what is meningitis? aseptic meningitis? encephalitis? meningoencephalitis?
Meningitis = Infection of the meninges
•Aseptic meningitis = meningitic symptoms plus white cells in CSF, but no growth on routine cultures
•Encephalitis = Inflammatory process of the brain (usually acute and diffuse, often viral, altered mental status early, focal signs)
•Meningoencephalitis = combination of meningeal and parenchymal disease)
seizures, focal signs, altered mentation reduced GCS
history and examination?
Fever, headache, photophobia, neck stiffness
•Rash, sore throat, swollen glands, vomiting, genitourinary symptoms
•Illness in contacts
•HIV risk factors
•Exposure to rodents / ticks
three signs of meningism?
nuchal rigidity - Nuchal rigidity is the inability to flex the neck forward due to rigidity of the neck muscles; if flexion of the neck is painful but full range of motion is present, nuchal rigidity is absent.
Kernig's sign - Kernig's sign (after Waldemar Kernig (1840–1917), a Baltic German neurologist) is positive when the thigh is bent at the hip and knee at 90 degree angles, and subsequent extension in the knee is painful (leading to resistance). This may indicate subarachnoid hemorrhage or meningitis. Patients may also show opisthotonus—spasm of the whole body that leads to legs and head being bent back and body bowed backwards.
Brudzinski's sign - Jozef Brudzinski (1874–1917), a Polish pediatrician, is credited with several signs in meningitis. The most commonly used sign (Brudzinski's neck sign) is the appearance of involuntary lifting of the legs when lifting a patient's head off the examining couch, with the patient lying supine.
Other signs attributed to Brudzinski:
The symphyseal sign, in which pressure on the pubic symphysis leads to abduction of the leg and reflexive hip and knee flexion.
The cheek sign, in which pressure on the cheek below the zygoma leads to rising and flexion in the forearm.
Brudzinski's reflex, in which passive flexion of one knee into the abdomen leads to involuntary flexion in the opposite leg, and stretching of a limb that was flexed leads to contralateral extension.
Clear / colourless
•Glucose 60-70% of blood glucose
•White cells <5 / mm3
•Red cells <1 / mm3
veinsengorged run downhjill to retinal surface
blurry indistint margin
Feathery kane shaped hemorrhage in nerve fiber layer
Enteroviruses (46%) now most common because of MMR
•HSV type 2 (31%)
•Varicella zoster virus
•HSV type 1
•Often no cause identified
Coxsackie A & B, echoviruses, polioviruses, enterovirus 71
•Systemic infection; neuroinvasion
•Check viral PCR
HSV type 2?
Second most common cause
•Esp. young adults
•In genital HSV-2 meningeal symptoms in:
But frequently unrelated to genital herpes
infections and cells involved
1. Pneumococcal (streptococcus pneumoniae): esp. elderly, immunocompromised, alcoholics, smokers, diabetics
2.Meningococcal (neisseria meningitides): children & young adults; epidemics
3.Listeria monocytogenes: neonates; defective cell-mediated immunity
Treatment of pneumococcal/meningococca meningitis?
Benzylpenicillin IV / IM (if no access)
•Adults and children >10 y: 1.2g
•1-9 y: 600mg
•Under 1 year: 300mg
empirical antimicrobial therapy?
•Vancomycin 15mg/kg every 8h +/- ceftriaxone 2g bd or cefotaxime 2g qds
sensitivity of s.pneumonia, menigitidis, ad l. monocytogenes?
S. pneumoniae, H influenzae, gp B strep – 10 days of antibiotics
•N. meningitidis – 7 days of antibiotics (plus: Rifampicin 600mg orally every 12 h for 2 days to eradicate nasal carriage)
•L monoctogenes / enterobacteriacaea – 3-4 weeks
Helpful in pneumococcal
•NOT all types and NOT for postsurgical meningitis or severe immunocompromise
Hypotension (septic shock) = poor prognosis……ITU
2.Hyponatraemia <135 esp. L monocytogenes
3.Hypernatraemia >143 = poor prognosis…more severe disease, seizures, coma
4.Arthritis..from blood or immune complexes…abrupt onset of single hot, swollen, painful joint
HSV (15% of all cases)
•Arboviruses (arthropod borne viruses)
herpes simplx virus?
Reactivation of dormant HSV-1 in trigeminal ganglion / olfactory bulb
•Viral spread to brain via sensory pathway
•Fatal in 40% untreated cases
•Fever, confusion, headaches and seizures
diagnosis of hsv encephalitis?
1Compatible clinical history of encephalitis
2CSF analysis and PCR
what does PLED stand for?
Periodic lateralised epileptiform discharges (PLEDs)
PLEDs are an electroencephalographic phenomenon consisting of high voltage stereotyped periodic transients distributed over one hemisphere, associated with acute or subacute structural lesions as well as with metabolic abnormalities
Acyclovir 10 mg/kg IV every 8 hours for 14 - 21 days
•Start ASAP - fatality reduced by 50%
•May need anticonvulsants e.g. phenytoin
•ICP monitoring of comatose patients
•Ensure adequate hydration and monitor renal function
chloramphenicol / cefotaxime
•2-3 weeks IV then 3-4 weeks oral
•Surgical drainage / excision
CT LP CT of HIv infection?
Acquired by inhalation
•CD4+ < 50
•Acute or latent reactivation ?
•Meningitis / encephalitis
CSF diagnosis of cryptococcus?
Organisms in CSF
•India ink stain
2 weeks of:
IV Amphotericin B
Fluconazole (8 weeks)
Headache, fever, neck stiffness, +/- coma, cranial nerve palsies
TB mengitisi causes?
•Culture of TB (3-6/52)
•PCR (c.f. ZN stain and specificity variable)
4.Ethambutol OR Streptomycin
Dexamethasone 0.3 - 0.4 mg/kg
•Taper over 6-8 weeks
•23% reduction in mortality
primary cns lymphoma?
Non-Hodgkin’s B cell
•Related to EBV
•EBV transforms B cells
•Meningitis in 25%
treatment for primary cns lymphoma?
Radiotherapy improves symptoms in 50-70%
•Median survival <3/12
•HAART treatment prolongs survival
progresive multifocal leucoencephalopathy
JC virus acquired childhood / young adult (70-90%)
•Latent in kidney, lymphoid tissue, CNS
•Death within 1-6 months
•Fever and headache usually absent
•PCR JC virus in CSF
•Tx: Antivirals (HAART /Ganciclovir/ Foscarnet/ Cidfovir)
Encephalitis with dementia
2.Ventriculoencephalitis:delirium, cranial neuropathy, nystagmus, ataxia
rodent eate by cat,makes unsporulated oocyst in feces, this then goes in litter or food and we inhale o eat sporulated oocyst.
brina piospy for toxoplasmosis?
conditions toxoplasmosis can cause?
cerebral toxoplasmosis - features , Headaches
•Cranial nerve palsies
+ Headaches, fever, focal signs etc.
CD4 count < 200
= CEREBRAL TOXOPLASMOSIS
Pyrimethamine & sulphadiazine