MENINGITIS

Dra. Gloria M. Aguirre

Internal Medicine/ Infectious Diseases
Definition

◦ An acute inflammation of
the protective membranes
covering the brain and
spinal cord, known
collectively as the meninges

◦ Classification:
◦ Acute
◦ Subacute
◦ Chronic

◦ Triad: headache + fever +

neck stiffness
 Meningitis
Acute Bacterial
Aseptic Meningitis Chronic Meningitis
Meningitis

Pathogens:
Streptococcus pneumoniae,
Pathogens:
Non-polio human enteroviruses (NPEV) Illness
Neisseria meningitidis, Haemophilus
influenzae type b,
Coxsackievirus
Echovirus Progression
Listeria monocytogenes, Mycobacterium Enterovirus
tuberculosis. Herpes simplex virus type 1 and 2

van de Beek, D., Brouwer, M., Hasbun, R., Koedel, U., Whitney, C. G., & Wijdicks, E. (2016).
Community-acquired bacterial meningitis. Nature Reviews Disease Primers, 2(1), 1-20.

Wright, W. F., Pinto, C. N., Palisoc, K., & Baghli, S. (2019). Viral (aseptic)
meningitis: a review. Journal of the neurological sciences, 398, 176-183.
Epidemiology

◦ Most affected area: Africa

◦ The mortality depends on age, pathogen,
socioeconomic level
◦ Streptococcus pneumoniae
◦ Meningococcal meningitis “African belt”

van de Beek, D., Brouwer, M., Hasbun, R., Koedel, U., Whitney,
C. G., & Wijdicks, E. (2016). Community-acquired bacterial
meningitis. Nature Reviews Disease Primers, 2(1), 1-20.
Pathophysiology
◦ Transmitted from person-to-person through droplets of respiratory or throat
secretions from carriers

◦ Risk factors:
◦ Compromised immune system
◦ living in a community setting
◦ skipping vaccinations
◦ age

van de Beek, D., Brouwer, M., Hasbun, R., Koedel, U., Whitney,
C. G., & Wijdicks, E. (2016). Community-acquired bacterial
meningitis. Nature Reviews Disease Primers, 2(1), 1-20.
Pathophysiology

◦ Bacteria reaches the subarachnoid space

via hematogenous or by contiguity
(paranasal sinuses, middle ear)
◦ High levels of bacteremia  A higher
penetration into subarachnoid space.
◦ The bacteria reach the post-capillary
veins of the subarachnoid space and
perivascular spaces.

van de Beek, D., Brouwer, M., Hasbun, R., Koedel, U., Whitney,
C. G., & Wijdicks, E. (2016). Community-acquired bacterial
meningitis. Nature Reviews Disease Primers, 2(1), 1-20.
Pathophysiology
◦ Initial adherence step mediated by the binding of
bacterial adhesins to the laminin receptors
expressed on brain endotelial cells
◦ Surface protein PspA in S. pneumoniae
◦ Outer membrane protein porin A in N. meningitidis
◦ Platelet-activating factor receptor facilitates
transcellular and paracellular passage of bacteria
through the blood-brain barrier
◦ Pilus components PilE and PilV (N. meningitidis)
Common pathogens by age
Risk factors
Clinical manifestations
◦ Headache
◦ Pain and stiff neck Cerebral herniation
◦ High fever -Focal neurological deficit
◦ Altered mental status -Altered mental status
◦ Nausea/Vomit (projectile)
◦ Neurologic deficit (1/3)
◦ Rash (N meningitidis, varicela, enterovirus)

Griffiths, M. J., McGill, F., & Solomon, T. (2018). Management of

acute meningitis. Clinical Medicine, 18(2), 164.
 Diagnosis

◦ Confirmation: Pathogen detection in cerebrospinal fluid.

◦ Lumbar puncture: Opening pressure, CSF analysis, cultures,
stains (Gram), KOH, PCR
◦ Laboratories: Hb, Blood culture (50-80% positive), RT-PCR.
◦ Leukocytosis
◦ Elevation of acute phase reactants.
Before LP: Focal neurological deficit,
◦ Contrasted magnetic resonance papilledema, GCS <13, continuous/uncontrolled
◦ Meningeal enhancement seizures, history of CVD, focal tumor or
infection, immunocompromised
Smith, L. (2005). Management of bacterial Griffiths, M. J., McGill, F., & Solomon, T. (2018). Management of
meningitis: new guidelines from the IDSA. American acute meningitis. Clinical Medicine, 18(2), 164.
Family Physician, 71(10), 2003.
CSF
parameters
Imagen

TAC

Aksamit Jr, A. J., & Berkowitz, A. L. (2021).

Meningitis. CONTINUUM: Lifelong Learning in
Neurology, 27(4), 836-854.
Differential diagnosis
Brain abscess
Tuberculous meningitis
Viral encephalitis
Septic encephalopathy
Aseptic meningitis
Sinus infection
van de Beek, D., Brouwer, M., Hasbun, R., Koedel, U., Whitney,
C. G., & Wijdicks, E. (2016). Community-acquired bacterial
meningitis. Nature Reviews Disease Primers, 2(1), 1-20.
S. pneumoniae
◦ It’s the commonest cause of bacterial meningitis in
adults
◦ >90 antigenically different serotypes determined by
the polysaccharide capsule
◦ PCV (pneumococcal conjugate vaccines) have been
used for the past 15 years
◦ PCV7
◦ PCV10
◦ PCV13
◦ Polysaccharide vaccine PPV23
◦ Goal of vaccine: prevention of invasive disease
Neisseria
meningitidis
◦ Meningococci are categorised into 13 serogroups
◦ Five are responsible for most cases of invasive
diseasae (A, B, C, W135, Y)
◦ B most common in Europe
◦ Y predominant in USA
◦ W135: higher mortality

◦ Massive reductions have ocurred in recent years

following widespread vaccination
Haemophilus
influenzae type b
◦ It was a significant cause of meningitis,
especially in infants and young children
◦ Before the widespread of conjugate vaccines

◦ H. influenzae has virtually dissapeared

 Treatment

◦ GCS≤12  ICU
◦ ABC
◦ Treat sepsis (if present)
◦ Antibiotic therapy
◦ Broad initial spectrum
◦ Selection by initial studies
◦ Directed to the microorganism

◦ Dexamethasone 10mg IV/6h (along with or shrotly after AB <12h)

◦ Continue for 4 days if the pathogen is: H. influenzae or S. pneumoniae

Griffiths, M. J., McGill, F., & Solomon, T. (2018). van de Beek, D., Brouwer, M., Hasbun, R., Koedel, U., Whitney,
Management of acute meningitis. Clinical C. G., & Wijdicks, E. (2016). Community-acquired bacterial
Medicine, 18(2), 164. meningitis. Nature Reviews Disease Primers, 2(1), 1-20.
van de Beek, D., Brouwer, M., Hasbun, R., Koedel, U., Whitney,
C. G., & Wijdicks, E. (2016). Community-acquired bacterial
meningitis. Nature Reviews Disease Primers, 2(1), 1-20.
Vaccines
◦ Preventable disease
◦ Vaccines
◦ Haemophilus influenzae Hib Conjugate vaccine

Vacunas
◦ Streptococcus pneumoniae
◦ Neisseria meningitidis Pneumoccocal conjugate (13, 15, 20)
Meningoccocal

van de Beek, D., Brouwer, M., Hasbun, R., Koedel, U., Whitney,
C. G., & Wijdicks, E. (2016). Community-acquired bacterial
meningitis. Nature Reviews Disease Primers, 2(1), 1-20.
Aseptic meningitis
Pathophysiology
◦ The virus can reach the CNS, damaging
sensory and motor neurons.
◦ Infection causes release of chemotactic
 infiltration of cells of the innate
immune system
◦ In cerebrospinal fluid
◦ IL-6  significant elevation in the first 24
hrs
◦ IFN-γ  elevation at 5-6 days

Wright, W. F., Pinto, C. N., Palisoc, K., & Baghli, S. (2019).

Viral (aseptic) meningitis: a review. Journal of the
neurological sciences, 398, 176-183.
Clinical Manifestations

◦ Meningeal signs
◦ Kernig, Brudzinski

Wright, W. F., Pinto, C. N., Palisoc, K., & Baghli, S. (2019).

Viral (aseptic) meningitis: a review. Journal of the
neurological sciences, 398, 176-183.
 Treatment

◦ Acyclovir 10mg/kg IV/8h

◦ Only beneficial antiviral in herpetic encephalitis, NOT meningitis
◦ Reduces morbidity and mortality

Steroids are NOT recommended unless

vasculitis is present
Wright, W. F., Pinto, C. N., Palisoc, K., & Baghli, S. (2019).
Viral (aseptic) meningitis: a review. Journal of the
neurological sciences, 398, 176-183.
Chronic Meningitis
Clinical manifestations
*Progression
◦ Headache
◦ Lethargy.
◦ Changes in mental state.
◦ High-fever.
◦ Cranial nerve dysfunction (hearing impairment, diplopia)
◦ along its course through the subarachnoid space.
◦ Rapidly progressive dementia (*immunocompromised)

Aksamit, A. J. (2021). Chronic Meningitis. New

England Journal of Medicine, 385(10), 930-936.
Imagen

Aksamit, A. J. (2021). Chronic Meningitis. New

England Journal of Medicine, 385(10), 930-936.
Diagnosis
◦ Punción lumbar
◦ Leukocytosis
◦ They may be absent in severe immunosuppression
◦ Lymphocyte predominance
◦ Eosinophilia  parasites or cocci
◦ Hypoglycorrhachia.
◦ Elevated proteins.

Aksamit, A. J. (2021). Chronic Meningitis. New

England Journal of Medicine, 385(10), 930-936.
Treatment

◦ Empiric antibiotic therapy is not recommended (unless you have a history or risk factors suggestive of
bacterial infection).
◦ Antituberculosis therapy (in prevalent regions, not empirical) + Corticosteroids.
◦ if tuberculosis is not suspected, and no microorganism is identified  glucocorticoids + imaging
follow-up in 4-8 weeks

Aksamit, A. J. (2021). Chronic Meningitis. New

England Journal of Medicine, 385(10), 930-936.