I.

II.

General Characteristics a. Inflamm of meningeal membranes that envelop brain & SC b. Assoc. w/infectious causes; non-infectious causes exist (meds, SLE, sarcoidosis, carcinomatosis) c. Pathophys i. Infectious agents colonize nasopharynx & resp tract ii. Bugs enter CNS via one of the following routes 1. Invasion of bloodstream hematogenous seeding of CNS 2. Retrograde transport along cranial (i.e. olfactory) or peripheral nn 3. Contiguous spread from sinusitis, otitis media, surgery or trauma d. Can be acute or chronic depending on onset of sx i. Acute: w/in hours to days ii. Chronic: w/in wks to months; usually due to mycobacteria, fungi, Lyme disease or parasites e. Can be bacterial or aseptic i. Acute bacterial 1. Causes a. Neonates: GBS, E. coli, Listeria b. Kids > 3 mos: Neisseria, Strep pneumo, H. flu c. Adults 18-50 yo: Strep pneumo, Neisseria, H. flu d. Elderly (> 50 yo): Strep pneumo, Neisseria, Listeria e. Immunocompromised: Listeria, gram-negative bacilli, Strep pneumo 2. Complications a. Seizures, coma, brain abscess, subdural empyema, DIC, respiratory arrest b. Permanent sequelae: deafness, brain damage, hydrocephalus ii. Aseptic 1. Due to non-bacterial bugs, usually viruses (enteroviruses, HSV) or parasite, fungi and certain bacteria 2. Can be hard to distinguish from clinically from bacterial type if so, tx for acute bacterial type 3. BETTER PX than acute bacterial type Clinical Features a. Sx: headache (worse when lying down), fever, N/V, stiff & painful neck, malaise, photophobia, altered mental status (confusion, lethargy, even coma) b. Signs i. Nuchal rigidity: stiff neck w/resistance to flexion of spine (may be absent) NOT PAIN ii. Rashes 1. Maculopapular w/petechiae-purpura is classic for Neisseria 2. Vesicular lesions in varicella or HSV

iii. Increased ICP & its manifestations, i.e. papilledema, seizures iv. CN palsies v. Kernings sign: cant fully extend knees when supine w/hips flexed at 90 degrees; due to irritation of meninges vi. Brudzinskis sign: flexion of legs & thighs due to passive flexion of neck III. Dx a. CSF exam (LP): perform UNLESS there is evidence of space-occupying lesion; note opening pressure i. If cloudy pyogenic leukocytosis ii. Send CSF for following: cell count, chemistry (protein, glucose), Gram stain, culture (incl. AFB: acid-fast bacilli), cryptococcal Ag (better) or India ink iii. If bacterial pyogenic inflamm response in CSF 1. Elevated WBC count (esp PMNs) 2. Low glucose/high protein 3. Gram stain + in most iv. If aseptic non-pyogenic inflamm response in CSF 1. Increase in mononuclear cells, also lymphocytic pleocytosis 2. Protein normal or slightly elevated 3. Glucose & CSF usually normal b. Do CT of head before LP IF there are focal neuro signs or evidence of space-occupying lesion w/elevations in ICP c. Blood cultures before giving abx d. Normal CSF findings i. WBC count: < 5 ii. WBC diff: all lymphocytes or monocytes, NO PMNs iii. Glucose: 50-75 iv. Protein: < 60 e. Bacterial meningitis CSF findings i. WBC count: > 1000 (1000-20,000) ii. WBC diff: mostly PMNs iii. Glucose LOW; protein HIGH f. Aseptic meningitis CSF findings i. WBC count: < 1000 ii. WBC diff: mostly lymphocytes & monoctes iii. Glucose NORMAL; protein moderate elevation Tx a. Bacterial type i. Empiric abx right after LP; if CT has to be done or there are delays in LP, give abx 1st ii. IV abx 1. Start right away if CSF is cloudy or if bacterial infection is suspected 2. Empiric therapy according to age

IV.

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a. Infants (< 3 mos) i. Likely GBS, E. coli, Klebsiella, Listeria ii. Cefotaxime + ampicillin + vancomycin (aminoglycoside if < 4 wks) b. 3 mos to 50 yo i. Likely Neisseria, Strep pneumo, H. flu ii. Ceftriaxone or cefotaxime + vancomycin c. > 50 yo i. Likely Strep pneumo, Neisseria, Listeria ii. Ceftriaxone or cefotaxime + vancomycin + ampicillin d. Impaired cellular immunity (i.e. HIV) i. Likely Strep pneumo, Neisseria, Listeria, aerobic gram bacilli (incl. Pseudomonas) ii. Ceftazidime + ampicillin + vancomycin 3. Modify as needed based on Gram stain, culture & sensitivity findings iii. Steroids IF cerebral edema is present iv. Vaccination 1. All adults > 65 yo for Strep pneumo 2. Asplenic pts for Strep pneumo, Neisseria, H. flu (bugs w/capsules) v. Prophylaxis (i.e. RIF or ceftriaxone): for all close contacts of pts w/meningococcus (due to Neisseria), give 1 dose of IM ceftriaxone b. Aseptic type i. Only supportive care as the disease is self-limited ii. Can give analgesics & reduce fever Ddx in Pts w/Altered Mental Status a. Infection i. Sepsis, UTI/urosepsis, pneumonia, bacterial meningitis, intracranial abscess, subdural empyema b. Meds/drugs i. Neuroleptic malignant syndrome (haloperidol, phenothiazines) ii. Delirium tremens c. Metabolic thyroid storm