat meningococcal

A

Early Ax - cefotaxime
Fluid resus
ICU
Support shock and raised ICP due to cerebral oedema

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39
Q

What do you give pre-hospital

A

Benpen IM

Always give if suspect

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40
Q

What do you give on discharge

A

Rifampicin or ciprofloxacin

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41
Q

What do you do for raised ICP

A

Low threshold for intubation and ventilation

Mannitol

42
Q

What do you give prophylaxis

A 
Public health must be notified of all bacteria meningitis 
All close contacts
Ciprofloxacin preferred to Rifampicin
Target immunisation
Eliminate carriage
43
Q

What vaccine are available

A

Meningococcal A and C
Pneumococcus
H. influenza

44
Q

What suggests bad prognosis

A 
Delay in therapy
Age extreme
Purpura
Shock + no meningism
DIC
Metabolic acidosis
Neuro deficit 
Absence of raised WCC
45
Q

DDX

A

Encephalitis - headache / reduced GCS
SAH - fever unlikely
Migraine

46
Q

What is DIC

A

Abnormal clotting in small blood vessels
Low platelet
Increased fibrin

47
Q

What suggests chronic meningococcaemia

A 
Meningococcal sepsis in absence of meningitis 
Fever >1 week 
Rash
Joint pain
Malaise
48
Q

What is meningococcal septicaemia

A

CSF sterile

Septicaemia from meningococcal source (bug) - not infection in the menigniges

49
Q

Wha is mortality

A

50% die in 24 hours

50
Q

How does meningococcal septicaemia present

A 
Rapid decreased GCS/ change in mental
Fever
Headache
Purpuric rash = common feature 
- Not always present in meningitis 
Septic shock
Low urine / tachy / hypotension
DIC
Acidosis
Adrenal insufficiency
51
Q

How do you Dx

A

Blood culture / PCR

LP sterile so if suspect septicaemia don’t bother

52
Q

How do you Rx

A 
Treat sepsis
Supportive
Inotropes 
Vasodilators
Steroids
Senior
53
Q

What causes WCC to decrease

A

Seizure infection with septicaemia and DIC

54
Q

What are complications of septicaemia

A

Seizures
Organ failure
Permanent neuro
Limb gangrene

55
Q

What is Waterhouse Fredrickson Syndrome

A

Haemorrhage into adrenal gland causes insuffieincy
Hypotensive
Low Na and high K

56
Q

What causes Pneumococcal meningitis

A

Strep pneumonia

57
Q

What else can s.pneumonia cause

A

Otitis media
Sinusitis
Pneumonia

58
Q

What is most common in adults

A

Pneumococcal

59
Q

How does it present

A

Acute
Meningism
More likely altered consciousness/ focal neuro / seizures
GCS <15

60
Q

What is uncommon in pneumococcal

A

Petechiae

61
Q

What are RF

A 
Age
URTI
Pneumonia
Sinusitis
Endocarditis
Head trauma
Alcohol
Splenectomy
62
Q

What should you also do

A

CXR as 50% will have pneumonia

63
Q

How do you treat

A

Benzypen

Ceftriaxone if resistant

64
Q

What else do you give and why

A

Dexamethasone
Reduce likelihood of neuropathy / hearing loss
Same time as 1st dose of Iv Ax

65
Q

How do you prevent

A 
Once off Pneumococcal vaccine if 
>65
Children
DM
Immunocomprmoised
Chronic disease inc chronic liver 
Asplenia + CKD = 5 year booster 
HIV
Cochlear implant / skull trauma
Cerebral spinal fluid leaks
66
Q

What are complications

A 
Increased ICP and brain herniation 
Brain damage 
Sensorineural hearing loss
Visual loss 
CN palsies 
Ataxia
Hemiparesis
Obstructive hydrocephalus 
Seizure
Epilpesy
67
Q

When do you give dex

A

All meningitis except meningococcus

68
Q

What does H.influenza B cause

A

Mild URTI
Rapid deterioration
Fever
Lethargy

69
Q

What is rare

A

Meningism
Petechiae
Nuchal rigidity

70
Q

Who is at risk

A

Young children

Rare as vaccine

71
Q

How do you treat

A

Cefotaxime as B-lactamase resistance
Dexamethasone
Vaccine

72
Q

What do you give prophylaxis

A

Rifampicin

73
Q

What is Listeria monocytogenes

A

Gram +ve rod
Important cause of neonatal meningitis
Brain abscess

74
Q

Wha does it cause in pregnancy

A

Febrile flu

75
Q

When is it important to think of

A

Immunocompromised

Newborn

76
Q

How do you Dx

A

Blood culture

77
Q

How do you Rx

A

Iv amoxicillin + Gent

Ceftriaxone

78
Q

What are complications of Listeria

A

Long term neuro
Brain abscess
Abortion
Neonatal sepsis

79
Q

How does TB meningitis occur

A

Rupture of subependymal tubercle into SAH
Post primary event
Extrameningeal TB

80
Q

What are symptoms of TB meningitis

A 
Meningism 
Low grade fever
Extra-meningeal TB
Lethargy
Chronic headache
Change in mentation
Weight loss
Night sweats
Malaise
81
Q

How do you Dx TB meningitis

A 
AAFB ZN CSF 
Only 30% +Ve
Repeat LP
PCR sputum / urine
Mantoux
82
Q

When should you always consider TB

A

Reduced glucose and gram stain -ve

83
Q

How do you treat

A

Speicalist

84
Q

What can Leptospirosis and Lyme cause

A 
Septicaemia
Meningism
Fever
Rigors
Myalgia
Vomiting
Conjunctival effusio
Rash
Hepato-renal damage
85
Q

How do you Dx

A

Serology

Only small % develop

86
Q

What are viral causes

A 
HSV and VZV = most common 
Enterovirus - Echo / Coxsackie 
EBV 
HIV
CMV
87
Q

When is CMV common

A

Immunocompromised

88
Q

How does viral present

A 
Non specific prodromal
Rapid headache
Low grade fever
Phosphobia
Stiff neck
Usually lucid and alert
89
Q

What virus presents with rash

A

Enterovirus

90
Q

What is viral meningitis often associated with

A 
Encephalitis
Lethargy
Confusion
Seizures
Focal neuro
91
Q

When is viral common

A

Young adults and children
Immunocompromised
Travel

92
Q

How do you Dx

A

PCR CSF
Throat swab PCR
HIV test

93
Q

How do you treat

A

IV acyclovir
Most make full recovery
Supportive
IV Ig if chronic

94
Q

How do you prevent

A

MMR and Hib vaccine

95
Q

What causes fungal meningitis

A

Cryptococcus neoformans

96
Q

How does it present

A 
Subacute
Low grade fever
Headache
Nausea
Lethargy
Confusion
97
Q

Who is at risk

A

HIV
DM
Lymphoma
Immunocompromised

98
Q

How do you Dx

A

India ink CSF
Gram stain candida
Term cryptococcal antigen in CSF

99
Q

How do you treat

A

Specialist

IV amphotericin B

100
Q

How you prevent

A

Long term chemoprophylaxis with fluconazole if HIV

Infection (14 decks)

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