MENINGITIS AND

ENCEPHALITIS

DR.VIVEK BAXI
Meningitis:-infection or inflammation
of the meninges and subarachnoid
space.

Encephalitis:-infection of the brain

parenchyma with focal neurological
signs.
Case-1
62 year old female , brought to hospital in unresponsive
state. she had c/o-headache since last 2 days ,fever with
chills and cough(yellowish sputum) since last 4 days.
O/E-Temp-103.6°F,diaphoretic,unresponsive,
HR-110/min,
BP-110/80mmhg,
RS-RT.lower zone crepitations +,
CNS-neck rigidity+, Brudzinski sign+, fundi showed flat
disks but absent venous pulsations.
 Blood cultures were obtained.

WHAT IS YOUR DIAGNOSIS?

Meningitis:-
Questions :-
What features help in diagnosis?
Can we ascertain etiology?
When is a CT BRAIN necessary?
Is lumbar puncture safe in these patients?
What antibiotics should we use?
What about steroids?
What are the complications?
What features help in diagnosis?
Brudzinski’s Sign
Kernig’s Sign
Can we ascertain etiology?
BACTERIAL CAUSES :-
Age Bacteria
0-3-- months • Streptococcus aglactiae
•E.coli
• Listeria monocytogenes
3 months-16 years • Neisseria meningitidis
• Streptococcus pneumoniae
• Haemophilus influenzae
16 years-50 years • S.pneumoniae
• N.meningitidis
> 50 years • S.pneumoniae
• Monocytogens
• aerobic gram negative bacilli
ORGANISM FEATURE
Pneumococcus • Associated sinusitis,
OM,pneumonia
Meningococcus Petechiae,hypotension

Enteric gram neg

Diabetics, alcoholics

Staph aureus
Post operative , trauma
Listeria
Food borne spread

Viruses:-
Disease that can mimic as viral meningitis or
encephalitis
INVESTIGATIONS:-
CBC
CT BRAIN
LP-CSF  Gram stain, cell count with differential,
protein and glucose concentration with simultaneous
blood glucose level.culture and PCR.
 Blood cultures
Relevant Routine investigations -CXR,RFT,LFT,ABG
Investigations

When is a CT SCAN necessary?

Risk factors for abnormal CT
Age > 60
Immunocompromised
Hx of CNS disease
Seizures w/in 1 wk of presentation
Neurologic abnormalities at presentation: LOC, inability to
answer 2 consecutive questions appropriately, abnormal visual
fields, facial palsy, arm drift, leg drift, abnormal language
MRI with gadolinium contrast is more sensitive than
CT .
Focal abnormalities on MRI may suggest particular
diagnoses.

T2-weighted MRI
Showing-hyperintensity
In left temporal lobe in
a patient with HSV -1
encephalitis.
Is lumbar puncture safe in these patients?
Contraindications to LP
Absolute: Skin infection over site
Papilledema, focal neurological signs,

Relative: Increased ICP without papilledema

Suspicion of mass lesion
Spinal cord tumor
Spinal epidural abscess
Bleeding diathesis or ↓ plts
CSF:-
 Should be examined within 90 minutes of collection.
CSF glucose concentrations will be higher in
moderately to severely hyperglycemic patients.
In these patients, the CSF:blood glucose ratio
should be used to determine true CSF glucose
concentration.
The CSF glucose concentration is low when the
CSF:blood glucose ratio is <0.6 .
CSF interpretation
Cell Count:-
Normal:
Up to 5 WBCs / HPF in adults
Bacterial meningitis
75% have > 1000 WBCs / mm3
99% have > 100 WBCs / mm3
Traumatic tap:
Allow 1 WBC for every 500-1000 RBCs
Protein Level:-
Subtract 0.01 g/L for every 1000
RBCs / mm3
Aseptic meningitis
Bacteria can not be isolated from the CSF.
D/D:- 1) viral meningitis
2)partially treated bacterial meingitis
3)tuberculous meningitis
4)fungal meningitis
5)lymphoma
6)sarcoidosis
7)other collagen vascular disease.
Management:-

What antibiotics should we use?

An association is found between delays
in administering antibiotics longer than 6
hours after arrival in ER and death.

Antibiotics should be given as soon as

possible, even before CT and LP done.
Tuberculous meningitis
Duration of treatment
Pathogen Duration of Rx (d)

H. influenzae 7
N. meningitidis 7
S. pneumoniae 10-14
L. monocytogenes 14-21
Group B strep 14-21
Treatment of viral encephalitis
HSV-1 encephalitis is treated with i.v acyclovir-10
mg/kg every 8 hours for 3 weeks.
Varicella zoster virus encephalitis is treated with i.v
acyclovir-10 mg/kg every 8 hours for 10-14 days.
Rocky mountain spotted fever –doxycycline 100 mg
twice daily for at least 3 days after the patient
becomes afebrile.
CMV encephalitis-i.v foscarnet-60 mg/kg every 8
hours and i.v ganciclovir-5 mg/kg every 12 hours.
When should corticosteroids be administered?
All patients presenting with suspected bacterial meningitis
should receive dexamethasone prior to or with the first
dose of antibiotics.

Dosage-0.6 mg/kg, total dose daily -6 hourly –for 4 days.

Supportive treatment
Anticonvulsants- benzodiazepines, phenytoin.

Treat raised ICP

i.v fluids

Respiratory support when needed.

Complications:
Seizures

Hydrocephalus

Infarction

Herniation
Complications during clinical course
Cardiorespiratory 29%
Hyponatremia 26%
Seizures 15-23%
Hearing loss 14%
Cognitive impairment 10%
Arterial infarction 10-15%
Preventing an epidemic…
Prophylaxis
Who?
Anyone with close contact for > 4hrs during the week
before onset of illness.
Exposure to patient’s oropharyngeal secretions.

What?
Rifampin 10 mg/kg PO q12h x 2 days.
THANK YOU