INFLAMMATORY CONDITIONS OF THE BRAIN

Meningitis
Meninges
 Definition

• Meningitis is an acute inflammation of the meninges, which cover and

protect the brain and spinal cord.

• Meningitis specifically refers to infection of the arachnoid mater and

the CSF.

• The three major cause of meningitis are bacterial, viral, and fungal
infections.
 Bacterial meningitis

• Bacterial meningitis primarily cause inflammation of the

leptomeninges (pia mater and arachnoid) and involves the CSF in the
subarachnoid space. It is considered as a medical emergency.
 Incidence and etiology

• It affects the very young and very old and favors males over females,
with a high incidence in the black versus the white population.

• According to the CDS more than 300 people die each year from this
disease.
 Common pathogens..

• Haemophilus influenzae

• Neisseria meningitidis

• Diplococcal pneumoniae (pneumococcal)

• Nosocomial infections (gram negative)

• Staphylococci

• Streptococci
 Risk Factors

• All age group are at risk for meningitis.

• Persons living in communities

• Persons with compromised immune system

• Missing out the recommended vaccinations

• Pregnant women

• Farm workers
 Pathophysiology

Transmitted in one of four ways:

• Air borne droplets

• Direct contamination,

• The blood stream

• Direct invasion of the meningeal membranes

 Clinical Manifestations

• Fever, headache, and nuchal rigidity (the most common symptoms)

• Nausea, vomiting and irritability
• Meningeal irritation: Kernig’s sign, Brudzinski’s sign, and
photophobia
• Altered level of consciousness that ranges from confusion and
drowsiness to coma
• Cranial nerve palsy
• Rash (in70% of people) and petechiae may be seen
• Generalized seizures
 Diagnostic Studies

• Health history and physical exam

• Blood cultures

• Complete blood count

• Imaging. Computerized tomography (CT) or magnetic resonance

imaging (MRI) scans

• Spinal tap (lumbar puncture)

CSF analysis
 Pathogen detection

• Cerebrospinal fluid microscopy with Gram stain

• Cerebrospinal fluid culture

• Cerebrospinal fluid polymerase chain reaction

• Blood tests

• Swabs
 Treatment

Medical/clinical management
• Acute care
• IV mannitol for rapid elevation in ICP
• Fluids with intake and output
• ICP monitoring; CSF drainage if ICP is elevated
• Bedrest with head of bed (HOB) elevated 30 to 45 degrees
• Intubation and hyperventilation to maintain the PaCO2 between 25
and 35 mm of Hg
• Blood and CSF cultures
Conti.
• Administration of glucose for a low glucose concentration (less than
40 mg/dl) or for a CSF/blood glucose ratio less than 0.6

• Antimicrobial therapy: Ampicillin, penicillin, vancomycin,

cefotaxime, ceftriaxone, ceftizoxime, and ceftazidime

• Dexamethasone therapy to decrease meningeal inflammation

• Seizure precautions and anticonvulsant therapy

Conti.

• Private room from decreased lighting; a non-stimulating environment

with respiratory isolation for 24 hours after the initiation of
appropriate antibiotic therapy

• Pain management

• Fever management with antipyretics and cooling blankets to control

hyperpyrexia

• Induction of barbiturate coma if ICP continues to rise.

 Antibiotic therapy
Category Empirical therapy
Neonates Cephalosporin + ampicillin
Infants and children Cephalosporin (+ vancomycin or rifampin3)
Adults CephaLosporin (+ ampicillin)
Nosocomial, trauma, ventriculitis, Meropenem or cephalosporin5 + vancomycin (or rifampicin or
shunt infection
Fosfomycin or linezolid)
Immunocompromised patients CephaLosporin1 + ampicillin (+ vancomycin3)
Resource-limited countries Ceftriaxone6 chloramphenicol7, penicillin G 7, ampicillin/amoxicillin’
rifampicin8
Chemo-prophylaxis of close contacts Adult doses9: rifampicin (600mg b.i.d., 2 days), ciprofloxacin (500mg
single dose), ceftriaxone (250 mg single dose)
Conti..
Corticosteroids

• Societal guidelines recommend routine treatment with dexamethasone

for community-acquired meningitis of children (0.15mg/kg every 6
hours for 2–4 days) and adults (10 mg every 6 hours for 4 days

• The first steroid dose should be administered 10–20 min before

initiating antibiotic treatment
Other symptomatic therapy

• Severe headache requires generous analgesia, often including opioids.

Antiepileptic treatment is indicated if seizures occur; prophylactic
treatment is not recommended
 Prevention and Control

• Vaccines and immunization

• Chemoprophylaxis

• Health education
 Complications

• Increased ICP.
• Neurological dysfunction
• Papilledema, blindness
• Hemiparesis, dysphasia, hemianopsia
• Hydrocephalus
• Waterhouse Friderichsen syndrome
• Epilepsy
 Aseptic (viral) meningitis

• Viral meningitis is defined as a process of meningeal inflammation

that results from viral or non-viral causes.

• Viral meningitis is an acute, non-purulent inflammatory process that is

confined to the meninges, choroid plexus, and ependyma.
 Causes of viral meningitis

• Mumps virus
• Echovirus
• Adenovirus
• Coxsackievirus
• Arbovirus
• Poliovirus
• Herpes simplex virus types1 and 2
• HIV
Conti.

• Epstein-Barr virus

• Influenza virus type A and B

• Enteroviruses

• Encephalitis virus: California, Western equine, Venezuelan equine, and

St. Lois

• Colorado tick fever

 Pathophysiology

• A viral infectious process that occurs outside the CNS often precedes
the onset of viral meningitis.

• Viral meningitis can result from infecting viruses that reach the CNS
by way of number of transmittable routes, the most common of which
are respiratory, oral, and fecal-oral.
 Clinical manifestations
• Acute onset of headache: typically described as “the worst ever”
• Fever
• Vomiting: usually 24 to 48 hours after initial symptoms
• Muscle rigidity
• Neck stiffness: usually 24 to 48 hours after initial symptoms
• Slight irritability or lethargy
• Abdominal pain (in some cases)
 Fungal meningitis

• The most common fungal infection of the CNS are cryptococcosis,

coccidiodomycosis, mucronycosis, and aspergillosis.

• The condition is more common in patients who are

immunocompromised with AIDS, following an organ transplant,
during chemotherapy, or with chronic corticosteroid use.
Nursing management
Acute Encephalitis
 Definition

• Encephalitis is an acute inflammation(swelling) of the brain usually

resulting from either a viral infection or due to the body's own immune
system mistakenly attacking brain tissue.
 Risk factors

• Age

• Weakened immune system. People

• Geographical regions. 

• Season of the year

 Etiology

• Encephalitis is defined as an acute infection of the brain parenchyma

and meninges that often is caused by herpes simplex or by any number
of arboviruses.

• Arbovirus is a collective term that refers to the many arthropod-borne

viruses, the majority of which belong to the Togaviridae, Flaviviridae,
or bunyaviridae families.
 Common viruses - encephalitis
• Herpes simplex virus (HSV) : HSV type 1 ,HSV type 2

• Other herpes viruses: Epstein-Barr virus, Varicella-zoster virus

• Enteroviruses

• Mosquito-borne viruses

• Tick-borne viruses

• Rabies virus
Childhood infections. 

• measles (rubeola), mumps and German measles (rubella) — used to be

fairly common causes of secondary encephalitis.
 Types

• Primary encephalitis

• Secondary encephalitis
 Other classification of encephalitis

• Infectious encephalitis
• Autoimmune encephalitis
• Chronic encephalitis
• Limbic encephalitis
• HIV encephalitis
• Encephalitis Lethargica
 Infectious Encephalitis

Viruses are the most common agents that cause Infectious Encephalitis

• Herpes Simplex Encephalitis

• West Nile Encephalitis

• Tick Borne Encephalitis

• Japanese Encephalitis
 Autoimmune Encephalitis

• Autoimmune Encephalitis may be triggered by infection in which case

the term "Post-infectious Encephalitis" is used. ADEM (Acute

Disseminated Encephalomyelitis) is a Post-infectious Encephalitis.

• Chronic Encephalitis: A Chronic Encephalitis as a result of Measles

• Limbic Encephalitis: The term ‘Limbic Encephalitis’ (LE) is used

when the limbic areas of the brain are inflamed (swollen) and
consequently not functioning properly.

• HIV Encephalitis: Human Immunodeficiency Virus (HIV) can affect

the brain in different ways
 Pathophysiology

• The inflammation of encephalitis is non-suppurate.

• After the virus enters the CNS via the blood stream or peripheral
nerves, there is infiltration of polymorphonuclear leukocytes and
mononuclear cells.
• This infiltration causes congestion and swelling, vasculitis lesions,
myelin destruction, widespread nerve cell degeneration, necrosis,
and/or hemorrhage.
• 
 Clinical Manifestations
• High fever
• Vomiting
• Neck stiffness
• Seizure activity
• Cranial nerve palsies
• Motor changes, such as hemiparesis
• Changes in level of consciousness (LOC): confusion and, later, drowsiness that
progresses to coma
 Infants and young children

• Bulging in the soft spots (fontanels) of an infant's skull

• Nausea and vomiting

• Body stiffness

• Poor feeding or not waking for a feeding

• Irritability
 Diagnosis
• Blood tests

• Imaging techniques

• Electroencephalogram (EEG),

• Cerebrospinal fluid tests

• Brain biopsy
 Treatment
• Maintain a patent airway and respiratory status

• Control ICP, fever and seizures

• Monitor fluid and electrolyte balance; syndrome of inappropriate

antidiuretic hormone (SIADH) often occurs

• Promote adequate nutrition

• Establish a safe environment

• Prevent associated complications

 Specific management

• Antiviral agents :acyclovir and foscarnet (Foscavir)

• Corticosteroids

• Anticonvulsants

• Sedatives can be effective for seizures, restlessness, and irritability.

• For patients with mild symptoms, the best treatment is rest, plenty of
fluids, and Tylenol (paracetamol) for fever and headaches.
 Complications

• Loss of memory

• Behavioural or personality changes - such as mood swings,

bouts of frustration and anger, and anxiety

• Epilepsy

• Aphasia
conti..

• Persistent fatigue

• Weakness or lack of muscle coordination

• Paralysis

• Hearing or vision defects

 Prevention

• Keeping up-to-date with vaccines is the most effective

way of reducing the risk of developing encephalitis

• Take measures to reduce the risk of being bitten

THANK YOU….