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Meningitis Flashcards

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1
Q

What was mortality rate for meningitis caused by S pneumoniae, 90yrs ago / today?

A

90 yrs ago = 98-100%

Today = 40%

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2
Q

What was mortality rate for meningitis caused by N meningitidis, 90yrs ago / today?

A

90 yrs ago = 77%

Today = 10%

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3
Q

What was mortality rate for meningitis caused by H influenzae, 90yrs ago / today?

A

90 yrs ago = 98-100%

Today = 5-10%

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4
Q

When was penicillin discovered / on the market?

A

Discovered - 1928

On the market - 1942

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5
Q

What is mortality rate for meningitis now?

A

S pneumoniae - 40%
N meningitidis - 10%
H influenzae - 5-10%

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6
Q

What morbidity is associated with meningitis?

A 
deafness
paralysis
speech issues
epilepsy
neuro-psychiatric issues
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7
Q

Who gets meningitis?

A

neonates

  • poorly developed capillaries (not closely knit)
  • from flora from mother’s birth canal

young & old
- weaker BBB

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8
Q

Why do neonates get meningitis?

A
  • poorly developed capillaries (not closely knit)

- from flora from mother’s birth canal

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9
Q

What are three meninges layers?

A

dura mater
arachnoid mater
pia mater

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10
Q

where is CSF?

A

subarachnoid space

between arachnoid and pia mater

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11
Q

What is in subarachnoid space?

A

CSF (cerebrospinal fluid)

Blood vessels

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12
Q

Define meningitis

A

inflammation of lepto-meningeal membranes

ie dura / arachnoid / pia mater

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13
Q

What are 4 main causes of meningitis?

A
  • inflammation
  • infection
  • parameningeal foci (max sinus, venous plexus)
  • neo-plastic / para-neoplastic (ie a consequence of cancer, eg lymphoma)
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14
Q

What parameningeal foci can cause meningitis?

A
  • infection in maxillary sinus / venous plexus
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15
Q

What is a neoplastic / paraneoplastic cause of meningitis?

A

a consequence of cancer, eg lymphoma

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16
Q

What infectious agents cause meningitis?

A

Virus - most common
- enterovirus, mumps, herpes
Bacteria - 2nd most common
- meningococci, Pneumococci, H. influenzae
Fungal
- Cryptococus neoformans, Coccidioidomycosis
- NOT usually candida
Parasitic
- Naegleria fowleri, Acanthamoeba spp. (ie amoeba)

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17
Q

What viruses cause meningitis?

A
  • enterovirus
  • mumps
  • herpes
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18
Q

What bacteria cause meningitis?

A
  • meningococci
  • pneumococci
  • H influenzae
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19
Q

What fungus causes meningitis?

A
  • Crytococcus neoformans
  • Coccidioidomycosis
  • NOT candida
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20
Q

What parasites cause meningitis?

A
  • Naegleria fowleri

- Acanthamoeba spp

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21
Q

How does the blood brain barrier (BBB) work?

A

closely knit capillaries

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22
Q

Where is the likely entry point into the BBB?

A

choroid plexus - weaker emissary veins (connect the extracranial venous system with the intracranial venous sinuses)

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23
Q

What three ways can organisms reach the CSF?

A

BBB
- bacteraemia / viraemia / parasitaemia
- can enter anywhere, but most likely at choroid plexus
Direct
- chronic infections in cranial bones, ears, sinuses, oral cavity, upper respiratory tract
Neuronal
- infection in peripheral neurons, axonal transport, replication, cell-to-cell spread of infection to connection neurons in CNS
- eg rabies

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24
Q

How do organisms causing meningitis DIRECTLY access the CSF?

A

chronic infections in:

  • cranial bones
  • ears
  • sinuses
  • oral cavity
  • upper respiratory tract
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25
What type of blood infections can cause meningitis?
bacteraemia viraemia parasitaemia
26
How does a neuronal infection reach the CSF to cause meningitis?
- infection in peripheral neuron - axonal transport - replication - cell-to-cell spread - infection passed to connecting neurons in CSF
27
What is the pathogenesis of meningitis?
- mucosal colonisation - eg in sinus / oropharyngeal fossa - intravascular survival (ie pathogen gets from origin into blood) - meningeal invasion (through dura and arachnoid mater) - survival in subarachnoid space - inflammatory response / increase BBB permeability / cerebral vasculitis - vessels leaky and blocked, therefore cerebal oedema - CSF flow disturbances - increased intercranial pressure - decreased cerebral blood flow - loss of cerebro-vascular autoregulation - coma / death
28
What are the 4 main risk factors for meningitis?
Age - neonates - close knit capillaries not well dev - young / old (75+) - weaker BBB Geography - overcrowding - tropical climates - increased organisms, meningitis 'belt ' in Africa Immunity - steroids, chemotherapy, HIV Trauma / post-neurosurgical - esp base of skull trauma - Neurosurgery (cerebral shunt, external vascular drain)
29
What are the GEOGRAPHICAL risk factors for meningitis?
- overcrowding | - tropical climates - increased organisms, meningitis 'belt ' in Africa
30
What are the IMMUNITY risk factors for meningitis?
- steroids, chemotherapy, HIV
31
What NUEROLOGICAL SURGERY could cause meningitis?
- cerebral shunts | - external vascular drain
32
Where is worst place to have skull fracture?
Base of skull (base of occipital / temporal bones) | - rare
33
What bacteria commonly cause meningitis in neonates?
Group B streptocuccus E coli Listeria K pneumoniae (NOT S pneumoniae)
34
What bacteria commonly cause meningitis in
S pneumoniae | N meningitidis
35
What bacteria commonly cause meningitis in >50yrs?
S pneumoniae N meningitidis Listeria aerobic gram -ve bacilli
36
What bacteria commonly cause meningitis in immunocompromised?
``` S pneumoniae N meningitidis Listeria gram -ve bacilli Pseudomonas aeruginosa ```
37
What bacteria commonly cause meningitis in basilar skull fracture (base of skull)?
S pneumoniae H influenzae Group A beta-haemolytic streptococci ie oral organisms
38
What bacteria commonly cause meningitis in head injuries / post-neurosurgery?
A aureus S epidermidis aerobic gram -ve bacilli P aeruginosa ie skin flora
39
What oral organisms can cause meningitis and what type of person is at risk?
S pneumoniae H influenzae Group A beta-haemolytic streptococci Base of skull fracture
40
What skin flora organisms can cause meningitis and what type of person is at risk?
A aureus S epidermidis aerobic gram -ve bacilli P aeruginosa Head injury / post-neurosurgery
41
Who is at risk of S pneumoniae and N meningitidis meningitis?
50yrs | immunocompromised
42
Who is at risk of S pneumoniae meningitis?
50yrs immunocompromised base of skull fracture
43
Who is at risk of N meningitidis meningitis?
50yrs | immunocompromised
44
Who is at risk of H influenzae meningitis?
basilar skull fracture (base of skull)
45
Who is at risk of Listeria meningitis?
neonates >50yrs immunocompromised
46
Who is at risk of gram -ve bacilli meningitis?
>50ys immunocompromised head injury post-neurosurgery
47
What are four clinical signs of meningitis?
- fever - neck stiffness - altered mental state - headache / photophobia
48
What % get 3 of 4 signs of meningitis?
44%
49
What % get 2 of 4 symptoms of meningitis?
95%
50
What could fever and headache be a symptom of?
meningitis!
51
What positional tests are there to diagnose meningitis?
Kernig's sign - lie flat, lift head, if meningitis - knees will bend too Brudzinski's sign - lie flat, lift one left 90 degrees in air, if can't straighten leg = meningitis (stiff hamstring)
52
What is Kernig's sign?
- lie flat, lift head, if meningitis - knees will bend too
53
What is Brudzinski's sign?
- lie flat, lift one left 90 degrees in air, if can't straighten leg = meningitis (stiff hamstring)
54
What is sensitivity of Kernig's and Brudzinski's sign?
5% !
55
What is gold std to diagnose meningitis?
Lumber puncture
56
How do you do lumber puncture?
foetal position insert needle between L3 and L4 collect CSF
57
What are normal CSF values?
- clear appearance - opening pressure 5-20cm - cell count
58
What is the opening pressure during a lumber puncture?
The pressure measured in CSF when needle first inserted Normal = 5-20cm
59
``` What is - cell count - cell type - glucose CSF : blood ratio - Protein levels in CSF in viral meningitis? ```
- cell count = 50-1000 - cell type = lymphocytes - glucose CSF : blood ratio >0.45 (ie >45% of blood glucose) - Protein
60
``` What is - cell count - cell type - glucose CSF : blood ratio - Protein levels in CSF in bacterial meningitis? ```
- cell count = 1000-10,000 - cell type = neutrophils - glucose CSF : blood ratio
61
``` What is - cell count - cell type - glucose CSF : blood ratio - Protein levels in CSF in fungal meningitis? ```
- cell count = 20-500 - cell type = lymphocytes - glucose CSF : blood ratio 45mg/dL
62
``` What is - cell count - cell type - glucose CSF : blood ratio - Protein levels in CSF in TB meningitis? ```
- cell count = 50-300 - cell type = lymphocytes - glucose CSF : blood ratio
63
``` What is - cell count - cell type - glucose CSF : blood ratio - Protein levels in CSF in partially treated meningitis? (ie with antibiotics) ```
unknown!
64
When should lumber puncture be done?
ASAP | - antibiotics will affect results of CSF
65
What type of meningitis has CSF with: | cell count 750?
Viral
66
What type of meningitis has CSF with: | cell count 300?
viral, TB, fungal
67
What type of meningitis has CSF with: | cell count 9000?
bacterial
68
What type of meningitis has CSF with: | lymphocytes as main cell type?
viral, fungal, TB
69
What type of meningitis has CSF with: | neutrophils as main cell type?
bacterial
70
What type of meningitis has CSF with:
bacterial, TB, fungal
71
What type of meningitis has CSF with: | >0.45 CSF : blood glucose ratio?
viral
72
What type of meningitis has CSF with: | 0.5 CSF : blood glucose ratio?
viral
73
What type of meningitis has CSF with: | 0.6 CSF : blood glucose ratio?
This is the normal level!
74
What type of meningitis has CSF with: | protein 150mg/dL?
viral (45mg/dL)
75
What type of meningitis has CSF with: | The highest protein?
bacterial (100-500mg/dL)
76
What type of meningitis has CSF which is sterile?
viral
77
What type of meningitis has CSF with: | the highest glucose CSF : blood ratio?
viral (>0.45)
78
What extra tests can be done on CSF?
PCR - Meningococci, Pneumococci Virology PCR Antigen test - Cryptococcal Ag, Pneumo latex India ink - Cryptococci Fungal cultures - Crytococcus neoformans, Coccidioidomycosis ZN stain AFB culture - acid fast bacilli smear and culture - test for TB Cytology Oligoclonal bands - bands of Ig seen in CSF after electrophoresis Xanthochromia - yellow discolouration = bilirubin present (likely subarachnoid haemorrhage)
79
What is a Xanthochromia test?
tests CSF for yellow discolouration = bilirubin present (likely subarachnoid haemorrhage)
80
What is a Oligoclonal bands test?
tests CSF for bands of Ig seen in CSF after electrophoresis
81
What is a AFB culture?
acid fast bacilli smear and culture - test for TB in CSF
82
What can india ink test for?
Cryptococci
83
Is an MRI / CT needed before lumbar puncture?
most people have normal MRI / CT with meningitis but should do MRI / CT - exclude other diagnoses (intracranial haemorrhage, migraine, cerebral tumour) - all get headaches and neck stiffness
84
Apart from meningitis, what other diagnoses for headaches and neck stiffness?
- intracranial haemhorrhage - migraine - cerebral tumour
85
How you do determine if it's meningitis or a haemorrhage?
MRI / CT
86
When should you do neuro-imaging in meningitis?
``` Before lumbar puncture If history of unconsciousness history of seizures focal neurology (specific area of body affected) low GCS ```
87
What is GCS?
Glasgow Coma Scale
88
Where is the inflammation in meningitis?
subarachnoid space mainly
89
Why do you do neuro-imaging (MRI / CT) in meningitis?
if cerebral abcess, then can't do lumbar puncture - it may rupture and cause hernia Symptoms of cerebral abcess - seizures - focal neurology (specific area of body affected) - Low GCS (Glasgow Coma Scale
90
What are 4 main complications of meningitis?
Seizures - scar tissue from infection / inflam = scar epilepsy Hydrocephalus - increase in CSF in ventricles, therefore compression of brain - CSF is thicker (increase cell count), therefore reduced flow, therefore increased risk blockage - pressure released down and out via foramen magnum (pons compressed = cardiorespiratory arrest) - rare Transtentorial herniation - brain expands inwards, towards pons/brain stem (motor / respiratory centre) - can cause coma, death Infarcts - caused by vasculitis and vascular compression
91
What is Seizure complication in meningitis?
- scar tissue from infection / inflam = scar epilepsy
92
What is hydrocephalus complication in meningitis?
- increase in CSF in ventricles, therefore compression of brain - CSF is thicker (increase cell count), therefore reduced flow, therefore increased risk blockage - pressure released down and out via foramen magnum (pons compressed = cardiorespiratory arrest) - rare
93
What is transtentorial herniation complication in meningitis?
- downward brain hernia - brain expands inwards, towards pons/brain stem (motor / respiratory centre) - can cause coma, death
94
What is infarct complication in meningitis?
- caused by vasculitis and vascular compression
95
How do you manage meningitis?
Supportive care - specialist input - if lacking, most common reason meningitis gets worse Specific antimicrobial therapy - give ASAP - via IV (not all AB can cross BBB), IT (intrathecal - into spinal cord), IM, PO - duration of treatment - consider allergies / renal function Steroids (?) - views keep changing on use - evidence shows in developed world - steroids beneficial if used before or with first dose AB. - if given after 1st dose AB - effects unknown Surgical intervention Prophylaxis - vaccinations - universal - antibiotics - for ppl close to others with meningitis - prevents secondary infection
96
What is most common cause of meningitis getting worse?
Lack of supportive care / specialist input
97
What is early meningitis treatment?
ABCDE
98
What is late meningitis treatment?
Nutrition Physiotherapy Rehabilitation
99
What is issue with IV antibiotics?
Some drugs cannot cross BBB
100
What is alternative to IV is drug cannot cross BBB to treat meningitis?
Intrathecal injection (IT)
101
Which AB can cross BBB?
Penicillin Ceftriaxone Meropenem Choramphenicol
102
Which AB cannot cross BBB?
Vancomycin | Gentamicin
103
What should your chose of AB depend on in treating meningitis?
- cause of meningitis | - route of administration
104
What other medication can be used with AB in meningitis treatment?
Steroids - views keep changing on use - evidence shows in developed world - steroids beneficial if used before or with first dose AB. - if given after 1st dose AB - effects unknown
105
What types of supportive methods can be used with neurosurgery in meningitis?
- EVD - external ventricular drain (needed for hydocephalus) | - IT of AB (intrathecal injection of AB) - port needs to be added by surgeon
106
What surgery can be done in hydrocephalus?
EVD - external ventricular drain
107
What types of prophylaxis is available for meningitis?
- vaccinations - universal | - antibiotics - for ppl close to others with meningitis - prevents secondary infection
108
Who should you tell about pt with meningitis?
BACTERIAL meningitis is a notifiable disease - public health issue - legal requirement to tell public health authorities

Human Disease (10 decks)

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