Meningitis: Difference between revisions
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==Classification==
<span class="Apple-style-span" style="font-size: 19px; font-weight: bold; ">Classification</span>
# <span style="line-height: 20px">Acute (<24 hrs): usually bacterial in origin (25%)</span>
 
# Subacute (1-7 days): viral or bacterial
#<span style="line-height: 20px">Acute (<24 hrs): usually bacterial in origin (25%)</span>
# Chronic (>7 days): viral, TB, syphilis, fungi, carcinomatous
#Subacute (1-7 days): viral or bacterial
#Chronic (>7 days): viral, TB, syphilis, fungi, carcinomatous
 
== Risk Factors ==


==Risk Factors==
#Age >60 or <5
#Age >60 or <5
#Immunosuppressed/Immunocompromised (DM, adrenal insufficiency, HIV, cystic fibrosis, pts on steroids, Sickle Cell, etc)
#Immunosuppressed/Immunocompromised (DM, adrenal insufficiency, HIV, cystic fibrosis, pts on steroids, Sickle Cell, etc)
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#Malignancy
#Malignancy


==Signs/Symptoms==
== Signs/Symptoms ==
#Headache
*Almost all patients present w/ at least 2 of the following:
#Nuchal rigidity (may not be present in those with AMS)
**Headache
#Fevers/chills
**Fever
#Photophobia
**Neck stiffness
#Vomiting
**Altered mental status
#Prodromal URI
*Also may have:
#Focal neuro sx (ie seizure)
**Photophobia
#AMS (may be the only complaint esp in elderly)
**Vomiting
**Prodromal URI
**Focal neuro sx
 
== Physical Exam Findings ==


==Physical Exam Findings==
#Signs of Meningeal Irritation
#Signs of Meningeal Irritation
##''Kernigs'': passive knee extension while pt is supine causes neck pain and hamstring resistance
##Kernigs: passive knee extension while pt is supine causes neck pain and hamstring resistance
##''Brudzinski:'' when you flex pts neck you see involuntary flexion of b/l lower ext
##Brudzinski: when you flex pts neck you see involuntary flexion of b/l lower ext
#Jolt Test (100% Sn)
#Fever
#Fever
#Rash
#Rash
#Abnl Neuro exam (altered, focal cranial nerve defect)
#Abnl Neuro exam (altered, focal cranial nerve defect)
#papilledema 
#Papilledema / incr optic nerve diameter (UTZ)


==Differential Diagnosis==
== Differential Diagnosis ==
#encephalitis
#encephalitis
#brain mass
#brain mass
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#migraine
#migraine


==Orders/Workup==
== Orders/Workup ==
#isolation of patient (if suspect bacterial meningitis)
 
#cbc
#Droplet Precautions (if suspect bacterial meningitis)
#blood cultures
#CBC,&nbsp;Chemistry, coags
#coags
#Blood cx
#chem panel
#CT head
#CT head
##Consider LP w/o CT if:
#CXR (50% of pts w/pneumoccocal meningitis have e/o pna on CXR)  
###Normal mental status
###Normal neuro exam
###No immunocompromise
###No papilledema or normal optic nerve sheath diameter
#CXR (50% of pts w/ pneumoccocal meningitis have e/o pna on CXR)
#CSF studies
#CSF studies
##Glucose and protein (Tube 1)  
##Glucose and protein (Tube 1)
##Gram stain and culture (Tube 2)
##Gram stain and culture (Tube 2)
##Cell count and differential (Tube 3)
##Cell count and differential (Tube 3)
##Special studies if indicated (e.g. HSV PCR or india ink in HIV pt) - Tube 2  
##Special studies if indicated (HSV PCR, india ink) - Tube 2


== Interpreting CSF ==
== Interpreting CSF ==
{| style="width: 500px" border="1" cellpadding="1" cellspacing="1"
{| style="width: 500px" border="1" cellpadding="1" cellspacing="1"
|-
|-
| '''Measure<br/>'''
| '''Measure'''<br/>
| '''Bacterial<br/>'''
| '''Bacterial'''<br/>
| '''Viral<br/>'''
| '''Viral'''<br/>
| '''Fungal<br/>'''
| '''Fungal'''<br/>
| '''Neoplastic<br/>'''
| '''Neoplastic'''<br/>
|-
|-
| Opening Pressure<br/>
| Opening Pressure<br/>
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| <500<br/>
| <500<br/>
|-
|-
| % PMNs<br/>
| &nbsp;% PMNs<br/>
| >80%<br/>
| >80%<br/>
| 1-50%<br/>
| 1-50%<br/>
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|}
|}


==Treatment==
== Treatment ==
''Goal is to initiate treatment within 30 minutes of presentation (if pt is acutely ill). Abx given 2 hr prior to LP will NOT decrease the sensitivity of CSF culture''
*Give Abx as soon as possible
 
**Abx given 2hr prior to LP will not decrease Sn of CSF cx
===Antibiotics===
*CTX 2g, Vanco
#Ampicillin + cefotaxime or amp +gent
**If young or old (age >60): add ampicillin for listeria coverage
#Ampicillin + Cefotax or Ceftriaxone
**If e/o AMS, neuro deficits: add acyclovir for HSV
#Cefotax or Ceftriaxone </nowiki></font></font></span>
**If recent hospitalization: switch CTX to cefepime or imipenem for pseudomonas coverage
#''Adults'': Cefotaxime or ceftriaxone + vanco; Add Ampicillin if Listeria suspected
**If immunocompromised and suspect TB: add rifampin
 
**if immunocompromised and suspect fungal: add amphotericin
===Steroids===
(Dexamethasone 0.15mg/kg Q6hrsx4dys; 10mg max) --give 15-20 minutes before antibiotics
#Neonates (<6wks) --> No
#Infants/child --> Yes
#Adults --> Yes
^prior to or with abx = only group w/ benefit


==Prophylaxis==
=== Steroids ===
Cipro 500mg PO x 1 or rifampin x 4 doses or ceftriaxone x1
*Give prior to or w/ abx
*Dexamethasone 0.15mg/kg Q6hr x4d (10mg max)
*Do not give to neonates (<6wk)


*For N. meningitis
== Prophylaxis ==
*Rx primary caregivers (those in close contact to nasopharyngeal secretions or those who were with the patient at least 4 hours during week before onset of symptoms)
*For N. meningitis exposure
**Close contact to nasopharyngeal secretions or those who were w/ the pt at least 4hr during week before onset of symptoms
**Cipro 500mg PO x 1 or rifampin x 4 doses or ceftriaxone x1


[[Category:ID]]
<br/>[[Category:ID]] <br/><br/>

Revision as of 21:05, 27 June 2011

Classification

  1. Acute (<24 hrs): usually bacterial in origin (25%)
  2. Subacute (1-7 days): viral or bacterial
  3. Chronic (>7 days): viral, TB, syphilis, fungi, carcinomatous

Risk Factors

  1. Age >60 or <5
  2. Immunosuppressed/Immunocompromised (DM, adrenal insufficiency, HIV, cystic fibrosis, pts on steroids, Sickle Cell, etc)
  3. Crowding (military, dormitory)
  4. Alcoholism/cirrhosis
  5. Recent exposure to someone with meningitis
  6. Contiguous infection/ dural defect (traumatic, surgical (VP shunt))
  7. IVDA/endocarditis
  8. Malignancy

Signs/Symptoms

  • Almost all patients present w/ at least 2 of the following:
    • Headache
    • Fever
    • Neck stiffness
    • Altered mental status
  • Also may have:
    • Photophobia
    • Vomiting
    • Prodromal URI
    • Focal neuro sx

Physical Exam Findings

  1. Signs of Meningeal Irritation
    1. Kernigs: passive knee extension while pt is supine causes neck pain and hamstring resistance
    2. Brudzinski: when you flex pts neck you see involuntary flexion of b/l lower ext
  2. Jolt Test (100% Sn)
  3. Fever
  4. Rash
  5. Abnl Neuro exam (altered, focal cranial nerve defect)
  6. Papilledema / incr optic nerve diameter (UTZ)

Differential Diagnosis

  1. encephalitis
  2. brain mass
  3. brain abscess
  4. subarachnoid hemorrhage
  5. migraine

Orders/Workup

  1. Droplet Precautions (if suspect bacterial meningitis)
  2. CBC, Chemistry, coags
  3. Blood cx
  4. CT head
    1. Consider LP w/o CT if:
      1. Normal mental status
      2. Normal neuro exam
      3. No immunocompromise
      4. No papilledema or normal optic nerve sheath diameter
  5. CXR (50% of pts w/ pneumoccocal meningitis have e/o pna on CXR)
  6. CSF studies
    1. Glucose and protein (Tube 1)
    2. Gram stain and culture (Tube 2)
    3. Cell count and differential (Tube 3)
    4. Special studies if indicated (HSV PCR, india ink) - Tube 2

Interpreting CSF

Measure
 Bacterial
 Viral
 Fungal
 Neoplastic
Opening Pressure
 ↑↑ Normal, mild ↑ Normal, mild ↑ Normal, mild ↑
Cell Count
 >1000
 <1000
 <500
 <500
 % PMNs
 >80%
 1-50%
 1-50%
 1-50%
Glucose
 <40
 >40
 <40
 <40
Protein
 >200
 <200
 >200
 >200
Gram Stain
 + (80% effective)
 neg
 AFB, India ink

Treatment

  • Give Abx as soon as possible
    • Abx given 2hr prior to LP will not decrease Sn of CSF cx
  • CTX 2g, Vanco
    • If young or old (age >60): add ampicillin for listeria coverage
    • If e/o AMS, neuro deficits: add acyclovir for HSV
    • If recent hospitalization: switch CTX to cefepime or imipenem for pseudomonas coverage
    • If immunocompromised and suspect TB: add rifampin
    • if immunocompromised and suspect fungal: add amphotericin

Steroids

  • Give prior to or w/ abx
  • Dexamethasone 0.15mg/kg Q6hr x4d (10mg max)
  • Do not give to neonates (<6wk)

Prophylaxis

  • For N. meningitis exposure
    • Close contact to nasopharyngeal secretions or those who were w/ the pt at least 4hr during week before onset of symptoms
    • Cipro 500mg PO x 1 or rifampin x 4 doses or ceftriaxone x1




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