LECTURER: Ms.Nur Hafzan Md Hanafiah


non-distended Bowel sound positive Alert and oriented Extremities Clubbing. eyes. edema Keep vein open k) VS l) BP m) HEENT n) PERLLA o) EOMI p) JVD q) RRR r) CTA s) ABD t) NT/ND u) BS+ v) A&O w) EXT x) CCE y) KVO 2 . a) CC b) PTA c) ED d) HPI e) FH f) SH g) QID h) NKDA i) j) ROS PE Chief complaint Prior to admission Emergency Department History of present illness Family History Social History 4 times a day No known drug allergy Review of system Physical examination Vital signs Blood pressure Head. cyanosis.TOPIC: MENINGITIS (GROUP 1) 1) Define abbreviations and technical terms. nose and throat Pupils equal. and react to light and accommodation Extraocular movements (muscles) intact Jugular venous distension Regular rate and rhythm Clear to auscultation Abdomen Non-tender. ears. round.

headache. photobhobia(eye discomfort in exposure to bright light).Stiffness in the nape of the neck. arthralgias. cyanosis (bluish skin).2) What signs. Both of these signs are thought to be caused by the irritation of motor nerve roots passing through inflamed meninges as the roots are brought under tension. symptoms. Others: mental confusion (altered mental status). aching over her neck Laboratory values CSF WBC CSF Glucose CSF Protein 850/mm3 (>500/mm3) 32mg/dL(<50% serum glucose) 94mg/dL (> 50 mg/dL) elevated lowered elevated 3) What other clinical features not identified in this patient? Several clinical signs facilitate the diagnosis of meningitis. Kernig¶s sign and Brudzinski¶s sign are easy to elicit and can alert physicians to the precarious situation of a patient with meningitis. etc 3 .fever Symptoms: -neck stiffness. vomiting -skin rash/aches -others: complained of myalgias. the most common sign of meningitis) . y Brudzinski¶s sign ± Flexing the patient¶s neck causes flexion of the patient¶s hips and knee y Kernig¶s sign ± Flexing the patient¶s hip 90 degrees then extending the patient¶s knee causes pain. and laboratory values are consistent with meningitis in this patient? Signs: .nuchal rigidity (neck stiffness . sleepiness. N/V. often accompanied by pain and spasm on attempts to move the head.

viral (also called aseptic) and bacterial (septic). A sample of spinal fluid. sharing of food. are at higher risk for getting pneumococcal meningitis.causes illness in people of any age called ³meningococcal. Meningitis caused by Streptococcus pneumoniae is not spread from person-to-person. It is usually less severe. 4 . For most people. It becomes meningitis when the virus or bacteria travels through the bloodstream to the brain and spinal cord and infect the meninges (the protective tissue layers lining the brain¶s internal structures) Septic (bacterial) meningitis is commonly caused by the following 3 causative agents: (accounted for ~ 80% of cases caused by bacterial) Neisseria meningitidis . However. A virus or bacteria can enter the body through the nose or mouth and travel to different places in the body. drinks or cigarettes. usually collected by a spinal tap. Streptococcus pneumoniae are bacteria that cause lung and ear infections but can also cause ³pneumococcal´ meningitis. Most people who have these bacteria in their throats stay healthy.´. The bacteria are spread through saliva during kissing. Haemophilus influenzae type b bacteria. Only a few kinds of bacteria cause bacterial meningitis. especially enterovirus. called Hib. this causes an infection in the nose. Bacterial meningitis even though less common. Viral meningitis is the most common form. and those who are very young or very old. The bacteria can destroy the tissue that they infect and cause a lot of complications. is needed to find out if someone has meningitis and to see what caused it. but is very serious.4) Discuss possible causes: (septic or aseptic) There are two types of meningitis . can also cause meningitis. people with comorbidities or with weakened immune systems. and by close contact with infected people who are sneezing or coughing. Many kinds of viruses can cause viral meningitis. throat or ear. Certain people who have come in close contact with the saliva of a person with meningitis from this type of bacteria may need antibiotic. There is a vaccine called ³Hib vaccine´ that prevents infants and young children from getting Hib disease.

particularly in an immunocompromised host. 5 . then touch their own mouths. The virus is most likely to be spread when people do not wash their hands after using the toilet or changing a diaper or soiled sheets. prepare food for others. fungi.  Cytomegalovirus and Epstein-Barr virus may cause aseptic meningitis in association with a mononucleosis syndrome. Example:  MUMPS VIRUS in an unimmunized population. herpes simplex viruses account for approximately 0. Cases of vaccine-associated mumps meningitis have also been reported. or touch others with their contaminated hands. mumps is one of the most common causes of aseptic meningitis and encephalitis.Other bacteria can also cause meningitis. In the vast majority of cases the illness resolves itself within a week without any complications or need for specific treatment. Others may cause only mild diarrhea or vomiting. or parasites. Many enteroviruses don¶t cause people to feel very sick. aseptic meningitis can also be caused by bacteria.  HIV VIRUS can infect the meninges early and persist in the CNS after initial infection  HERPESVIRUSES: Overall. These viruses are found in the throat and feces of infected people. where infant & young children is the common victim. These viruses can also be spread by the kind of close face-to-face contact. but meningitis from these other bacteria is much less common and usually not contagious. Aseptic meningitis A group of viruses called enteroviruses is the most common cause(account for 85-95% ) of viral meningitis.5 to 3% of all cases of aseptic meningitis. However.

From: 6 .medscape.

Absence of risk factors for bacterial meningitis Pregnancy: Pregnant women are at an increased risk of getting listeriosis. household exposure 7 . medications and surgical procedures that may weaken the immune system and increase risk of meningitis. In this case. and other people who work with domestic animals are at an increased risk of contracting listeriosis which can also cause meningitis. IV drug use IV drug use may increase the chance of bacterial infections. military personnel and children in childcare facilities are at an increased risk. Infectious diseases tend to spread quickly wherever larger groups of people gather together.4) Discuss presence or absence of risk factors for bacterial meningitis Presence of risk factors for bacterial meningitis a.  Others: absence of concurrent upper respiratory tract infection. ranchers. Weakened immune system(immunosuppressed individual) There are certain diseases. As a result. S pneumoniae (most common) & Haemophilus influenzae b. active and ( passive )smoking. The bacteria that cause listeriosis. c) Community setting. Working with animals: Dairy farmers. Age Patient at age of 20 yo may prone to infection by N meningitides. HIV infection. college students living in dormitories (as in this case). patient is on IV hydration and IV Ketorolac 30mg before she was discharged. listeria bacteria. can also cause meningitis.

light sensitivity. skin rashes (aching). headache. Main problem: meningitis Patient is presented with the signs and symptoms of meningitis. etc 8 . headache. etc) Findings: Bacterial Meningitis Findings: Viral Meningitis CSF Color: Cloudy CSF CSF Glucose much less than 50 CSF Protein much greater than 45 CSF Leukocytes: CSF Color: Clear to Cloudy Fluid CSF Glucose: Normal (50-80mg/dl) CSF Protein > 45 (normal 20-45mg/dl) Markedly CSF Leukocytes: Increased increased Neutrophils CSF Opening Pressure: increased >200 CSF Lymphocytes CSF Opening Pressure: Normal or increased Associated problems: pain. rash.6) Devise a problem list for this patient. most probably bacterial meningitis based on lab data & presenting symptoms (fever.

edu/bugdrug/antibiotic_manual/idsameningitisNov04.7) What are the treatment goals for this patient? The goals of treatment are: 1) eradication of infection 2) amelioration of signs and symptoms(fever. coma.uphs. etc) 3) preventing of neurologic sequelea such as seizures.pdf 9 . rashes. deafness. S. headache. death 4) to prevent disease progression and subsequently the complication and mortality 8) Suggest therapeutic alternatives for empiric treatment of meningitis for this patient? Suspected individual of 2±50 years-most commonly N . pneumoniae Empirical treatment: Vancomycin plus a third-generation cephalosporin (ceftriaxone or cefotaxime) Recommended dose (adult) : cefotaxime (total daily dose: 8±12 g (4±6 hourly)) OR ceftriaxone (4 g/daily (12±24 hourly)) + vancomycin 30±45 mg/kg/day (8±12 hourly) (TDM?? Maintain serum trough concentrations of 15±20 mg/mL) Reference : ISDA Guidelines http://www.upenn. meningitidis.

then KVO 9) Discuss the rationale for the above treatment.5 mg/kg up to 500 mg (child <12 years: 15 mg/kg up to 500 mg) IV. daily. Cefotaxime is known to have good cerebrospinal fluid penetration while vancomycin has broad spectrum activity to cover the commonly suspected organism. The third-generation cephalosporins (the agent chosen in this case is cefotaxime) are the preferred empirical treatment on admission.2% NaCl is administered to restore fluid /electrolyte level. D5W/0. It¶s quite effective in meningitis especially those caused by aerobic gram-negative bacilli with cure rates of 78%±94% have been reported Most clinical practices recommended a combination of 3rd Gen cephalosporin (cefotaxime or cefriazone) plus a vancomycin for empirical treatment until the definitive causative organism is confirmed. the more likely the possibility of experiencing an adverse outcome-thus empirical treatment is vital as any delay in administration of antimicrobial therapy might be associated with an adverse clinical outcome due to increased progeny of infectious organism. use: (i) vancomycin 12. KCl is given to restore electrolyte level probably because the Cl value suggests that patient is dehydrated. Most studies showed that longer the duration of symptoms in patients with bacterial meningitis. 6-hourly PLUS (ii) ciprofloxacin 400 mg (child: 10 mg/kg up to 400 mg) IV.2% NaCl +20mEq/L KCl at 40cc/hr for 24hours.Initial treatment was started as follows: IV Cefotaxime 2g q6h x 10 days IV Vancomycin 500mg q6h x 10 days D5W/0. **Extra info: For patients with immediate penicillin or cephalosporin hypersensitivity. 12-hourly OR (iii) moxifloxacin 400 mg (child: 10 mg/kg up to 400 mg) IV. 10 .

11 .meningitidis.meningitides only. Alternative treatment: third generation Cephalosporins (Ceftriaxone or cefotaxime)-duration 7-10 days 3rd generation cephalosporins Cefotaxime 200 mg/kg/24hour IV in 3 divided doses (max:12/day) (Usual dose: 2g q8hour) OR Ceftriaxone 50-100 mg/kg/24hour IV in 2 divided doses (max:4g/day) (Usual dose: 2g q12hour) For this case. Based on this new information. if otherwise. Blood cultures showed no growth. patient should be continued with previous treatment of IV Cefotaxime 2g q6h provided she shows good response or change to benzylpenicillin.10) The CSF culture was reported as positive for N. what is your response with regards to antimicrobial therapy for this patient? Standard treatment: Benzylpenicillin(Pen G) 4 mega units IV q 4-6hours for 7-10 days is the preferred treatment for N.

skin rashes. signs of bleeding. CBC (Complete Blood Count). etc Drug-level monitoring may be needed for some antibiotics such as vancomycin and the aminoglycoside 12 . normal vital signs. mental status changes. ineffective tissue perfusion(monitor CVP frequently ). etc) Coagulopahty : assess PT. diminished cognitive functions Monitor/assess risk for deficient fluid volume. Aptt. etc) -maintaining fluid balance-monitor output and input Evaluation: expected outcomes: -afebrile. protein. oxygen saturation. fever. such as hypersensitivity reactions. electrolyte assessment. urine output. Blood and CSFs¶ glucose. LFTs. adequate urine output.11) What monitoring parameters are used to assess therapeutic efficacy and to detect complications from the infection or treatment? To assess therapeutic efficacy: -monitor temperature (every 4-6hours). CVP in normal range. pain controlled and optimal level of functioning after resolution. RR. Cr. lactate etc -improvement/resolution of sign/symptoms of meningitis over the period of therapy (assess pain. alert mental status. urea. blood pressure. To detect complications from the infection or treatment: y Monitor patients for potential adverse effects of medications. HR. cytopenia. or liver dysfunction-monitor LFT y y y Assess neurologic status and vital signs Assess sensorineural status (hearing and vision). WBC with differential(daily). CSF culture. widening pulse pressure. etc y y y Obrserve signs/symptoms of ICP(dilated pupils.

kissing. or eating utensils with other people can also may help. drinks. 13 . such as cerebral edema. These data support the use of adjunctive dexamethasone in infants and children with S. influenzae type B (HiB) meningitis. cerebral vasculitis. 2) Need for prophylaxis This prophylaxis is necessary because the germs that cause meningitis are spread easily from person to person by direct contact. The virus may also be found in the stool of the infected person Frequent handwashing with soap and water or use of alcohol-based hand rubs or gels can help stop the spread of many viruses and bacteria.Self-study: 1) Role of corticosteroid therapy in meningitis -The rationale for use of adjunctive corticosteroid (commonly used agent: dexamethasone) in certain patients with suspected or proven bacterial meningitis is that the subarachnoid space inÀammatory response during bacterial meningitis is a major factor contributing to morbidity and mortality. eating utensils. shaking hands. breathing. -Animal studies and clinical trials have demonstrated that adjunctive corticosteroid therapy reduces the production of cytokines in the CSF resulting in decreased severity of the inflammatory process and fewer neurologic sequelae. the routine use of dexamethasone in adult meningitis cannot presently be recommended. and neuronal injury. toothbrush. meningitidis. sneezing or coughing on someone. altered cerebral blood Àow. Also. This may include: sharing a pacifier. Attenuation of this inÀammatory response may be effective in decreasing many of the pathophysiologic consequences of bacterial meningitis. increased intracranial pressure.thus need careful monitoring for the possibility of GIT bleeding. pneumoniae and H. Not sharing food. as mediated by proinÀammatory cytokine expression. drooling. or drinking glasses. There is not sufficient evidence supporting the use of adjunctive corticosteroid therapy in children with meningitis caused by N.

ncbi. or in the short term with antibiotics There are 5 vaccines that can help prevent meningitis: ‡ Haemophilus influenzae (Hib) vaccine is usually given at 2. prophylaxis can be provided in the long term with vaccine. ciprofloxacin or ceftriaxone) can reduce their risk of contracting the condition. 6 and between 12 and 15 months of age.For some causes of meningitis. but does not protect against future infections.pdf http://www.) This vaccine is also recommended for everyone 65 years of age and older. 4.1056/NEJMc076554 14 . ‡ Meningococcal conjugate vaccine.nlm.g. References for self-study question: http://www.uphs.for use in people 2 years of age and older and provides protection for about 3-5 http://www.nih. ‡ Pneumococcal conjugate vaccine 7-valent (PCV7) is recommended for all children less than 24 months old and in certain high-risk children between the ages of 24 and 59 months. (High-risk children less than 5 years of age should also receive rifampicin. prophylactic treatment of close contacts with antibiotics (e.nejm. ‡ Meningococcal polysaccharide vaccine .upenn. -In cases of meningococcal approved for use in people 11-55 years of age and is expected to help decrease disease transmission and to provide more long-term protection. ‡ Pneumococcal polysaccharide vaccine 23-valent (PPV23) is used in high-risk individuals 2 years of age or older.

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