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ETIOLOGY
• Meningitis: inflammation of the leptomeninges caused by bacteria, viruses or rarely
fungi.
• aseptic meningitis= viral meningitis, but a similar picture seen with:
1. infectious organisms (Lyme disease- borrelia bugdorferi, TB,Syphilis)
2. parameningeal infections (brain abscess, epidural abscess, venous sinus empyema)
3. chemical exposure (NSAIDs, IV Ig)
4. autoimmune disorders
• The organisms commonly causing bacterial meningitis before the availability of current
conjugate vaccines were Hib, S. pneumoniae, and N. meningitidis.
• The bacteria causing neonatal meningitis are the Age Most Common Less Common
same as the bacteria that cause neonatal sepsis. Neonatal Group B streptococci Staphylococcus aureus
• Staphylococcal meningitis occurs in patients who
Escherichia coli Coagulase-negative staph.
have had neurosurgery or penetrating head trauma
Klebsiella Enterococcus faecalis
• Viral meningitis:
caused most commonly by entero-viruses ( Enterobacter Citrobacter diversus
usually last 2-4 days, may improve after lumbar Salmonella
puncture): Listeria monocytogenes
1. coxsackieviruses Pseudomonas aeruginosa
2. echoviruses Haemophilus influenzae
3. polioviruses ( if unvaccinated) types
Other viruses: HSV, EBV, CMV, lymphocytic a, b, c, d, e, f, and
nontypable
choriomeningitis virus, and HIV.
>1 mo Streptococcus H. influenzae type b ( in
Enteroviruses and arboviruses are the principal pneumoniae ( with areas without vaccine)
causes of meningoencephalitis. highest rate of
Mumps virus is a common cause of viral commplicatons)
meningitis in unvaccinated children. Neisseria meningitidis Group A streptococci
Gram-negative bacilli
EPIDEMIOLOGY L. monocytogenes
• bacterial meningitis is highest among children <1
year of age.
• Risk factors:
1. Genetic factors
2. acquired or congenital immunodeficiencies
3. hemoglobinopathies ex. sickle cell disease, functional or anatomic asplenia.
4. Crowding.
5. CSF leak resulting from congenital anomaly or after a basilar skull fracture especially
caused by S. pneumoniae.
6. Low birth weight, PROM, chorioamionitis.
Note:
Most common 3 symptoms:
CLINICAL MANIFESTATIONS 1. vomiting.
• Preceding upper respiratory tract symptoms are common. 2. lethargy
• Rapid onset is typical of S. pneumoniae and N. meningitidis. 3. fever
• Indications of meningeal inflammation include ( symptoms) : headache: if old age.
1. headache
2. irritability
3. nausea & vomiting
4. nuchal rigidity
5. lethargy
6. photophobia
7. Fever (95%)( in bacterial = high fever / in lyme dz = low grade fever)
Signs:
1. Young infants: irritability, restlessness, depressed mental status, and poor
feeding as signs of meningeal inflammation.
2. Children >I year of age: Kernig sign (flexion of the hip 90 degrees with subsequent
pain with extension of the leg), and Brudzinski sign (involuntary flexion of the knees
and hips after passive flexion of the neck while supinesigns of meningeal irritation
are positive.
3. others: Focal neurologic signs, seizures, arthralgia, myalgia, petechial or purpuric
lesions(with rapid onset in N. Meningitis), erythema migrans (lyme disease),sepsis,
shock, and coma.
4. increased intracranial pressure complaints are:
1. headache
2. diplopia
Note:
3. vomiting N. meningitides: C5-9 terminal
4. bulging fontanel in infants
complement
5. Ptosis, H. influenzae: humeral immunity
6. sixth nerve palsy deficiency.
7. anisocoria,
8. bradycardia with HTN
9. apnea
10. Papilledema (uncommon)
DIFFERENTIAL DIAGNOSIS
Many disorders show signs of meningeal irritation & ICP including :
1. encephalitis
2. hemorrhage
3. rheumatic diseases
4. malignancies
5. malignant HTN
6. hypoxia/anoxia
7. drug intoxication
Seizures are associated with meningitis, encephalitis, and intracranial abscess or brain
edema, cerebral infarction or hemorrhage, or vasculitis.
TREATMENT
Treatment of bacterial meningitis focuses on sterilization of the CSF by antibiotics (
effective + cross BBB) and maintenance of adequate cerebral and systemic perfusion.
If suspected bacterial meningitis give: 3ed generation cephalosporins ( cefotaxime or
ceftriaxon) in meningitis dose – the highest dose. As no H.Inf or N.M were reported to be
resistant.
If suspect S. pneumoniae: cefotaxime (or ceftriaxone) plus vancomycin (relatively
resistant to penicillin or cephalosporins – in some places up to 60%)
N. meningitidis and H. influenzae types a -f: Cefotaxime or ceftriaxone only.
Infants <2 months of age: add ampicillin to cover the possibility of Listeria
monocytogenes.
In H. influenza : antibiotic bacteria lyses release toxic metabolites affect hearing (
so give steroids before antibiotic to prevent inflammation – proven to H. inf but can be
given in case of N.M or Strep.
Duration of treatment:
1. 10 -14 days for S. pneumoniae
Note:
2. 7 -10 days for H. influenzae
Best empirical therapy:
3ed generation cephalosporins + vancomycin
3. 5 -7 days for N. meningitides (Gram -) (Gram +)
Initial Antimicrobial Therapy by Age for Presumed
Bacterial Meningitis
Alternative
Age Recommended Treatment Treatments
Newborns Cefotaxime or ceftriaxone plus ampicillin Gentamicin plus ampicillin
(0-28 days) with or without gentamicin
Ceftazidime plus ampicillin
Infants and toddlers Ceftriaxone or cefotaxime plus Cefotaxime or ceftriaxone plus
(1 mo-4 yr) vancomycin rifampin
Children and adolescents Ceftriaxone or cefotaxime plus Ampicillin plus chloramphenicol?
(5-13 yr) & adults vancomycin Don’t use…
COMPLICATIONS
Include:
1. SIADH: necessitates balancing the need for fluid administration for hypotension and
hypoperfusion.
2. seizures
3. strike
4. cerebral and cerebellar herniation
5. transverse myelitis
6. ataxia
7. thrombosis of dural venous sinuses
CT or MRI detects subdural effusions with S. pneumoniae &Hib meningitis. Most are
asymptomatic &do not need drainage unless associated with ICP or focal neurologic
signs.
Persistent fever (n= 5-7 days, if >10 days as in 10% of pts) think of:
1. infective or immune complex-mediated pericardial or joint effusions
2. thrombophlebitis
3. drug fever
4. nosocomial infection
5. intracranial viral infection
6. secondary bacterial infection
A repeat lumbar puncture is not indicated for fever in the absence of other signs of
persistent CNS infection.
PROGNOSIS
the mortality rate for bacterial meningitis in children is significant:
25% for S. pneumoniae,
15% for N. meningitidis,
8% for Hib.
35%, particularly after pneumococcal infectiondeafness, seizures, learning disabilities,
blindness, paresis, ataxia, or hydrocephalus.
All patients with meningitis should have hearing evaluation.
Poor prognosis is associated with:
1. young age < 6 months
2. delayed antibiotic treatment
3. seizures ( only after 4th day)
4. coma at presentation
5. shock
6. low or absent CSF WBC count with visible bacteria on Gram stain of the CSF
7. immunocompromised status.
Rarely, relapse occurs 3 to 14 days after treatment from parameningeal foci or resistant
organisms.
Recurrence indicate an immunologic or anatomic defect.
PREVENTION
Routine immunizations against Hib and S. pneumoniae are recommended for children
beginning at 2 months of age.
Vaccines against N. meningitidis are recommended for young adolescents and college
freshmen as well as military personnel and travelers to highly endemic areas.
Close contacts: who stay with the index case more than 24 hrs/ week.