Acute Bacterial Meningitis

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1 : Meningitis Gary R. Skankey, MD, FACP
2 : Causes of Meningitis Bacteria Community-acquired - S. pneumoniae, N. meningitidis, gp B streptococcus Post-op or hospital acquired – MRSA, Ps. Aeruginosa In the very young and very old Listeria monocytogenes Viruses Enterovirus, coxsackie virus, echovirus, HSV-2, etc Fungi Coccidioides, cryptococcus TB
3 : Clincal Presentation Acute meningitis Abrupt or rapid onset “flu-like” prodrome – myalgias Fever Headache Nucal stiffness Altered sensorium (meningo-encephalitis) Rash
4 : Clinical Presentation Chronic meningitis Insidious, gradual onset Weeks of headache Low grade fever Sweats, chills Weight loss
5 : Acute Meningitis
6 : Physical Exam Koenig-Brudzinski’s sign – uncommon Nucal rigidity – common Photophobia – common Rash - uncommon
7 :
8 :
9 : Lab CT head – r/o cerebritis, brain abscess, brain edema Lumbar puncture Pleocytosis High protein Low glucose (CSF:serum glucose < 50%) Bacterial antigens – more sensitive in children Gram stain and culture
10 :
11 : Treatment Ceftriaxone 2 gm IV Q 12, or Cefotaxime 2 gm IV Q 4, plus Vancomycin 1.5 gm IV Q 12 In the very young or very old add Ampicillin 2 gm IV Q 4 If pcn allergic, ask for details: Rash : use cephalosporin Anaphylactic : use Aztreonam 2 gm IV Q 8
12 : IN The ER 1st step – Give antibiotics ASAP 2nd step – draw labs 3rd step – CT head 4th step - LP
13 : Prevention Vaccines Pneumovax Meningicoccal vaccine Both should be administered to any asplenic patient Exposure to meningococcus Rifampin 600 mg PO BID x 4 doses Only for intimate contacts: spouse, boyfriend/girlfriend, household contacts Not needed for: classmates, co-workers, HCWs (ER personnel, EMTs, etc)
14 : Viral Meningitis 75% caused by enteroviruses Enterovirus Coxsackie virus Echo virus Other viruses HSV2 (HSV1 causes encephalitis) HIV Lymphocytic choriomeningitis virus Mumps Varicella Zoster
15 : Viral Meningitis Cannot distinguish initially from bacterial meningitis Severe HA, photophobia, nucal rigidity, fever May be preceded by a few weeks by viral gastroenteritis Ask pt is he/she had the “stomach flu” some time in the past couple weeks Almost never involves brain (meningoencephalitis) Pt never obtunded, no Hx of seizure Disease is self-limited, resolves after 7 to 10 days without treatment No serious sequelae
16 : CSF Low numbers of WBCs : 10 to 500 PMNs predominate early, Monos or Lymphocytes later CSF to serum glucose ratio usually = 50% Protein may be high Gram stain, culture and bacterial antigens negative Enteroviral PCR positive about 70% of time
17 : Approach to Viral Meningitis Treat like bacterial meningitis until the 72 hr culture comes back negative, or… Enteroviral PCR comes back positive Consider acyclovir if CSF HSV PCR positive HSV meningitis is self-limited
18 : Chronic Meningitis
19 : Causes Cryptococcus Coccidioides immitis Mycobacterium tuberculosis Other fungal – histoplasmasma, blastomyces, sporotrix Other bacteria – brucella, francisella, nocardia, borellia Non-infectious – Wegener’s, sarcoid, malignanacy
20 : Presentation Insidious onset Low grade fever if any Persistant, worsening headache Photophobia and nucal rigidty usually absent Symptoms have usually lasted several weeks by the time diagnosis is made
21 : Diagnosis History Exposure to bird droppings (crypto) Travel to Arizona, Central Valley California, Desert Southwest (cocci) Contacts with TB pts CSF Modest pleocytosis Glucose may be normal, but protein usually high (very high if coccidioma causes CSF obstruction)
22 : Diagnosis TB CSF AFB smear usually negative AFB culture takes 6 weeks Positive PPD or quantiFERON may suggest diagnosis CSF PCR not standardized yet, but may be helpful; Cryptococcus India ink Cryptococcal Ag in CSF
23 : Diagnosis Coccidioidomycosis Difficult diagnosis to make CSF fungal smear and cultures usually negative Titers have high false negativity rate even from CSF Cocci CF titer from serum may give clue. Any pt with history of pulmonary cocci who develops HA with pleocytosis should be treated for cocci meningitis
24 : Treatment TB Treat like pulmonary TB: INH, Rif, Eth, PZA for two months, then INH, Rif to comlete 12 months Steroids – improves mortality, reduces adverse events (infarcts) Crytpococcus Amphotericin plus flucytosine for 6 weeks followed by fluconazole to complete 6 months High toxicity rate (renal failure, pancytopenia) High dose fluconazole (400 to 800 mg QD) if can’t tolerate ampho + 5FC Serial LPs to reduce CSF pressure and assure clearing of infection In AIDS pts – continue Fluconazole until CD4 >100
25 : Treatment Coccidioidomycosis Intrathecal amphotericin now rarely used Chemical arachnoiditis High dose fluconazole (800 to 1200 mg QD) Serial LPs to assure improvement of infection Incurable – symptoms may resolve, but patient can never stop fluconazole Taper down to no lower than 400 to 600 mg QD
26 : Recurrent meningitis Mollaret’s meningitis Most common cause is HSV2 Many other poorly defined causes as well Leaking arachnoid cyst Cryptogenic May respond to acyclovir
27 : Conclusion Acute bacterial meningitis is most commonly caused by viruses, then bacteria Chronic meningitis can be caused by fungi and TB Recurrent meningitis – Malloret’s Call ID when pt has meningitis


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