Meningitis: Difference between revisions

(Created page with "Def: inflammation of the leptomeninges and underlying subarachnoid CSF 3 types: * acute (<24 hrs): usually bacterial in origin (25%) * subacute (1-7 days): viral or bacteria...")
 
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Def: inflammation of the leptomeninges and underlying subarachnoid CSF
Classification


   
   


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


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* 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)
* Crowding (military, college dorm rooms)
* Crowding (military, dormitory)
* Alcoholism/cirrhosis
* Alcoholism/cirrhosis
* Recent exposure to someone with meningitis
* Recent exposure to someone with meningitis
* Contiguous infection Dural defect (traumatic, surgical (VP shunt))
* Contiguous infection/ dural defect (traumatic, surgical (VP shunt))
* Thalassemia major  IVDA Endocarditis  Malignancy
* IVDA/endocarditis
* Malignancy
   
   


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* Rash
* Rash
* Abnl Neuro exam (altered, focal cranial nerve defect)
* Abnl Neuro exam (altered, focal cranial nerve defect)
* papillaedema  
* papilledema  
   
   


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* CXR (50% of pts w/pneumoccocal meningitis have e/o pna on CXR)  
* CXR (50% of pts w/pneumoccocal meningitis have e/o pna on CXR)  
* CSF studies
* CSF studies
* cell count
* Glucose and protein (Tube 1)
* gram stain
* Gram stain and culture (Tube 2)
* culture
* Cell count and differential (Tube 3)
* glucose
* Special studies if indicated (e.g. HSV PCR or india ink in HIV pt) - Tube 2
* protein
* special studies if indicated (i.e. HSV PCR or india ink in HIV pt)  
 
Interpreting CSF
Interpreting CSF


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Treatment
Treatment


Goal is to initiate treatment within 30 minutes of presentation (if pt is acutely ill). Abx givein 2 hr prior to LP will NOT decrease the sensitivity of CSF culture
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


Antibiotics
Antibiotics
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Adults --> Yes
Adults --> Yes


*prior to or with abx = only group w/ benifit
*prior to or with abx = only group w/ benefit


   
   
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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




Revision as of 23:40, 1 March 2011

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:

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


Signs/Symptoms:

  • Headache
  • Nuchal rigidity (may not be present in those with AMS)
  • Fevers/chills
  • Photophobia
  • Vomiting
  • Prodromal URI
  • Focal neuro sx (ie seizure)
  • AMS (may be the only complaint esp in elderly)


Physical Exam Findings

  • Signs of Meningeal Irritation:
  • Kernigs: passive knee extension while pt is supine causes neck pain and hamstring resistanc
  • Brudzinski: when you flex pts neck you see involuntary flexion of b/l lower ext
  • Fever
  • Rash
  • Abnl Neuro exam (altered, focal cranial nerve defect)
  • papilledema


Differential Diagnosis:

  • encephalitis
  • brain mass
  • brain abscess
  • subarachnoid hemorrhage
  • migraine


Orders/Workup

  • isolation of patient (if suspect bacterial meningitis)
  • cbc
  • blood cultures
  • coags
  • chem panel
  • CT head
  • CXR (50% of pts w/pneumoccocal meningitis have e/o pna on CXR)
  • CSF studies
  • Glucose and protein (Tube 1)
  • Gram stain and culture (Tube 2)
  • Cell count and differential (Tube 3)
  • Special studies if indicated (e.g. HSV PCR or india ink in HIV pt) - Tube 2


Interpreting CSF


Bacterial Viral Fungal Neoplastic Opening Pressure ↑↑ Normal, mild ↑ Normal, mild ↑ Normal, mild ↑ Cell Cnt >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

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

Antibiotics

  • Neonates: Ampicillin + cefotaxime or amp +gent
  • Infants(3 mo): Ampicillin + Cefotax or Ceftriaxone
  • Children: Cefotax or Ceftriaxone
  • Adults: Cefotaxime or ceftriaxone + vanco; Add Ampicillin if Listeria suspected


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 (N. meningit)

  • 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)

Cipro 500mg PO x 1 or rifampin x 4 doses or ceftriaxone x1

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