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Meningitis

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DEEPAK MEGHWAL
DEEPAK MEGHWAL

This case study describes a 22-year-old man who presented with headache, photophobia, pyrexia, and disorientation. His general practitioner diagnosed him with meningococcal meningitis based on his symptoms and stiff neck. He was given benzyl penicillin and admitted to the hospital, where tests would be done to confirm the diagnosis. On admission, he developed a non-blanching petechial rash and was hypotensive. Cerebrospinal fluid analysis and blood tests would be done, and the causative organism Neisseria meningitidis would likely be isolated from these samples, confirming meningococcal meningitis.

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CASE STUDY Represent by :- ROLL NO. :- 81 TO 93 MODERATOR :- DR.RISHI DIWAN SIR ( DEPARTMENT OF PATHOLPGY)
CASE STATEMENT A 22 YEARS OLD MAN WAS COMPLAINING OF A HEADACHE AND SAID THAT THE LIGHT HURT HIS EYES. HIS GP WAS CALLED AND OBSERVED THAT THE PATIENT WAS PYREXIAL AND DISORIENTATED AND HAD A STIFF NECK . A PROVISIONAL DIAGNOSIS OF MENINGOCOCCAL MENINGITIS WAS MADE. HE GAVE THE PATIENT AN INJECTION OF BENZYL PENICILLIN AND ARRANGED FOR ADMITION TO HOSPITAL . ON ADMITION TO HOSPITAL IT WAS NOTED THAT THE PATIENT DOVELOPED A PETECHIAL RESHS THAT DID NOT BLANCH ON PRESSURE AND HE WAS HYPOTENSIVE . BENZYL PENICILLIN WAS CONTINUED, AWAITING THE RESULT OF MICROBIOLOGY .PLEASE GIVE A DETAILED ACCOUNT OF INVESTIGATION AND LIKELY POSITIVE FINDING ON THIS CASE. WHAT SPECIAL TEST YOU WILL DO TO CONFIRM THE DIAGNOSIS.
CLINICAL FEATURES PRESENTED COMPLAINS AT TIME OF ADMITION - HEADACHE - PHOTO PHOBIA(LIGHT HURTS HIS EYES) - PYREXIA - DISORIENTATION - STIFF NECK
Probable diagnosis Headache with Photophobia shows that the person having a CNS problem and on calling General presentation pyrexia and disorientation (state of confusion ) also noted. CNS problems :- -Meningitis -Encephalitis -Brain abscess
Explaination of clinical presentation of patient Headache :- -Bacterial exotoxins, cytokines, and Intra Cranial Pressure stimulate nociceptors in the meninges . Stiff neck :- Flexion of the spine leads to stretching of the meninges because In meningitis, traction on the inflamed meninges is painful, resulting in limited range of motion through the cervical spine .
Photo phobia :- Due to meningal irritation and involvement of the trigeminal nerve. Pyrexia :- Endogenous cytokines affect the thermoregulatory neurons of the hypothalamus, changing the central regulation of body temprature. Bacteria produce exogenous substances (pyrogens) that can also re-set the hypothalamic thermal set point. DISORIENTATION :- ICP brain herniation damage to the reticular formation .
PETECHIAL RASH Due to Meningococcemia by causative agent N. meningitidis.
Meningitis transformation Meningitis Pachymeningitis Leptomeningitis Encephalitis Brain abscess (Tubular encephalitis,Neuro encephalitis)
Diagnosis CSF examination Blood test Diagnostic methods A careful evaluation of history A careful evaluation of infants signs and symptoms A careful evaluation of information on longitudinal changes in vital signs and laboratory indicators
Lumber Puncture for CSF examination
Cerebrospinal fluid (CSF) analysis may be used to help diagnose a wide variety of diseases and conditions affecting the brain and spinal cord (central nervous system). Infectious diseases such as meningitis and encephalitis.Testing is used to determine if infection is caused by bacteria,viruses or, less commonly, by Mycobacterium tuberculosis, fungi or parasites, and to distinguish them from other conditions.
Collection and transport of CSF CSF is collected in three sterile container, each one for cell count, biochemical analysis and bacteriological examination. Fluid should be examined immediately after collection or placed in incubator at 37*c. Transport of CSF to the lab must be as soon as possible. NOTE :- NEVER REFRIGRATE THE CSF AS H.INFLUENZAE MAY DIE.
Normal CSF EXAMINATION CSF opening pressure: 50180 mmH2O Glucose: 4085 mg/dL. Protein (total): 1545 mg/dL. Leukocytes (WBC): 05/袖L (adults / children); up to 30/袖L (newborns). Gram stain: negative. Culture: sterile. Specific gravity: 1.0061.009. Gross appearance: Normal CSF is clear and colourless. Differential: 6070% lymphocytes; up to 30% monocytes and macrophages; other cells 2% or less.
Bacterial Meningitis CSF opening pressure : increases Glucose (mg/dL):Normal to marked decrease. <40 mg/dL. Protein (mg/dL)(Marked increase) > 250 mg/Dl WBCs (cells/袖L)>500 (usually > 1000). Early: May be < 100. Cell differential :-Predominance of Neutrophils (PMNs) Culture :-Positive Opening Pressure:-Elevated Gram staining:- positive
Viral meningitis Opening CSF pressure :- normal or slightly increased CSF glucose :- Normal CSF protein :- slightly increased
Blood examination Blood tests are performed for markers of inflammation (e.g. C- reactive protein),as well as blood cultures.
Isolation of the organism from CSF or blood.
Neisseria Meningitides Bean shaped Gram negative Aerobic, F. anaerobes, diplococci Bacteria surrounded by outer membrane of lipids, membrane proteins and lipopolysaccharide.
The most important pathogen for meningitis is NEISSERIA MENINGITIDES because of its potential to cause epidemic. Meningococcal Meningitis
Etiology Neonates (<3 mo) Children Adults Elderly (>65) Group B Streptococcus Escherichia coli Staph. aureus Streptococcus pneumoniae (pneu mococcus) Neisseria meningitidis (meni ngococcus) Haemophilus influenzae type B (l ess common now with the advent of the HiB vaccination) Streptococcus pneumoniae Neisseria meningitidis (these two organisms cause 80% of cases) Streptococcus pneumoniae Neisseria meningitidis Listeria monocytogenes
Pathogenesis A offending bacterium from blood invades the leptomeninges. Bacterial toxics and Inflammatory mediators are released. Bacterial toxics Lipopolysaccharide, LPS Teichoic acid Peptidoglycan Inflammatory mediators Tumor necrosis factor, TNF Interleukin-1, IL-1 Prostaglandin E2, PGE2
Meningitis
The outer membrane is surrounded by a polysaccharide capsule that is necessary for pathogenecity because it helps the bacteria resist phagocytosis and complement-mediated lysis. The outer membrane proteins and the capsular polysaccharide make up the main surface antigens of the organism.
Pathogenesis Cont. to next 壊鉛庄糸艶..
Meningitis
Transmission & Communicability The main modes of transmission are direct contact and respiratory droplets. Close contact like living in close quarters (like hostel dormitories) and sharing of utensils enhance the risk of transmission The average incubation period is 3 - 4 days with a range of 2 to 10 days. This is also the period of communicability. The bacteria are rapidly eliminated from the nasopharynx after starting antibiotics, usually within 24 hours
Therapeutic principle Good permeability for Blood-brain barrier Drug combination Intravenous drip Full dosage Full course of treatment Treatment Antibiotic Therapy
Antibiotic Therapy Selection of antibiotic No Certainly Bacterium Community-acquired bacterial infection Nosocomial infection acquired in a hospital Broad-spectrum antibiotic coverage as noted below Children under age 3 months 損 Cefotaxime and ampicillin 損 Ceftriaxone and ampicillin (children over age 1months) Children over 3 months 損 Cefotaxime or Ceftriaxone or ampicillin and chloramphenicol
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Meningitis

  • 1. CASE STUDY Represent by :- ROLL NO. :- 81 TO 93 MODERATOR :- DR.RISHI DIWAN SIR ( DEPARTMENT OF PATHOLPGY)
  • 2. CASE STATEMENT A 22 YEARS OLD MAN WAS COMPLAINING OF A HEADACHE AND SAID THAT THE LIGHT HURT HIS EYES. HIS GP WAS CALLED AND OBSERVED THAT THE PATIENT WAS PYREXIAL AND DISORIENTATED AND HAD A STIFF NECK . A PROVISIONAL DIAGNOSIS OF MENINGOCOCCAL MENINGITIS WAS MADE. HE GAVE THE PATIENT AN INJECTION OF BENZYL PENICILLIN AND ARRANGED FOR ADMITION TO HOSPITAL . ON ADMITION TO HOSPITAL IT WAS NOTED THAT THE PATIENT DOVELOPED A PETECHIAL RESHS THAT DID NOT BLANCH ON PRESSURE AND HE WAS HYPOTENSIVE . BENZYL PENICILLIN WAS CONTINUED, AWAITING THE RESULT OF MICROBIOLOGY .PLEASE GIVE A DETAILED ACCOUNT OF INVESTIGATION AND LIKELY POSITIVE FINDING ON THIS CASE. WHAT SPECIAL TEST YOU WILL DO TO CONFIRM THE DIAGNOSIS.
  • 3. CLINICAL FEATURES PRESENTED COMPLAINS AT TIME OF ADMITION - HEADACHE - PHOTO PHOBIA(LIGHT HURTS HIS EYES) - PYREXIA - DISORIENTATION - STIFF NECK
  • 4. Probable diagnosis Headache with Photophobia shows that the person having a CNS problem and on calling General presentation pyrexia and disorientation (state of confusion ) also noted. CNS problems :- -Meningitis -Encephalitis -Brain abscess
  • 5. Explaination of clinical presentation of patient Headache :- -Bacterial exotoxins, cytokines, and Intra Cranial Pressure stimulate nociceptors in the meninges . Stiff neck :- Flexion of the spine leads to stretching of the meninges because In meningitis, traction on the inflamed meninges is painful, resulting in limited range of motion through the cervical spine .
  • 6. Photo phobia :- Due to meningal irritation and involvement of the trigeminal nerve. Pyrexia :- Endogenous cytokines affect the thermoregulatory neurons of the hypothalamus, changing the central regulation of body temprature. Bacteria produce exogenous substances (pyrogens) that can also re-set the hypothalamic thermal set point. DISORIENTATION :- ICP brain herniation damage to the reticular formation .
  • 7. PETECHIAL RASH Due to Meningococcemia by causative agent N. meningitidis.
  • 9. Diagnosis CSF examination Blood test Diagnostic methods A careful evaluation of history A careful evaluation of infants signs and symptoms A careful evaluation of information on longitudinal changes in vital signs and laboratory indicators
  • 10. Lumber Puncture for CSF examination
  • 11. Cerebrospinal fluid (CSF) analysis may be used to help diagnose a wide variety of diseases and conditions affecting the brain and spinal cord (central nervous system). Infectious diseases such as meningitis and encephalitis.Testing is used to determine if infection is caused by bacteria,viruses or, less commonly, by Mycobacterium tuberculosis, fungi or parasites, and to distinguish them from other conditions.
  • 12. Collection and transport of CSF CSF is collected in three sterile container, each one for cell count, biochemical analysis and bacteriological examination. Fluid should be examined immediately after collection or placed in incubator at 37*c. Transport of CSF to the lab must be as soon as possible. NOTE :- NEVER REFRIGRATE THE CSF AS H.INFLUENZAE MAY DIE.
  • 13. Normal CSF EXAMINATION CSF opening pressure: 50180 mmH2O Glucose: 4085 mg/dL. Protein (total): 1545 mg/dL. Leukocytes (WBC): 05/袖L (adults / children); up to 30/袖L (newborns). Gram stain: negative. Culture: sterile. Specific gravity: 1.0061.009. Gross appearance: Normal CSF is clear and colourless. Differential: 6070% lymphocytes; up to 30% monocytes and macrophages; other cells 2% or less.
  • 14. Bacterial Meningitis CSF opening pressure : increases Glucose (mg/dL):Normal to marked decrease. <40 mg/dL. Protein (mg/dL)(Marked increase) > 250 mg/Dl WBCs (cells/袖L)>500 (usually > 1000). Early: May be < 100. Cell differential :-Predominance of Neutrophils (PMNs) Culture :-Positive Opening Pressure:-Elevated Gram staining:- positive
  • 15. Viral meningitis Opening CSF pressure :- normal or slightly increased CSF glucose :- Normal CSF protein :- slightly increased
  • 16. Blood examination Blood tests are performed for markers of inflammation (e.g. C- reactive protein),as well as blood cultures.
  • 17. Isolation of the organism from CSF or blood.
  • 18. Neisseria Meningitides Bean shaped Gram negative Aerobic, F. anaerobes, diplococci Bacteria surrounded by outer membrane of lipids, membrane proteins and lipopolysaccharide.
  • 19. The most important pathogen for meningitis is NEISSERIA MENINGITIDES because of its potential to cause epidemic. Meningococcal Meningitis
  • 20. Etiology Neonates (<3 mo) Children Adults Elderly (>65) Group B Streptococcus Escherichia coli Staph. aureus Streptococcus pneumoniae (pneu mococcus) Neisseria meningitidis (meni ngococcus) Haemophilus influenzae type B (l ess common now with the advent of the HiB vaccination) Streptococcus pneumoniae Neisseria meningitidis (these two organisms cause 80% of cases) Streptococcus pneumoniae Neisseria meningitidis Listeria monocytogenes
  • 21. Pathogenesis A offending bacterium from blood invades the leptomeninges. Bacterial toxics and Inflammatory mediators are released. Bacterial toxics Lipopolysaccharide, LPS Teichoic acid Peptidoglycan Inflammatory mediators Tumor necrosis factor, TNF Interleukin-1, IL-1 Prostaglandin E2, PGE2
  • 23. The outer membrane is surrounded by a polysaccharide capsule that is necessary for pathogenecity because it helps the bacteria resist phagocytosis and complement-mediated lysis. The outer membrane proteins and the capsular polysaccharide make up the main surface antigens of the organism.
  • 24. Pathogenesis Cont. to next 壊鉛庄糸艶..
  • 26. Transmission & Communicability The main modes of transmission are direct contact and respiratory droplets. Close contact like living in close quarters (like hostel dormitories) and sharing of utensils enhance the risk of transmission The average incubation period is 3 - 4 days with a range of 2 to 10 days. This is also the period of communicability. The bacteria are rapidly eliminated from the nasopharynx after starting antibiotics, usually within 24 hours
  • 27. Therapeutic principle Good permeability for Blood-brain barrier Drug combination Intravenous drip Full dosage Full course of treatment Treatment Antibiotic Therapy
  • 28. Antibiotic Therapy Selection of antibiotic No Certainly Bacterium Community-acquired bacterial infection Nosocomial infection acquired in a hospital Broad-spectrum antibiotic coverage as noted below Children under age 3 months 損 Cefotaxime and ampicillin 損 Ceftriaxone and ampicillin (children over age 1months) Children over 3 months 損 Cefotaxime or Ceftriaxone or ampicillin and chloramphenicol