http://www.youtube.com/watch?v=PYoTQ9HG_cE http://www.youtube.com/watch?v=ayzKqxzTa7U http://www.youtube.com/watch?

v=NTMcFaMbVqg

The word meningitis usually describes inflammation of the meninges owing to the infective agents.

Acute

pyogenic (usually bacterial meningitis), Aseptic (usually acute viral meningitis), and Chronic (usually tuberculosis, spirochetal, or cryptococcal) The above classification is based on the characteristics of inflammatory exudate on CSF examination and the clinical evolution of the illness

-is caused by any one of several bacteria.

-is the leading cause of acute confusional state and one of which early diagnosis greatly improves the outcome

-Primary causative agents 1. Haemophilus influenzae type b 2. Neisseria meningitidis or "meningococcus" 3. Streptococcus pneumoniae or "pneumococcus"

Staphylococcus

aureus Sterptococcus group B Listeria monocytogenes Gram-negative bacilli Mycobacterium tuberculosis Treponema pallidum Eischerichia coli

Age or condition Less than 3 months

Etiologic agents S agalactiae E coli L monocytogenes N meningitidis S pneumoniae H infuenzae N meningitidis S pneumoniae S pneumoniae L monocytogenes Gram negative bacilli L monocytogenes Gram negative bacilli Staphylococci, gram ve cocci and S pneumoniae

3 month -8 yrs

18-50 yrs

50+
Impaired cellular immunity

Head trauma, neurosurgery, or csf shunt

Three main routes by which microbes enter the nervous system

1. Hematogenous spread (most common means of entry) 2. Direct implantation (trauma, congenital malformations)

3. Local extension (otitis media and sinusitis)

Physical examination shows:

1. fever 2. neck stiffness 3. thigh flexion upon flexion of the neck

(Brudzinskis sign)

4.resistance to the passive extension of the knee with the hip flexed (kernigs sign)

5. Vomiting, photophobia may be seen 6. Patients always like to lie still 7. petechial rashes is seen in 50-60% patients 8. Meningeal irritation is seen is 80% patients

1.Acute confusional state 2. Seizures and cranial nerve palsy 3. Coma in severe cases

-when meningococcal meningitis is diagnosed clinically by petechial rashes accompanied by other symptoms, immediate parenteral antibiotics should be given before any further investigations. (benzylpenicilin 1200 mg, alternative : cefotaxime) -the causative organisms can be cultured from blood in 40-90% cases -if there is any suspicion of the intracranial lesion, CT scan or MRI can be done

-Although these studies may be helpful, the most essential test in all suspected case is prompt lumbar puncture and CSF examination. {in case of meningococcal meningitis, CSF is usually not performed since it may result cerebellar tonsils, so blood culture is main in this case}

CSF examination

CSF pressure is elevated in about 90% of the cases Appearance of fluid ranges from slightly turbid to grossly purulent WBC count 90,000 /mm3 consisting of chiefly polymorphonuclear leukocytes (predominantly in L monocytogenes meningitis)

-CSF protein rises to 0.5-2 g/L ( normal 0.2-0.4 g/L)

-CSF glucose level is lower than half of normal blood glucose level -Gram stained smears of CSF identify the causative organism is 80% cases.

Normal Appearance Crystal clear

Infected Turbid/purulent
<50 mm3

Mononuclear <5 mm3 cells Polymorph cells Nil protein Glucose 0.2-0.4 g/L 2/3 of blood glucose

200-300/ mm3
0.5-2.0 g/L <1/2

-it may be difficult to distinguish between the sudden headache of SAH, migraine and meningitis -neck stiffness should be considered carefully -cerebral malaria often mimics bacterial meningitis

Children

should be routinely immunized against H influenza by vaccination

N

meningitidis vaccine is recommended for military recruits, college students and travelers to areas of ongoing epidemics

Treatment
Organism
Unknown pyogenic

Antibiotic
Cefotaxime( 50 g/kg intravenously every 6 hrs) Benzylpenicilin Cefotaxime Cefotaxime

Alternative (eg. allergy)

Benzylpenicilin or Chloramphenicol Cefotaxime Penicillin Chloramphenicol

Meningococcus Pneumococcus Haemophilus

Nonpyogenic bacteria associated with aseptic meningitis

Mycobacterium tuberculosis Leptospira Treponema pallidum Borrelia Nocardia Bartonella Atypical mycobacteria Brucella

TUBERCULOUS MENINGITIS
Considered in patients who present with a confusional state specially if there is history of pulmonary tuberculosis, alcoholism, corticosteroid treatment, HIV infection or any other condition associated with impaired immune responses. Patients usually have symptoms of headache, malaise, mental confusion, and vomiting

A moderate

CSF pleocytosis made up of mononuclear cells or a mixture of polymorphonuclear and mononuclear cells
The
The

protein level is elevated (strikingly), and

glucose content is moderately reduced or normal

Neonatal

meningitis is inflammation of the meninges due to bacterial invasion in the 1st 90 days of life.
Neonatal

meningitis occurs in 2/10,000 full-term and 2/1,000 low-birth-weight (LBW) neonates, with a male predominance

Primary causative agents(75%) 1. Group B streptococcus (predominantly type III) 2. Escherichia coli (particularly those strains containing the K1 polysaccharide) 3. Listeria monocytogenes

Secondary causative agents 1. -hemolytic streptococci 2. gram-negative enteric organisms (eg, Klebsiella sp, Enterobacter sp, Citrobacter diversus) 3. Haemophilus influenzae type b, Neisseria meningitidis, and Streptococcus pneumoniae

Symptoms