Meningitis Flashcards

1
Q

Define meningitis

A

Inflammation of the inner meningeal/leptomeningeal (pia mater and arachnoid) coverings of the brain, most commonly due to infection

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2
Q

What is the most common cause of meningitis

A

Viral causes
Enteroviruses (coxsackie A/B)
Mumps
HSV
VZV
HIV

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3
Q

Aetiology of bacterial meningitis

A

Neonates: Group B streptococci, E. coli, Listeria monocytogenes
Children: Haemophilus influenzae (Hib), Neisseria meningitidis, S. Pneumoniae
Teenagers: Neisseria meningitides (Hib if unvaccinated)
Adults: S. pneumoniae, Neisseria meningitidis, TB
Elderly: S. pneumoniae, Listeria monoyctogenes

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4
Q

Risk factors for meningitis

A

Young age
Winter season (bacterial)
Close communities e.g. dormitories, military barracks
Contiguous infection: Sinusitis, otitis media, Mastoiditis, pneumonia
Immunodeficiency: HIV, chemotherapy, leukaemia, lymphoma
Alcoholism, smoking
Basal skull fracture
Incomplete immunisation
Absent/non-functioning: Splenectomy
Sickle cell anaemia
CSF shunts
Intracranial surgery
Recent travel and exposure (rodents, ricks, mosquitos, sexual activity)

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5
Q

What are the symptoms of meningitis

A

Meningism: (1) headache (2) neck stiffness (3) photophobia
Rash: non-blanching petechial (meningococcal)
Fever
Neck or backache
GI: N&V, diarrhoea, abdominal pain/distension
Seizures

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6
Q

What are the signs of meningitis on examination

A

Obs: fever, tachycardia, hypotension

General exam:
Rash
- non-blanching petechial rash (meningococcal)
- Darker skin: check the soles/palms/conjunctivae/palate (i.e. paler areas)
Altered mental state (reduced GCS)
Prolonged CRT
Cold extremities

Meningitis specific:
Kernig’s sign = pain/resistance on passive knee extension with hips flexed
Brudzinski’s sign = flexing the neck causes automatic flexion of the hips and knees
Meningism: photophobia, neck stiffness

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7
Q

What investigations should be done for meningitis

A

(Initiate sepsis 6)

Bedside: ?petechial scraping
Bloods: Blood cultures, Blood gas, FBC, CRP , glucose, coagulation screen, PCR for meningococcal disease, U&Es, LFTs
Other: Lumbar puncture (Confirm diagnosis)

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8
Q

What results will you see for bacteral, viral, TB, and cryptococcal meningitis on lumbar puncture

A

Bacterial: Turbid/cloudy, high neutrophils (polymorphs), low glucose, high protien

Viral: clear, high lymphocytes (mononuclear), normal glucose, normal/high protein

TB: Fibrin web, high lymphocytes (mononuclear), low glucose, high protein

Cryptococcus: stains with india ink

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9
Q

When is a LP contraindicated

A

Raise ICP (reduced consciousness, bradycardia + HTN, focal neurologicla signs, unequal/unreponsive pupils, papilloedema)
Overlying skin infection
Extensive/spreading purpura (indicator of coagulopathy, DIC)
Shock

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10
Q

What is the management for bacterial meningitis in primary care (+doses)

A

IV/IM benzylpenicillin + Call for ambulance for urgent hospital referral
<1yo - 300mg
1-9yo - 600mg
>10yo - 1200mg

If there is no non-blanching rash → do NOT give Abx, call for hospital

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11
Q

What is the management of bacterial meningitis in secondary care

A
  1. ABCDE: Give oxygen, check airways, crystalloid fluids,
    a. Fluid bolus of normal saline
  2. Take blood cultures
  3. IMMEDIATE empirical IV/IM antibiotics
  4. Dexamethasone 10mg IV shortly before or with the first dose of antibiotics
  5. If severe → ITU admission

+ notify public health England (notifiable disease)
+ follow up + hearing test

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12
Q

What antibiotics are indicated for meningitis

A

<3 months: cefotaxime + amoxicillin/ampicillin
>3 months: IV ceftriaxone
Meningococcal: Benzylpeniciliin
Listeria: ampicillin/amoxicillin IV
?encephalitis: Acyclovir
Penicillin and cephalosporin resistant pneumococci: vancomycin and rifampicin
Penicillin allergic: Ceftaxime
Travel Hx/prolonged Abx exposure: add vancomycin

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13
Q

What is the management for viral meningitis

A

conservative management (self-limiting with good prognosis)

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14
Q

What is the prophylaxis for close contacts for meningitis

A

Ciprofloxacin for 2 days and vaccination
given to everyone who has had prolonged close contact with the case in a household-type setting during the 7 days BEFORE onset of illness

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15
Q

What are the complications of meningitis

A

Septicaemia, shock, DIC
Neuro: cerebral infarction, hearing loss, seziures, cognitive impairment, motor deficits, visual impairment, cerebral oedema
Clotting: DVT, peripheral gangrene
Hydrocephalus, learning difficulties
Water-house-Friderichsen syndrome

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16
Q

What is the prognosis for meningitis

A

Outcome is excellent with prompt and adequate antimicrobial and supportive therapy
Prognosis depends on age, presence of comorbidity, causative pathogen and severity at presentation
Mortality rate for bacterial meningitis is 10-40%

17
Q

What results on LP indicate the need for steroids and when are steroids contraindicated

A

Frankly purulent CSF
WBC > 1000/microlitre
Raised WBC with protein concentration >1g/L
Bacteria on Gram stain

<3months, high dose CI in meningococcal disease

18
Q

Management for chronic meningitis

A

Seen with TB, syphillis, cryptococcus
Lower mortality

Cryptococcus → ambisome ± flucytosine

19
Q

What is seen on MRI in TB meningitis

A

Leptomeningeal enhancement
Basal cistern enhancement
Dilatation of ventricles