approach to meningitis and encephalitis

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Khushbu on Jul 18, 2012 Says :

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MENINGITIS AND ENCEPHALITIS DR.VIVEK BAXI

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Meningitis:-infection or inflammation of the meninges and subarachnoid space. Encephalitis:-infection of the brain parenchyma with focal neurological signs.

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Case-1 62 year old female , brought to hospital in unresponsive state. she had c/o-headache since last 2 days ,fever with chills and cough(yellowish sputum) since last 4 days. O/E-Temp-103.6°F,diaphoretic,unresponsive, HR-110/min, BP-110/80mmhg, RS-RT.lower zone crepitations +, CNS-neck rigidity+, Brudzinski sign+, fundi showed flat disks but absent venous pulsations. Blood cultures were obtained. WHAT IS YOUR DIAGNOSIS?

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Meningitis:- Questions :- What features help in diagnosis? Can we ascertain etiology? When is a CT BRAIN necessary? Is lumbar puncture safe in these patients? What antibiotics should we use? What about steroids? What are the complications?

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Can we ascertain etiology? BACTERIAL CAUSES :-

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ORGANISM Pneumococcus Meningococcus Enteric gram neg Staph aureus Listeria FEATURE Associated sinusitis, OM,pneumonia Petechiae,hypotension Diabetics, alcoholics Post operative , trauma Food borne spread

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Viruses:-

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What features help in diagnosis?

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Kernig’s Sign

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Brudzinski’s Sign

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Disease that can mimic as viral meningitis or encephalitis

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INVESTIGATIONS:- CBC CT BRAIN LP-CSF ? Gram stain, cell count with differential, protein and glucose concentration with simultaneous blood glucose level.culture and PCR. Blood cultures Relevant Routine investigations -CXR,RFT,LFT,ABG

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Investigations When is a CT SCAN necessary?

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Risk factors for abnormal CT Age > 60 Immunocompromised Hx of CNS disease Seizures w/in 1 wk of presentation Neurologic abnormalities at presentation: LOC, inability to answer 2 consecutive questions appropriately, abnormal visual fields, facial palsy, arm drift, leg drift, abnormal language

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MRI with gadolinium contrast is more sensitive than CT . Focal abnormalities on MRI may suggest particular diagnoses. T2-weighted MRI Showing-hyperintensity In left temporal lobe in a patient with HSV -1 encephalitis.

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Is lumbar puncture safe in these patients?

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Contraindications to LP Absolute: Skin infection over site Papilledema, focal neurological signs, Relative: Increased ICP without papilledema Suspicion of mass lesion Spinal cord tumor Spinal epidural abscess Bleeding diathesis or ? plts

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CSF:- Should be examined within 90 minutes of collection. CSF glucose concentrations will be higher in moderately to severely hyperglycemic patients. In these patients, the CSF:blood glucose ratio should be used to determine true CSF glucose concentration. The CSF glucose concentration is low when the CSF:blood glucose ratio is <0.6 .

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CSF interpretation

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Cell Count:- Normal: Up to 5 WBCs / HPF in adults Bacterial meningitis 75% have > 1000 WBCs / mm3 99% have > 100 WBCs / mm3 Traumatic tap: Allow 1 WBC for every 500-1000 RBCs Protein Level:- Subtract 0.01 g/L for every 1000 RBCs / mm3

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Aseptic meningitis Bacteria can not be isolated from the CSF. D/D:- 1) viral meningitis 2)partially treated bacterial meingitis 3)tuberculous meningitis 4)fungal meningitis 5)lymphoma 6)sarcoidosis 7)other collagen vascular disease.

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Management:- What antibiotics should we use?

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An association is found between delays in administering antibiotics longer than 6 hours after arrival in ER and death. Antibiotics should be given as soon as possible, even before CT and LP done.

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Tuberculous meningitis

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Duration of treatment Pathogen Duration of Rx (d) H. influenzae 7 N. meningitidis 7 S. pneumoniae 10-14 L. monocytogenes 14-21 Group B strep 14-21

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Treatment of viral encephalitis HSV-1 encephalitis is treated with i.v acyclovir-10 mg/kg every 8 hours for 3 weeks. Varicella zoster virus encephalitis is treated with i.v acyclovir-10 mg/kg every 8 hours for 10-14 days. Rocky mountain spotted fever –doxycycline 100 mg twice daily for at least 3 days after the patient becomes afebrile. CMV encephalitis-i.v foscarnet-60 mg/kg every 8 hours and i.v ganciclovir-5 mg/kg every 12 hours.

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When should corticosteroids be administered?

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All patients presenting with suspected bacterial meningitis should receive dexamethasone prior to or with the first dose of antibiotics. Dosage-0.6 mg/kg, total dose daily -6 hourly –for 4 days.

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Supportive treatment Anticonvulsants- benzodiazepines, phenytoin. Treat raised ICP i.v fluids Respiratory support when needed.

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Complications: Seizures Hydrocephalus Infarction Herniation

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Complications during clinical course Cardiorespiratory 29% Hyponatremia 26% Seizures 15-23% Hearing loss 14% Cognitive impairment 10% Arterial infarction 10-15%

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Preventing an epidemic… Prophylaxis Who? Anyone with close contact for > 4hrs during the week before onset of illness. Exposure to patient’s oropharyngeal secretions. What? Rifampin 10 mg/kg PO q12h x 2 days.

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THANK YOU

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HOW TO DIAGNOSE?,HOW TO TREAT?WHEN TO TREAT?
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