Meningitis

By- Dr Nimco A. MD
 Definition
 Differences
 Diagnoses
 Treatement
 Summary
Definition

 Meningitis, a clinical syndrome that

results from inflammation of the
meninges,
 can be caused by a wide range of
organisms – viruses,
 bacteria, yeasts or helminths and, rarely,
it has a non-infectious cause
 Depending upon its cause, meningitis may present as an acute or
as a chronic illness. In tropical Africa, acute bacterial meningitis is the
most important form of meningitis. Major causes of chronic meningitis
are tuberculosis and cryptococcal infection.
 The incidence of tuberculous, cryptococcal and pneumococcal meningitis has increased
significantly as a consequence of the HIV epidemic.
Acute bacterial meningitis

 Epidemiology
 Acute bacterialmeningitis is still a major cause of mortality and morbidity throughout
tropical Africa.
 Surveys of the cause of death in children that have employed the post-mortem
questionnaire technique suggest that about 2 per cent of deaths in children under the age of
5 years are due to meningitis.
Aetiology

 A large number of bacteria can occasionally cause acute bacterial meningitis, but
throughout tropical Africa, the majority of cases
 are caused by three bacteria – Streptococcus pneumoniae (the pneumococcus),
 Haemophilus influenzae type b (Hib)
 and Neisseria meningitidis (the meningococcus).
 Other Gram-negative bacilli cause meningitis in immunocompromised
children, such as those with malnutrition, and a wide range of bacteria
may cause meningitis in neonates.
Geographical distribution

 The pneumococcus and Hib are the most important causes of acute
bacterial meningitis in children in most parts of Africa. However,
in countries of the Sahel and sub-Sahel, the African ‘meningitis belt’, the meningococcus
predominates
 Pneumococcal meningitis in adults follows the distribution of HIV, being most common in
southern Africa but epidemics may occur in the African meningitis belt.
Age distribution

 Each of the three main types of acute bacterial meningitis has a

characteristic age distribution.
Invasive Hib disease is seen primarily in very young children.
 The incidence of pneumococcal meningitis is also highest
during the first year of life, but in both Africa and in industrialized
countries there is a rise in the incidence of invasive pneumococcal
disease in the elderly, and it is the predominant form of acute
meningitis in HIV-positive adults.
Predisposing factors

 The pneumococcus, the meningococcus and Hib are transmitted

from person to person by respiratory droplets. In most instances,
this results in asymptomatic colonization of the nasopharynx.
 In sub-Saharan Africa, nearly all children carry a pneumococcus in their
nasopharynx, and the pharyngeal carriage rates of Hib and of meningococci may be as high
as 10–20 per cent.
Pathology and pathogenesis

 In most instances, acute bacterial meningitis follows invasion of the

blood by bacteria colonising the nasopharynx with subsequent
invasion of the meninges. If invasion occurs, it usually does so within
a week or two of colonization.
 Occasionally, acute bacterial meningitis results from the direct spread of bacteria to the
meninges from a near by focus of infection such as suppurative otitis media or mastoiditis.
 Rarely, meningitis follows a penetrative injury of the skull or invasion through the
cribriform plate in patients who have a cerebrospinal (CSF) leak from the nose
(rhinorrhoea) as a result of a congenital abnormality or trauma.
Clinical features

 Symptoms
 Most patients with acute bacterial meningitis present with a characteristic
 two or three day history of fever, headache and a painful, stiff neck.
 There may be photophobia and/or vomiting.
 There may be a history of convulsions, especially in young children. However, these
characteristic symptoms may not be present in the very young or in the old.
 Failure to feed may be the only indication of the presence of meningitis in infants and
confusion may be the most prominent symptom in the elderly.
 Physical signs
 Patients with meningitis are often dehydrated, drowsy and confused by the time that they
reach hospital so that it may be necessary to take a history from a relative.
 Occasionally, patients are already comatose on arrival; this is a bad prognostic sign.
 Inflammation of the meninges produces characteristic clinical signs. Flexion of the neck is
resisted.
 Flexion of the hips and subsequent straightening of the leg produces
 pain in the back (Kernig’s sign).
 Bright light is painful, and patients with meningitis often lie facing away from the light.
Neurological examination may show localizing signs.
 The most frequent of these is a sixth cranial nerve palsy, which may be a consequence of
raised intracranial pressure .
 Less frequently, other cranial nerve palsies, such as a third nerve palsy, are found.
 Examination of the optic fundi may show distended veins, but papilloedema is unusual. In
infants, raised intracranial pressure may lead to bulging of the anterior fontanelle.
 Some patients with meningococcal septicaemia or meningitis develop arthritis, cutaneous
vasculitis, conjunctivitis or pericarditis a few days after the onset of their illness when their
general condition is improving .
Diagnosis

 Clinical diagnosis
 Clinical diagnosis of acute bacterial meningitis is not difficult in a patient who presents
with a characteristic history, who is confused and who has a stiff neck.
 However, diagnosis is more difficult in the very young and in the elderly who may not
have neck stiffness.
 Cerebral malaria is an important differential diagnosis in the unconscious patient in areas
where infection with Plasmodium falciparum is prevalent. Patients with cerebral malaria
do not usually have a stiff neck.
 Blood
 Examination of the blood will usually show a raised white blood cell count with a
predominance of polymorphonuclear neutrophil leukocytes.
 There may be thrombocytopenia. The presence of malaria parasites does not exclude a
diagnosis of meningitis as the patient may have both infections and detection of
parasitaemia is not a reason for not undertaking a lumbar puncture.
 Blood culture is positive in about 30 per cent of patients with acute bacterial meningitis.
 Cerebrospinal fluid
 Examination of cerebrospinal fluid (CSF) usually shows a turbid or purulent fluid.
 However, about 200 cells per μl are required to produce turbidity so that the finding of a
clear CSF does not rule out a diagnosis of meningitis and microscopy is required.
 Biochemical examination of the CSF usually shows an increase in CSF protein and a low
CSF glucose, which is lower than the blood glucose concentration measured at the same
time.
 Some patients with acute bacterial meningitis have already received antibiotics before they
reach hospital and this may make isolation of the causative organism from blood or CSF
difficult.
Management

 Patients with acute bacterial meningitis are often severely ill and so require the best
nursing and medical care that is available. They should be managed in an intensive care
unit if this is possible.
 Hyponatraemia may occur as a result of inappropriate secretion of anti-diuretic hormone
and it has been recommended in the past that fluids should be restricted.
 However, there is no evidence that this improves outcome, and dehydration, which is
often present, should be treated with intravenous fluids. Headache may be severe and is an
important cause of restlessness and irritability; its control may require powerful analgesics.
 Convulsing patients need an anti-convulsant such as diazepam. Neonates with meningitis
require especially skilled management.
 Shock is often a prominent feature of acute meningococcaemia and it may be difficult to
sustain blood pressure. Hypotension should be treated initially with an infusion of colloid
solution such as 4.5 per cent albumin (20 ml/kg) or plasma.
 It may be necessary to repeat this, but there is a danger of fluid overload and the
development of pulmonaryoedema.
 Whenever possible, fluid replacement should be guided by measurement of the central
venous pressure. If a colloid infusion does not restore blood pressure, a dopamine infusion
(5 mg/kg/min) should be tried.
 Oxygen should be given to patients who are severely shocked.
Antibiotics

 Antibiotic therapy should be started as soon as possible.

 It is advisable to give an initial dose of a broad spectrum antibiotic to a patient with
suspected meningitis at a peripheral clinic if their journey to a referral hospital is likely to
take many hours.
 If a patient has not received an antibiotic before reaching hospital, it is reasonable to wait
until a lumbar puncture and an initial microscopical
 examination of the CSF has been done before initiating
 therapy but not to wait for the results of culture, which may take 2 or 3 days.
 If microscopy is negative or if lumbar puncture cannot be done for clinical, logistic or
financial reasons, antibiotic treatment has to be initiated in the absence of a
microbiological diagnosis.
 Thus,each facility where cases of acute bacterial meningitis are treated regularly should
have a standard treatment protocol for the management of patients with this condition.
 This should follow regional or national guidelines or, when these are not available, it
should be developed locally on the basis of knowledge of the most important bacterial
causes of meningitis in the area and their antibiotic sensitivity
 Until recently, penicillin or ampicillin, with or without chloramphenicol, was the
recommended treatment for cases of acute bacterial meningitis in children in the
developingworld inwhomno aetiology had been established.
 There is no evidence that, in cases caused by sensitive organisms the efficacy of the
penicillin/chlormaphenicol combination is greater than that of chloramphenicol used alone
 The emergence and rapid spread of penicillin-resistant pneumococci in many parts of the
developing world, including parts of Africa, now makes penicillin a hazardous choice for
treatment of acute bacterial meningitis of unknown cause and a third-generation
cephalosporin,such as ceftriaxone, is a safer option.
 Ceftriaxone is effective against most of the major causes of acute bacterial meningitis
occurring in Africa.
 Some pneumococci are now partially resistant to third-generationcephalosporins and, in
industrialized countries, some physicians recommend that patients with pneumococcal
meningitis should also begiven vancomycin, but this antibiotic is expensive and toxic.
 A single dose of an antibiotic that provides 2–3 days of protective blood levels is probably
sufficient for the effective treatment of meningococcal meningitis but 5 days of treatment
is usually recommended.
 Pneumococcal and Hib meningitis requires a longer period of treatment and a minimum of
10 days is usually recommended.
 Antibiotics should initially be given parenterally, but a change to oral treatment can be
made as the patient improves provided that the antibiotic is well absorbed.
Corticosteroids

 Whether or not patients with acute bacterial meningitis should be given corticosteroids is
still controversial.
 There is reasonably strong evidence that their administration has reduced the incidence of
neurological sequelae, particularly deafness, in both children and adults in Europe and
America, especially following Hib meningitis .
 However, studies conducted in Malawian children and adults, many of the latter with HIV
infection, did not show any benefit from administration of corticosteroids
Outcome

 Unfortunately, many survivors of acute bacterial meningitis are left with permanent
neurologicaldamage
 intellectual impairment, psychological problems, deafness,cortical blindness, cranial nerve
palsies or hemiplegia .
 Obstruction to the flow of CSF may result in hydrocephalus.
 Neurological sequelae are especially common after pneumococcal meningitis and, in
Africa, less than a quarter of paediatric patients with this infection recover completely.
 Meningococcal meningitis is an important cause of deafness in countries of the African
meningitis belt.
Any Question??!!
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