MENINGITIS

Definition
Bacterial meningitis is an acute purulent infection within the subarachnoid space.
The meninges, the subarachnoid space, and the brain parenchyma are all frequently
involved in the inflammatory reaction (meningoencephalitis).
Bacterial meningitis is the most common form of suppurative CNS infection.
ETIOLOGY
A) Acute meningitis
1) Virus

Enteroviruses
ECHO
Coxsackie
Mumps
HIV

2) Bacteria

Streptococcus pneumoniae
meningococcus (Neisseria meningitides)
Streptococcus Group B
Listeria monocytogenes
Gram-negative bacilli

Etiology based on age

Neonates
Enteric gram-negative bacilli, such as Escherichia coli
Group B streptococci (S. agalactiae)
Adults
S. pneumoniae
N. meningitidis
Elderly persons
S. pneumoniae
L. monocytogenes
Enteric gram-negative bacilli

Viral infection is the most common cause of meningitis

Streptococcus pneumoniae as the most common cause of bacterial meningitis.
The meningococcus (Neisseria meningitidis) is second most common cause.

SUBACUTE/CHRONIC MENINGITIS
M. tuberculosis,
Cryptococcus neoformans
Candida
Histoplasma
Blastomyces

T. pallidum
Malignant meningitis

Most of the fungal meningitis are common in HIV patients esp. cryptococcal.
Etiopathogenesis
Pneumococcal meningitis may be associated with pneumonia and occurs especially
in older patients and alcoholics, as well as those without functioning spleens.
The meningococcus is normal commensal of the upper respiratory tract organism
invades through the nasopharynx, producing septicaemia that is usually associated
with pyogenic meningitis.
In acute bacterial meningitis, the pia-arachnoid is congested with polymorphs. A
layer of pus forms. This may organize to form adhesions, causing cranial nerve
palsies and hydrocephalus.
An obliterative endarteritis of the leptomeningeal arteries passing through the
meningeal exudate may produce secondary cerebral infarction.

Clinical features
The classic clinical triad of meningitis is fever, headache, and nuchal rigidity (stiff
neck).
Signs of meningeal irritation
1. Neck stiffness
2. Kernigs sign (supine position: thigh is flexed on abdomen, with the
knee flexed; attempts to passively extend the knee elicit pain)
3. Brudzinskis sign (supine position: passive flexion of neck causes
spontaneous flexion of hips and knees)
Acute bacterial meningitis
Onset is typically sudden, with rigors and high fever.
Seizures occur as part of the initial presentation of bacterial meningitis or during the
course of the illness
Alteration in mental status, Nausea, vomiting, and photophobia are also common
complaints.
Signs of increased ICP may be present
1. Deteriorating or reduced level of consciousness
2. Papilledema
3. Cushing reflex (bradycardia, hypertension, and irregular
respirations)
Meningococcal meningitis is often heralded by a petechial. . When accompanied by
Meningococcal septicaemia, disease may worsen very rapidly and cause circulatory
collapse.
Examination of ear and nose may give clue for source of infection.
focal neurological signs are very uncommon.
Viral meningitis
Occurs mainly in children or young adults, with acute onset of headache and
irritability and the rapid development of meningism.
Almost always a benign, self-limiting condition lasting 4-10 days.
Chronic meningitis

 Commence typically with vague headache, lassitude, anorexia and vomiting

Meningitic signs usually take some weeks to develop.
Fever is Low-grade
Drowsiness, focal signs (e.g. diplopia, papilloedema, hemiparesis) and seizures are
common.
Fungal infections are common in HIV patients
Differential diagnosis
Acute meningitis
Viral meningoencephalitis
Rickettsial disease
Brain abscess
Subarachnoid hemorrhage

Chronic meningitis
Intracranial mass lesion
Brain abscess

Complications
Increased ICP
Seizures
Hydrocephalus esp. with chronic meningitis
Dural sinus or cortical vein thrombosis
Brain abscesses
Laboratory Tests
1) Lumbar puncture
Lumbar puncture is mandatory unless there are contra-indications.
If the patient is drowsy with focal neurological signs or seizures, it is wise to obtain a
CT to exclude a mass lesion (such as a cerebral abscess)
Other CSF investigations
Gram stain demonstrate organisms e.g Gram-positive intracellular diplococci pneumococcus; Gram-negative cocci meningococcus
Ziehl-Neelsen stain demonstrates acid-fast bacilli (TB)
Indian ink stains Cryptococcus
Culture of CSF will confirm the organism.
Latex agglutination, Limulus amebocyte lysate, Polymerase chain reaction will
also help in identifying the organism.
Other investigations
Blood cultures
Skin biopsy - to diagnosis N. meningitides
CXR and mantoux for diagnosis TB

Typical CSF changes in meningitis

Appearance

Normal
Viral
Crystal-clear Clear/turbid

Pyogenic
Tuberculosis
Turbid/purulent Turbid/viscous

Mononuclear cells < 5 mm3

(Lymphocytes)

10-100 mm3

< 50 mm3

100-300 mm3

Polymorph cells
(neutrophils)

Nil

Nil*

200-300/mm3

0-200/mm3

Protein

0.2-0.4 g/L

0.4-0.8 g/L

0.5-2.0 g/L

0.5-3.0 g/L

Glucose

4585*

Normal or low Low (< 45)

Low (< 45)

*-5070% of the normal value of blood glucose. In bacterial meningitis the ratio of
glucose becomes <0.4
CSF of TB meningitis when allowed to stand forms a fine clot ('spider web')
Management
A)Acute bacterial meningitis
Recognition and immediate treatment of acute bacterial meningitis is vital.
Empirical Antimicrobial Therapy
1) Patients with a typical meningococcal rash
Benzylpenicillin 2.4 g i.v. 6-hourly
2. Adults aged 18-50 years without a typical meningococcal rash
Ceftriaxone 2 g i.v. 12-hourly
3. Patients in whom penicillin-resistant pneumococcalinfection is suspected
o As for (2) but add: Vancomycin 1 g i.v. 12-hourly
4. Adults aged over 50 years and those in whom Listeria monocytogenes
infection is suspected (e.g. brain-stem signs, immunosuppression, diabetic,
alcoholic)
As for (2) but add: Ampicillin 2 g i.v. 4-hourly
5. Patients with a clear history of anaphylaxis to -lactams

Chloramphenicol 25 mg/kg i.v. 6-hourly

plus
Vancomycin 1 g i.v. 12-hourly

Antimicrobial therapy based on pathogen

ORGANISM
ANTIBIOTIC
S. pneumoniae
Penicillin-sensitive --penicillin G
Penicillin-resistant --ceftriaxone or
cefotaxime, plus vancomycin
N. meningitidis

Penicillin-sensitive:
penicillin G or ampicillin
Penicillin-resistant:
ceftriaxone or cefotaxime

L. monocytogenes

Ampicillin + gentamycin

H. influenzae

ceftriaxone or cefotaxime

All antibiotics should be given by intravenous route.

Role of steroids in acute bacterial meningitis is not clear.
Duration of treatment is based on organism
1. N. meningitides
7-days,
2. S. pneumoniae and H. influenzae
2-week course
3. L. monocytogenes
3 weeks
Prevention
Meningococcal infection - immunization and prophylaxis of contacts, e.g. with
rifampicin or ciprofloxacin.
Vaccination can be used against pneumococcal and Haemophilus influenzae
infection.
VIRAL MENINGITIS
Treatment is symptomatic as most cases are self limiting.
Vaccination is an effective method of preventing.
Tuberculous meningitis
Should be treated with 4 drugs (EHRZ) for 2 months and isoniazid and rifampicin
continued alone for the next 6 to 12 months.
Total duration of treatment should be 9-12 months.
Dexamethasone (oral or IV) can be used esp. if there is suspicion of
hydrocephalus.
If indicated raised ICT should also be treated.

Cryptococcal meningitis
Amphotericin B and flucytosine for 2 weeks, followed by an 8- to 10-week course
of fluconazole.