Meningitis
Meningitis Encephalitis
• Meningitis is an inflammation
(swelling) of the protective
membranes (meninges) covering
the brain and spinal cord.
• A bacterial or viral infection of
the fluid surrounding the brain
and spinal cord usually causes
the swelling.
• Inflammation of the brain
parenchyma, presents as diffuse
and/or focal neuropsychological
dysfunction
• Most commonly a viral infection
with parenchymal damage
varying from mild to profound
Aetiology
Bacterial Cause
• Common cause: Neisseria meningitidis (In children 1 month to 12
month)
• Streptococcus pneumoniae and Haemophilus influenzae type b.
• less common pathogens such as Pseudomonas aeruginosa,
Staphylococcus aureus, coagulase- negative staphylococci, Salmonella
spp., and Listeria monocytogenes. (Due to Alterations of host
defence, anatomic defects or immune deficits).
Neisseria meningitidis
• Gram negative, non motile, non sporing diplococcus
• Contains capsular antigens (A, B, C, X, Y, W135) responsible for
immune complex formation.
• Produces endotoxin responsible for circulatory collapse & DIC.
IP: 3-4 days
(2- 10days average)
Viral Cause
• Viral meningitis comprises most aseptic meningitis syndromes.
The viral agents for aseptic meningitis include the following:

• Enterovirus (polio virus, Echovirus, Coxsackievirus )

• Herpesvirus (Hsv-1 ,2, Varicella.Z,EBV )
• Paramyxovirus (Mumps, Measles)
• Togavirus (Rubella)
• Rhabdovirus (Rabies)
• Retrovirus (HIV)
Fungal Cause
• It's rare in healthy people, but is a higher risk in those who
have AIDS, other forms of immunodeficiency or
1mmunosuppress1on.
• The most common agents are Cryptococcus
neoformans, Candida, H capsulatum.
Acute Bacterial Meningitis
Acute Bacterial Meningitis
• One of the most potentially serious infections occurring in
infants and older children.

• The incidence of bacterial meningitis is sufficiently high in

febrile infants.
Epidemiology
• Major risk factor for meningitis- lack of immunity to specific pathogens
associated with young age.

•Additional risks:
• recent colonization with pathogenic bacteria close contact (household,
daycare centres) with individuals having invasive disease caused by N.
meningitidis and H. influenzae type b, crowding, poverty

•Mode of transmission
Probably person-to-person contact through respiratory tract secretions or
droplet
• Defects of the complement system (C5- C8) have been
ass,ociated with recurrent meningococcal infection.

• Splenic dysfunction (sickle cell anemia) or asplenia (due to

trauma, or congenital defect) is associated with an increased
risk of pneumococcal, H. influenzae type b (to some extent),
and, rarely, meningococcal sepsis and meningitis.
Pathogenesis
• Bacterial meningitis most commonly results from
haematogenous
•dissemination of microorganisms from a distant site of
infection; bacteremia usually precedes meningitis or occurs
concomitantly.

• Usual source of bacteremia: bacterial colonisation of

naso-pharynx with potentially pathogenic microorganism.
Clinical Manifestations
•Common presentation is
• sudden onset
• rapidly progressive m1anifestations of shock
• Purpura
• disseminated intravascular coagulation (DIC)reduced levels of consciousness
often resulting in
• progression to coma or death within 24 hr.

•More often, meningitis is preceded by several days of fever accompanied

by upper respiratory tract or gastrointestinal symptoms , followed by nonspecific
signs of CNS infection such as increasing lethargy and irritability.
• The signs and symptoms of meningitis are related to the nonspecific findings associated
with a systemic infection and to manifestations of meningeal irritation.
•Nonspecific findings include:
• Fever
• Anorexia
• Poor feeding
• Headache
• Symptoms of upper respiratory tract infection
• Myalgias
• Arthralgias
• Tachycardia
• Hypotension
• Various cutaneous signs , such as petechiae, purpura, or an erythematous macular rash
•Meningeal irritation is manifested as:
• Nuchal rigidity- impaired neck flexion resulting from musc le spasm (not
actual rigidity) of the extensor muscles of the neck; usually attributed to
meningeal irritation.

• Back pain

• Kernig sign (flexion of the hip 90 degrees with subsequent pain with
extension of the leg), and

• Brudzinski sign (involuntary flexion of the knees and hips after passive f
lexion of the neck while supine)
Video
• Brudzinski neck/leg sign of Meningeal irritation @AllMS
(New Delhi)
•Pediatrics wards. mp4
•https://www.youtube.com/watch?v=oMh BVGJW9Cs

• Kernigs sign
•https://www .youtube.com/watch ?v=Ntus x07WYfQ
• Alterations of mental status are common among patients
with meningitis and may be the consequence of increased
ICP, cerebritis, or hypotension; manifestations include
irritability, lethargy, stupor, obtundation, and coma.
Diagnosis
• 1 . CSF Study
• Conf irmed by analysis of the CSF, which typically reveals
microorganisms on Gram stain and culture.
• Lumbar Puncture is done for CSF collection.

• Contraindications for an immediate LP include

• evidence of increased ICP, HTN.
• in patients in whom positioning for the LP would further compromise
cardiopulmonary function.
• infection of the skin overlying the site of the LP.
• The CSF leukocyte count in bacterial meningitis usually is e levated to>1,000/mm3 and ,
typically , there is a neutrophi lic pred o m inance (75- 95%)
• Turbid CSF is present when the CSF leukocyte count exceeds 200-400/mm 3 . viral or bacterial
meningitis have <5 leukocytes/mm3 in the CSF
Blood cultures
• Blood cultures reveal the responsible bacteria in up to 80-90% of
cases of meningitis. Elevations of the C- reactive protein,erythrocyte
sedimentation rate, and procalcitonin have been used to differentiate
bacterial (usually elevated) from viral causes of meningitis.
CT Scan
• Cranial computed tomography (CT) is of limited use in acute bacterial
meningitis CT in cerebral oedema may show slit- like lateral ventricle
and areas of low attenuation.
Differential Diagnosis
• Acute viral meningoencephalitis is the most likely infection
to be confused with bacterial meningitis
Treatment
• A child with rapidly progressing disease of less than 24 hr
duration, in the absence of increased ICP, should receive
antibiotics as soon as possible after an LP is performed.

• If there are signs of increased ICP or focal neurologic

findings, antibiotics
•should be given without performing an
• LP and before obtaining a CT scan
 Initial Empirical Therapy

• Vancomyci n (60 mg/kg/24 hr, given every 6 hr)

• Because of the efficacy of third-generation cephalosporins in the therapy of
meningitis caused by sensitive S. pneumoniae, N. meningitidis, and H. influenzae
type b:
• Cefotaxime (300 mg/kg/24 hr, given every 6 hr) or
• Ceftriaxone (100 mg/ kg/24 hr administered once per day or 50 mg/kg/dose,
given every 12 hr)

• Patients allergic to J3-lactam antibiotics and > 1 mo of age can be

treated with Chloramphenicol, 100 mg/kg/24 hr, given every 6
hr.
• Another option for patients with allergy to J3-lactam antibiotics is
a combination of Vancomycin and Rifampin.
Coticosteroids
• Use of intravenous dexamethasone
•0.15 mg/kg/ dose given every 6 hr for 2 days, in the treatment of
children older than 6 wk with acute bacterial meningitis caused by H.
influenzae type b.

• Among children with meningitis caused by H. influenzae type b,

corticosteroid recipients have a shorter duration of fever
(inflammation is reduced), ower CSF protein and lactate
• levels, and a reduction in sensorineural hearing loss
(result of cochlear infection).
Complications
• During the treatment of meningitis, acute CNS complications can
include seizures, increased ICP, cranial nerve palsies, stroke.

• Subdural effusions are especially common in infants

• Prolonged fever (>1O days) is noted in approximately 10°/o of

patients. Prolonged fever is usually caused by intercurrent viral
infection, nosocomial or secondary bacterial infection,
thrombophlebitis , or drug reaction.
Prevention
• Vaccination and antibiotic prophylaxis of susceptible at­ risk contacts
represent the 2 available means of reducing the likelihood of bacterial
meningitis.

•Neisseria meningitidis
• Two quadrivalent (A, C, Y, W-135 ), conjugated vaccines (MCV-4;
Menactra and Menveo) are licens,ed by the FDA.

• Menactra is licensed for use in infants older than 9 mo of age, and

Menveo for use in children older than 2 yr of age
Haemophilus influenzae Type B
• All children should be immunized with H. influenzae type b conjugate
vaccine beginning at 2 mo of age.

Streptococcus pneumoniae
• Routine administration of conjugate vaccine against S. pneumoniae is
recommended for children younger than 5 yr of age. The initial dose is
given at about 2 mo of age.
Prognosis
• Appropriate antibiotic therapy and supportive care have reduced the mortality of bacterial
meningitis after the neonatal period to <10°/o.

• The highest mortality rates are observed with pneumococcal meningitis.

• Sensorineural hearing loss is the most common sequela of bacterial meningitis and, usually,
is already present at the time of initial presentation.

• It is a result of cochlear infection and occurs in as many as 3 0°/o of patients with pneumococcal
meningitis, 10°/o with meningococcal, and 5-20°/o of those with H. influenzae type b meningitis