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Infection - meningitis Flashcards

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1
Q

What is meningitis?

A

Inflammation of the meninges

Usually due to infection

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2
Q

What is the pathogenesis of meningitis?

A 
Attachment  to mucosal epithelial cells
Transgression of mucosal barrier
Survival in blood stream
Entry into CSF
Production of overt infection in meninges (with or without brain infection - encephalitis)
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3
Q

What are the common bacterial causes of meningitis>

A

Neiseria meningitidis (mengiococcus)
Strepococcus pneumonia
Neonates - E. Coli + Group B streptococci

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4
Q

What are the common viral causes of meningitis>

A 
Enteroviruses
-Echoviruses
-Parechoviruses
-coxsackie viruses
-polio(not in UK)
Mumps (rarely)
Herpes simplex
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5
Q

What are the less common causes of meningitis ?

A 
Haem influ B
Listeria monocyotgenes
Mycobacterium TB
Leptosporosis
Borelia burgdorferi
Crytococcus neoformans
HIV
Varicella virus
Epstein-barr virus
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6
Q

What are the non-infective causes of meningitis?

A

Tumours

Causes aseptic meningitis

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7
Q

What is aseptic meningitis?

A

High protein + lymphocytes

No organism detected

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8
Q

How does meningitis present?

A 
Heaache
Photophobia
Neck stiffness
Vomiting
Lethargy
Clouding conciousness
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9
Q

When should you expect bacterial meningitis?

A

Clouded conciousness

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10
Q

How long are symptoms present in acute presentation of meningitis?

A

Less than 24 but rapidly progressive

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11
Q

What causes sub acute presentation of meningitis? What is the time period?

A

1-7 days

All viral and 65% bacterial. Fungal also possible

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12
Q

What are the side effects for late treatment of bacterial meningitis?

A

Long term deafness
Fits
Mental impairment

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13
Q

What are the key points in a general exmaination in suspected meningitis?

A

Pyrexial?
Level of conciousness?
Rashes - skin + conjunctival petechia in 60% with mengiococcal

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14
Q

What are the key points in a cardiovascular exmaination in suspected meningitis?

A 
Pulse - brady/tachy?
Blood pressure (septic shock?)
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15
Q

What are the key points in a neurological exmaination in suspected meningitis?

A

Focal neurological signs (TB/cryoticiccal meninigits)

Papilloedema (unusual - consider space occupying lesion)

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16
Q

What are the traditional physical signs in meningitis?

A 
Kernig sign (hip flexed, patients leg cannont be straightened due to hamstring spasm)
Flex neck in attempt to touch chin - difficult with neck stiffness
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17
Q

What specimines should you collect in suspected meningism?

A

Blood cultures (before antibiotics if possible, but take anyway even if antibiotics taken). Then treat with best guess
Lumber puncture
CT if papillodema to rule out lesion

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18
Q

What are the CSF findings in bacterial mengitis?

A

Looks turbid (nroamlly clear)
Cells - greatly increased (normally small unmbers)
Predominant cell type - neutrophils (normally phymphocytes)
Glucose reduced (normally 60% of blood level)
Protein greatly increased

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19
Q

What are the CSF findings in viral mengitis?

A

Looks clear- turbid (normally clear)
Cells - moderate increased (normally small unmbers)
Predominant cell type - lymphocytes (normally lymphocytes)
Glucose normal
Protein moderate increased

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20
Q

What are the CSF findings in TB mengitis?

A

Looks turbid (nroamlly clear)
Cells - moderate increased (normally small unmbers)
Predominant cell type - lymphocyte or mixed (normally phymphocytes)
Glucose reduced (normally 60% of blood level)
Protein greatly increased

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21
Q

How do you treat acute bacterial meningitis?

A

Use antibiotic that penetrates the CSF
Benzylpenicillin - if CSF inflamed + 4hrly doses
Ceftrizone in bacterial menigitis

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22
Q

What is the epidemiology of menigococcal meningitis?

A

Primarily young children
Sporadic disease
University student outbreaks in recent years

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23
Q

What is fulminant mengiococcal speticaemia?

A

Startling suddens of symptoms causing rapid deterionation in consciousness, fever, septicaemic shock with renal failure _ disseminated intravascular coagulation
Not techincally meningitis as CSF sterile

Purplish rash charecteristic

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24
Q

What is the management for fulminant mengiococcal septicamia?

A

Antiobiotics by GP immediately - penicillin

Modified after blood tests

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25
What is the rash assciated with mengioccoal disease?
Purplish rash that does not blanche under pressure | However, earlier signs exist (cold extremities, leg pains)
26
What factors indicated a bad prognosis of meningitis?
Delay of antibiotics Extremes of age Purpuric leasions Shock with absence of signs of meningitis Lab: Metabolic acidosis Abscence of polymorph leucotosis
27
Who should meningitis be reported to?
Local consultant in health protection
28
What is the epidemoiology of pneumococcal meningitis?
``` Most frequent cause of bacterial meningitis Predisposing factors: Pneumonia Sinusitis Endocarditis Head trauma Alcoholism Splenocetpmy ```
29
What is the microbiology of penumoccoci?
Gram positive | a haemolytic on agar jelly
30
What are the clinical features of pneumococcal meningitis?
Often acute within 1-2 days Focal neurological signs or altered conciousness more common in haemphilus or mengiococcal Concurrent infection in sinuses
31
What is the treatment for pneumoccoal meningitis?
Early administration of high dose ceftrixone
32
What are the complications of pneumococcal menginitis?
``` Death Loss of hearing Cranial nerve deficits Hydrocephalus Seizures ```
33
Who are immunised against pneumococcal meningitis?
``` Patients with Splenectomy Diabetes mellitus Chronic renal disease Cardio-respiratory disease HIV ```
34
What is the epidemiology of haemophilus inflenzae B meningitis?
Young children affected | Mild URTI followed by rapid deterioation
35
What is the treatment of choice in haemophilus influenzae meningitis?
Dexamethasone
36
What is the clinical picture in TB meningitis?
Meningitis follows rupture of subependymal tubercle Low grade fever + extrameningeal TB Lethargy Chronic headache Change in mentation
37
How do you investigate suspected TB meningitis?
Culture most sensitive Repeated LP CT head
38
What is the epidemiology of viral meningitis?
Young adults or children Enteroviruses most common Late summer/early autumn
39
What are the clinical features of viral meningitis?
``` No specific prodrome Rapid onset headache Photophobia Low grade fever Stiff neck ``` Patients normally altert and lucid Rash may be present
40
What are the investigations into suspected viral meningitis?
PCR of CSF | Shows lymphocytosis with normal glucose
41
How do you treat viral meningitis?
Enteroviruses Normally none needed as recover within 72 hours If immunocomprimised/chronic infection - IV immunoglobulin may be used For herpes - aciclovier IV, then oral
42
What yeast is most likely to cause meningitis?
Crytococcus neoformans Occurs in HIV Sometimes in diabetes + immunosupression
43
What is the clinical presentation of fungal meningitis?
``` Most commonly subacute onset of symptoms Low grade fever Headache Nausea Lethargy Confusion Abdominal pain ```
44
How do you treat fungal meningitis?
Amphotericin IV | Sometimes with fluconazole
45
How does neonate meningitis differ from adult meningitis?
Symptoms usually non specific or not well localised Bacteria involved often E coli, L monocytogenes, group B streptococci Enteroviruses Parechoviruses
46
What are the clinical signs of early onset neonatal meningitis?
Early onset - within 3 days of birth Marked respiratory disrtress Bacteraemia High mortality Associated with premature or difficult/prolonged birth
47
What are the clinical signs of late onset meningitis?
More than one week after birth Bacteraemia + meningitis Pulmonary involvment rare Moraltity 10-20%
48
How do you diagnose neonatal meningitis?
Bacterial - neonate CSF + blood cultures | Viral - neonate CSF, EDTA blood, faeces + nasopharyngeal secretions
49
What is the prognosis of neonate meningitis?
High mortality - up to 50% | Neurological + development difficulties in around 33%
50
How do you prevent neonatal meningitis?
High risk mothers given chemoprophylaxis during labour
51
What are the clinical features for Hep A?
``` Usually mild + subclinical Often children under 5 Fever Malaise Anorexia Nausea Vomiting Upper abdominal pain Jaundice Self limiting ```
52
How is hep A spread?
Faecal oral route MSM IV drug users
53
What is the treatment ofr hep A?
Supportive - no specific treatment as usually self limiting
54
What are the clinical features of hep B?
``` Anorexia Lethargy Nausea Fever Abdominal discomfort Arthralgia Urticarial skin lesion Dark coloured urine Jaundice ```
55
What antigens are seen in Hep B?
HBsAg (surface antigen) HBcAg (hep B core antigen HBeAg (chronically infected)
56
What are the routes of transmission for Hep B?
Vertical (mother to child), sexual, bloods etc
57
What are the predisposing factors to Hep B?
``` Injecting drug users Multiple secual partners Immigration from areas of high endemncity Learn disability in care Haemodialysis Tattoo ```
58
How do you diagnose an acute HBV infection?
HBsAg in serum on presentation However, in late disease may have disappeared (In which case diagnose with anti-HBc IgM antibodies)
59
What are teh clinical features of chronic HBV infection?
``` Persistence of HBsAg for more than 6 months 5-10% become chronically infected Risk to develop: Chronic liver disease Membranous glomerulonephritis ``` Jaundice unusual until late disease
60
What is the prognosis of hep B?
25% to go on to cirrhosis | Hepatoma can cause cancer
61
When do you treat hep B?
Asymptomatic with raised ALT consider antiviral therapy So should anyone with liver damage or cirrhosis Otherwise: 2+ of HBV DNA >2000 IU/ml Raised ALT Significant liver inflammation
62
How do you treat hep B?
Long acting a intergeron via subcut injection Entecavir Tenofovir In specialist clinics!
63
How are reccomended to get the HBV vaccine?
``` Healthcare personnel Travellers in endemic areas Renal dialysis patients People who change sexual partners frequently Some Police/emergency worers ```
64
How is passive immunisation for hepatitis given?
Through administration of hepatitis B specific immunoglobulin
65
What are the clinical features of Hep C?
Usually subclinical Malaise Anorezia Fatigue Jaundice + sever hepatitis can occur Symptoms rare in chronic HCV Hoever, AST/ALT levels fluxuate in chronic disease
66
What is the main mode of transmission for Hep C?
IV drug users Transfusions Needle-stick injuries Sexual transmission
67
How do you diagnose HCV?
IgG (although false positive) | HCV-RNA
68
How do you manage Hep C?
Alcohol abstention help | Pegylated a-interferon + rivavirin
69
How does one accquire Hep D?
Either co-infection (at the same time) as getting hep B | Or at a later date (superinfection)
70
How do you diagnose Hep D?
IgG and IgM to serum HDV, HDV-RNA and HDAg
71
How do you manage hep D?
Pegylated a-interferon
72
What are the clinical features of Hep E?
Subclinical or mild ilness in women + young people Severe in elderly men Liver failure may develop Persitant infection can be present in immunocompromised patients
73
What is the epidemiology of hep C?
Enterically transmitted Most common acute form of hepatitis in UK Transmitted from pigs
74
How do you diagnose Hep E?
IgG and IgM and HEV-RNA
75
What is the treatment for Hep E?
Self limiting - no treatment | In immunocormprimised - ribavirin to achieve viral clearance
76
What other infections can cause hepatitis (non viral)?
Leptospirosis Q fever Psittacosis/ornithosis
77
What is Q fever?
Zoonosis coxiella burnetii Acquired occupationally
78
What are the clinical features of Q fever?
Self-limiting hepatitis with Jaundice Pneumonia Meningoencephalitis Acute rarely fatal
79
How do you diagnose Q fever?
Serological
80
What is psittacosis?
Zoonosis - chlamydophila dound in bird faeces/bodily fluids of infected animals Human to human rare
81
What is the presentation of psittacosis?
``` Subclinical Febrile like flu illness Pnemonia Typhoid like illness Hepatitis (jaundice sometimes), cardiac (endocarditis/myocarditis) Neurological (meningitis, encephalitis) Can be fatal ```
82
When are health care workers excluded from doing an exposure prone procedure?
Hep B e antigen positive Hep B surface antigen positive with high levels of DNA Hep C PCR positive
83
What is the process after exposure to blood/bodily fluids?
Encourage bleeding Washing injury thoroughly Cover with waterproof plaster Report immediately

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