Meningitis

Department of Clinical Microbiology

 CNS : Brain and spinal cord
 Meninges : Covering of brain [dura mater , arachnoid and pia mater ]
 Leptomeninges : arachnoid and pia mater

 Meningitis :Meningitis is an inflammation of the leptomeninges (arachnoid and pia mater)

surrounding the brain and spinal cord, with involvement of the subarachnoid space.
• Based on changes in leukocytes in CSF,
 Aseptic meningitis: (Lack of infection)
• Elevated lymphocytes in CSF

 Pyogenic meningitis:

- Elevated polymorphonuclear cells in CSF

- Exclusively caused by bacterial agents

• Encephalitis is an acute inflammation of the brain parenchyma by invasion of

infectious agents, most often the viruses.
• Meningo-encephalitis is the inflammation of both brain and meninges.
 Pathogenesis
Routes of Infection:

I. Hematogenous spread: most common route

II. Direct spread from an infected site - otitis media, mastoiditis,
sinusitis
III. Anatomical defect in central nervous system (CNS): result of
surgery, trauma, congenital defects
IV. Direct intraneural spread along the nerve: least common route -
rabies virus or herpes simplex virus infection
Predisposing factors:
1. Age: Neonates are more prone to meningitis due to their
immature immune system, direct contact to the organism in
birth canal & increase permeability of BBB.
2. Vaccination: Increase vaccination decrease incidence of
meningitis.
3. Breach in the BBB
4. Microbial virulence factor
5. Factors that promote infection at primary site such as,
- Diabetes
- Immunosuppressants
Virulence factors for bacterial meningitis:
1. Capsule
2. IgA protease
3. Pili
4. Outer membrane protein
5. Endotoxin
Clinical manifestation
Laboratory diagnosis

Sample: CSF by lumber puncture

• Blood- For Culture
• Serum- For serological reaction
- CSF should be taken in 3 sterile vials separately.
1 for cell count, 1 for biochemical analysis and 1 for bacteriological
examination.
 Sample should be examine as soon as possible if not, preserve in incubator
at 37⁰C.
 Sample for bacterial culture should not be refrigerated as the H. influenzae
will die at 4⁰C.
Biochemical Analysis
• Biochemical analysis and cell count of CSF  preliminary clue

Acute pyogenic meningitis

• CSF pressure: highly elevated (>180 mm of water)
• Total leukocyte count: Highly elevated, neutrophilic (100–10,000 per
mm3)
• Glucose: Decreased to absent (<40 mg/dL)
• Total proteins: >45 mg/dL
CSF Microscopy
 Gram Stain: After centrifugation or heaped smear
 Ziehl-Neelsen staining
 India ink preparation - for detection of capsule of Cryptococcus neoformans
 Wet mount preparation - trophozoites of parasites such as Naegleria
 CSF Microscopy
Organism Direct demonstration Culture identification
Neisseria meningitidis Gram-negative cocci in pair, Oxidase positive, growth on
intracellular, inside the pus cells chocolate agar

Haemophilus influenzae Pleomorphic gram-negative bacilli Satellitism on blood agar with S.

aureus streak line, growth
surrounding disk containing
combined X and V factors

Escherichia coli or other gram- Gram-negative bacilli Identification is based on colony

negative bacilli grown on MacConkey agar and
biochemical reactions
 CSF Microscopy
Organism Direct demonstration Culture identification
Tubercular ZN stain of CSF showing acid fast Growth on Lowenstein Jensen
meningitis bacilli medium (rough tough buff colonies)
Detection of specific genes in CSF Growth on MGIT (mycobacterial
by PCR or GeneXpert growth indicator tube)
 Treatment
Empirical therapy :
Adult: IV cefotaxime or ceftriaxone and vancomycin, if Listeria is suspected, IV ampicillin
Neonates: IV ampicillin plus gentamicin is the recommended regimen
IV dexamethasone is added to the regimen to reduce intracranial pressure.

• Definitive therapy: After the culture report is available, the empirical therapy is
modified based on the organism isolated and its antimicrobial susceptibility pattern.
• For tubercular meningitis: according to RNTCP guidelines
• For cryptococcal meningitis:
- Induction phase: Amphotericin B + flucytosine for 2-4 wks
- Maintenance phase: Fluconazole for 6–12 months
For viral meningitis: Antiviral drugs such as IV acyclovir
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