Meningitis: Difference between revisions

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==Classification==
#Acute (<24 hrs)
##Usually bacterial in origin (25%)
#Subacute (1-7 days)
##Viral or bacterial
#Chronic (>7 days)
##Viral, TB, syphilis, fungi, carcinomatous


== Risk Factors ==
==Background==
#Age >60 or <5
*Microbiology
#Immunosuppressed/Immunocompromised (DM, adrenal insufficiency, HIV, cystic fibrosis, pts on steroids, Sickle Cell, etc)
**Bacterial meningitis:
#Crowding (military, dormitory)
***Pneumococcus (60%), meningococcus (15%), GBS (15%), H flu (7%), listeria (2%)
#Alcoholism/cirrhosis
*Pathophysiology
#Recent exposure to someone with meningitis
**Hematogenous spread via respiratory tract OR
#Contiguous infection/ dural defect (traumatic, surgical (VP shunt))
**Contiguous spread (otitis media, sinusitis, brain abscess)
#IVDA/endocarditis
 
===Risk Factors===
#Otitis media
#Sinusitis
#Immunosuppression/splenectomy
#Alcoholism
#Pneumonia
#DM
#CSF leak
#Endocarditis
#Neurosurgical procedure / head injury
#Indwelling neurosurgical device / cochlear implant
#Malignancy
#Malignancy


== Signs/Symptoms ==
== Clinical Features ==
*Almost all patients present w/ at least 2 of the following:
*Almost all patients present w/ at least 2 of the following:
**Headache
**Headache
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**Vomiting
**Vomiting
**Prodromal URI
**Prodromal URI
**Focal neuro sx
**Focal neuro sx (e.g.CN deficit)
**Seizure (25%)
*Jolt Test (100% Sn)
**Have pt rapidly shake head L and R; if does not bother pt unlikely to have meningitis
 
 
==Classification==
#Acute (<24hr)
##Usually bacterial in origin (25%)
#Subacute (1-7d)
##Viral or bacterial
#Chronic (>7d)
##Viral, TB, syphilis, fungi, carcinomatous
 
 


== Physical Exam Findings ==


#Signs of Meningeal Irritation
##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
#Jolt Test (100% Sn)
#Fever
#Rash
#Abnl Neuro exam (altered, focal cranial nerve defect)
#Papilledema / incr optic nerve diameter (UTZ)


== Differential Diagnosis ==
== Differential Diagnosis ==
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#migraine
#migraine


== Orders/Workup ==
== Work-Up ==
 
#Droplet precautions (if suspect bacterial meningitis)
#Droplet Precautions (if suspect bacterial meningitis)
#CBC, chemistry, coags
#CBC,&nbsp;Chemistry, coags
#Blood cx
#Blood cx
#CT head
#CT head
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== Treatment ==
== Treatment ==
*Antibiotics
#Abx
**Give as soon as possible
##Give as soon as possible (if given w/in 2hr of LP CSF culture will not be affected)
**Abx given 2hr prior to LP will not decrease Sn of CSF cx
##Vancomycin for penicillin-resistant pneumococci; ampicillin for listeria
*CTX 2g, Vanco
##Guidelines
**If young or old (age >60): add ampicillin for listeria coverage
###Age 18-50y
**If e/o AMS, neuro deficits: add acyclovir for HSV
####CTX 2gm IV q12hr + vancomycin 15mg/kg q8-12hr
**If recent hospitalization: switch CTX to cefepime or imipenem for pseudomonas coverage
###Age >50y
**If immunocompromised and suspect TB: add rifampin
####CTX 2gm IV q12hr + vancomycin 15mg/kg q8-12hr + ampicillin 2gm IV q4h
**if immunocompromised and suspect fungal: add amphotericin
###CSF leak w/ history of closed head trauma
*Steroids
####CTX 2gm IV q12hr + vancomycin 15mg/kg q8-12hr
**Give prior to or w/ abx
###History of recent penetrating head injury, neurosurgery, CSF shunt
**Dexamethasone 0.15mg/kg Q6hr x4d (10mg max)
####Vanco 25 milligrams/kg load + (ceftazidime 2gm IV q8hr or ceftazidime or meropenem)
**Do not give to neonates (<6wk)
#Dexamethasone
##Only give prior to or w/ first dose of abx
##10mg IV q6hr x4d
 
 


== Prophylaxis ==
== Prophylaxis ==
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**Close contact to nasopharyngeal secretions or those who were w/ the pt at least 4hr during week before onset of symptoms
**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
**Cipro 500mg PO x 1 or rifampin x 4 doses or ceftriaxone x1
==Source==
Tintinalli


[[Category:ID]]
[[Category:ID]]

Revision as of 02:29, 10 October 2011

Background

  • Microbiology
    • Bacterial meningitis:
      • Pneumococcus (60%), meningococcus (15%), GBS (15%), H flu (7%), listeria (2%)
  • Pathophysiology
    • Hematogenous spread via respiratory tract OR
    • Contiguous spread (otitis media, sinusitis, brain abscess)

Risk Factors

  1. Otitis media
  2. Sinusitis
  3. Immunosuppression/splenectomy
  4. Alcoholism
  5. Pneumonia
  6. DM
  7. CSF leak
  8. Endocarditis
  9. Neurosurgical procedure / head injury
  10. Indwelling neurosurgical device / cochlear implant
  11. Malignancy

Clinical Features

  • 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 (e.g.CN deficit)
    • Seizure (25%)
  • Jolt Test (100% Sn)
    • Have pt rapidly shake head L and R; if does not bother pt unlikely to have meningitis


Classification

  1. Acute (<24hr)
    1. Usually bacterial in origin (25%)
  2. Subacute (1-7d)
    1. Viral or bacterial
  3. Chronic (>7d)
    1. Viral, TB, syphilis, fungi, carcinomatous



Differential Diagnosis

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

Work-Up

  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

  1. Abx
    1. Give as soon as possible (if given w/in 2hr of LP CSF culture will not be affected)
    2. Vancomycin for penicillin-resistant pneumococci; ampicillin for listeria
    3. Guidelines
      1. Age 18-50y
        1. CTX 2gm IV q12hr + vancomycin 15mg/kg q8-12hr
      2. Age >50y
        1. CTX 2gm IV q12hr + vancomycin 15mg/kg q8-12hr + ampicillin 2gm IV q4h
      3. CSF leak w/ history of closed head trauma
        1. CTX 2gm IV q12hr + vancomycin 15mg/kg q8-12hr
      4. History of recent penetrating head injury, neurosurgery, CSF shunt
        1. Vanco 25 milligrams/kg load + (ceftazidime 2gm IV q8hr or ceftazidime or meropenem)
  2. Dexamethasone
    1. Only give prior to or w/ first dose of abx
    2. 10mg IV q6hr x4d


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

Source

Tintinalli

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