Meningitis: Difference between revisions
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*Viral meningitis | *Viral meningitis | ||
**Echo, coxsackie, entero (85%) | **Echo, coxsackie, entero (85%) | ||
**[[HSV]], [[CMV]], [[Herpes | **[[HSV]], [[CMV]], [[Herpes B]] | ||
===Pathophysiology=== | ===Pathophysiology=== |
Revision as of 19:51, 11 September 2015
Background
Microbiology
- Bacterial meningitis:
- Pneumococcus (60%), meningococcus (15%), GBS (15%), H flu (7%), listeria (2%)
- Viral meningitis
Pathophysiology
- Hematogenous spread via respiratory tract
- Contiguous spread (otitis media, sinusitis, brain abscess)
Risk Factors
- Otitis Media
- Sinusitis
- Immunosuppression/splenectomy
- Alcoholism
- Pneumonia
- Diabetes Mellitus
- CSF leak
- Endocarditis
- Neurosurgical procedure / head injury
- Indwelling neurosurgical device / cochlear implant
- Malignancy
- Drug induced aseptic meningitis
- NSAIDs
- Antimicrobials, see above page for list
Classification
- Acute (<24hr)
- Usually bacterial in origin (25%)
- Subacute (1-7d)
- Viral or bacterial
- Chronic (>7d)
Clinical Features
Almost all adults present with at least 2 of the following:[1]
- Headache
- Fever
- Neck stiffness
- Altered Mental Status
Other nonspecific symptoms include:
- Photophobia
- Vomiting
- Prodromal URI
- Focal neuro sx (e.g. CN deficit)
- Seizures
Differential Diagnosis
Headache
Common
Killers
- Meningitis/encephalitis
- Myocardial ischemia
- Retropharyngeal abscess
- Intracranial Hemorrhage (ICH)
- SAH / sentinel bleed
- Acute obstructive hydrocephalus
- Space occupying lesions
- CVA
- Carbon monoxide poisoning
- Basilar artery dissection
- Preeclampsia
- Cerebral venous thrombosis
- Hypertensive emergency
- Depression
Maimers
- Giant cell arteritis of temporal artery (temporal arteritis)
- Idiopathic intracranial hypertension (Pseudotumor Cerebri)
- Acute Glaucoma
- Acute sinusitis
- Cavernous sinus thrombosis or cerebral sinus thrombosis
- Carotid artery dissection
Others
- Trigeminal neuralgia
- TMJ pain
- Post-lumbar puncture headache
- Dehydration
- Analgesia abuse
- Various ocular and dental problems
- Herpes zoster ophthalmicus
- Herpes zoster oticus
- Cryptococcosis
- Febrile headache (e.g. pyelonephritis, nonspecific viral infection)
- Ophthalmoplegic migraine
- Superior Vena Cava Syndrome
Aseptic Meningitis
- Viral
- Tuberculosis
- Lyme disease
- Syphilis
- Leptospirosis
- Fungal (AIDS, transplant, chemotherapy, chronic steroid use)
- Noninfectious
Altered mental status and fever
- Infectious
- Sepsis
- Meningitis
- Encephalitis
- Cerebral malaria
- Brain abscess
- Other
Diagnosis
Finding | Description | Sensitivity | Specificity |
Nuchal rigidity |
|
13%[2] | 80% [2] |
Kernig's sign |
|
2%[2] | 97%[2] |
Brudzinski's sign |
|
2%[2] | 98%[2] |
Jolt Test |
|
100%?^ |
^Although a 1991 study[3] showed high sensitivity with this test, multiple newer studies have cast doubt on its sensitivity[4][5]. Although it may be clinically useful in the right subset of patients, it should not be considered to be 100% sensitive.
Work-Up
- CBC
- Chem
- Blood cx
- ?CT head: See CT Before Lumbar Puncture
- CXR (50% of pts w/ pneumoccocal meningitis have e/o pna on CXR)
- Lumbar Puncture
Lumbar Puncture Diagnosis
Measure | Normal | Bacterial | Aseptic (Viral) | Fungal | Tuberculosis | Subarachnoid hemorrhage | Neoplastic |
Appearance | Clear | Clear, cloudy, or purulent | Clear | Clear or opaque | Clear or opaque | Xanthochromia, bloody, or clear | Clear or opaque |
Opening Pressure (cm H2O) | 10-20 | >25 | Normal or elevated | >25 | >25 | >25 | Normal or elevated |
WBC Count^ (cells/µL) | 0-5^ | >100^ | 5-1000 | <500 | 50-500 | 0-5 (see correction section) | <500 |
% PMNs | >80-90% | 1-50%^^ | 1-50% | Early PMN then lymph | 1-50% | ||
Glucose | >60% of serum glucose | Low | Normal | Low | Low | Normal | Normal |
Protein^^^ (mg/dL) | < 45 | Elevated | Elevated | Elevated | Elevated | Elevated | >200 |
Gram Stain | Neg | Pos | Neg | India ink | Tb stain | Blood |
- ^Normal or lower WBC results may be found in immunocompromised, early, or partially treated (e.g. with oral antibiotics) bacterial menintigis, and those with tuberculosis meningitis
- ^^Lymph predominance may be found in patients with early bacterial meningitis or those that have been partially treated (e.g. with oral antibiotics)
- ^^^For unexplained elevations of protein, consider encephalitis, MS, Guillian Barre
Corrections
- WBC correction (for bloody tap)
- Simplified version (if peripheral WBC and RBC counts are within normal limits):
- Subtract 1 WBC for every 750 RBC in CSF
- Complex version (WBC and/or RBC not within normal limits):
- "WBCs added" = WBC(blood) x [RBC(CSF) / RBC(blood)]
- WBC counted/resulted - "WBCs added" = actual WBC
- Simplified version (if peripheral WBC and RBC counts are within normal limits):
- Protein correction (for bloody tap)
- For each 1000 RBC decrease protein value by 1mg/dl
Management
Antibiotics
- Give as soon as possible (if LP performed w/in 2hr of antibiotics, CSF culture will not be affected)
Neonates (up to 1 month of age)[6]
MRSA is uncommon in the neonate
- Ampicillin 75mg/kg IV q6hrs PLUS
- Cefotaxime 50mg/kg IV q6hrs OR Gentamicin 2.5mg/kg IV q8hrs
- Per AAP, ceftazidime 50mg/kg IV (q12hr for babies < 8 days of age, q8hr for >7 days old) is a reasonable alternative to cefotaxime, offering virtually the same coverage for enteric bacilli and is FDA approved for all age groups[7]
- If suspecting S. pneumoniae or MRSA, add Vancomycin
- Consider acyclovir for HSV
> 1 month old[8]
- Ceftriaxone 2gm (50mg/kg) IV BID daily PLUS
- Vancomycin 15-20 mg/kg IV BID daily
- Vancomycin is for resistant Pneumococcus
Adult < 50 yr[9]
- Ceftriaxone 2gm (50mg/kg) IV BID daily PLUS
- Vancomycin 15-20 mg/kg IV BID daily
- Vancomycin is for resistant Pneumococcus
Adult > 50 yr and Immunocompromised[10]
- Ceftriaxone 2gm (50mg/kg) IV BID daily PLUS
- Vancomycin 15-20 mg/kg IV BID daily PLUS
- Ampicillin 2gm IV q4h (hourly if listeria suspected)[11]
Post Procedural (or penetrating trauma)[12]
- Vancomycin 15-20mg/kg IV BID daily PLUS
- Cefepime 2g (50mg/kg) IV q8 hours daily OR Ceftazidime 2g (50mg/kg) IV q8 hours daily OR Meropenem 2gm (40mg/kg) IV q8 hours daily
Cryptococcosis Meningitis
Options
- Amphotericin B 1mg/kg IV once daily AND Flucytosine 25mg/kg PO q6hrs daily
- Amphotericin B 5mg/kg IV once daily AND Flucytosine 25mg/kg PO q6hrs daily
Meningitis with severe PCN allergy
- Chloramphenicol 1g IV q6h + Vancomycin 15mg/kg q8-12hr
Meningitis with VP shunt
- Coverage for skin contaminants (S. epidermis, S. aureus)
- Vancomycin plus ceftriaxone plus shunt removal
Neisseria meningitidis Prophylaxis
- Ceftriaxone 250mg IM once (if less than 15yr then 125mg IM)
- Ciprofloxacin 500mg PO once
- Rifampin 600 mg PO BID x 2 days
- if < 1 month old then 5mg/kg PO BID x 2 days
- if ≥ 1 month old then 10mg/kg (max at 600mg) PO BID x 2 days
Steroids
- Dexamethasone
- Only give prior to or with first dose of antibiotics
- 10mg IV q6hr x4d
The only benefit is shown in patients with meningitis from Streptococcus pneumoniae with a possible mortality benefit and a decrease in hearing loss[13]
AntiVirals
- Acyclovir
- Consider for pts w/ suspected viral meningitis who present w/ neurologic deficits
- 10mg/kg IV q8hr (Obese patients should be dosed using ideal body weight)
Osmotics
- Mannitol
- Rarely used
- Only for marked cerebral edema
Prophylaxis
- For meningococcus exposure
- Indications:
- Household contacts
- School or day care contacts in previous 7d
- Direct exposure to pt's secretions (kissing, shared utensils or toothbrush)
- Intubation without facemask
- Meds
- Rifampin 600mg PO BID x2d OR ceftriaxone 250mg IM x1 OR ciprofloxacin 500mg PO x1
- Indications:
Disposition
Bacterial meningitis
- Admit with droplet precautions
Viral meningitis
- Admit for empiric antibiotics until culture results return OR
- Discharge w/ 24hr f/u
See Also
References
- ↑ van de Beek D. et al. Clinical features and prognostic factors in adults with bacterial meningitis. N Engl J Med. 2004 Oct 28. 351(18):1849-59.
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Nakao JH, et al. Jolt accentuation of headache and other clinical signs: poor predictors of meningitis in adults. Am J Emerg Med. 2014;32(1):24-28.
- ↑ Jolt accentuation of headache: the most sensitive sign of CSF pleocytosis. Headache. 1991 Mar;31(3):167-71.
- ↑ Absence of jolt accentuation of headache cannot accurately rule out meningitis in adults. Am J Emerg Med. 2013 Nov;31(11):1601-4
- ↑ Jolt accentuation of headache and other clinical signs: poor predictors of meningitis in adults. Am J Emerg Med. 2014 Jan;32(1):24-8
- ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
- ↑ https://www.aappublications.org/content/early/2015/02/25/aapnews.20150225-1
- ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
- ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
- ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
- ↑ [Guideline] Chaudhuri A, Martinez-Martin P, Kennedy PG, et al. EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. Eur J Neurol. 2008 Jul. 15(7):649-59.
- ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
- ↑ Brouwer MC, McIntyre P, de Gans J, Prasad K, van de Beek D. Corticosteroids for Acute Bacterial Meningitis. Cochrane Database of Systematic Reviews 2010, Issue 9.