Snapshot A 34-year-old man is brought to the ER by his wife because she believes her husband is very ill. The patient initially had a headache that progressed to neck stiffness and an inability to look at bright lights. His temperture is 103.1 deg F (39.5 deg C), blood pressure is 130/85 mmHg, and respirations are 20/min. Extreme pain is elicited upon flexion of the patient's neck and the patient's legs. Introduction Neonates Causative Agent Facts Treatment Group B Strep (agalactiae) #1 cause in neonates Acquired at birth Ampicillin E. coli Common in neonates Aquired at birth Cefotaxime Listeria monocytogenes Occurs in AIDS patients, neonates, elderly, diabetics, patients taking steroids Difficult to see on Gram stain Ampicillin Children Neisseria meningitidis (meningococcal meningitis) Occurs in children > 1 yr old or adults Symptoms include petechiae on trunks, legs, conjunctivae 3rd generation cephalosporin such as ceftriaxone cefotaxime Rifampin prophylaxis H. influenzae Former #1 cause in children Cefotaxime Enteroviruses Viral meningitis in children of all ages Often prodromal illness Supportive Adults, Elderly, and Immunocompromised Streptococcus pneumoniae #1 cause in adults, elderly, asplenic patients Can progress from otitis media, sinusitis, bacteremia Penicillin G or cefotaxime Fungal (Cryptococcus, Coccidioides) AIDS India ink show cryptococcus in CSF Cocci blastocysts seen in CSF IV amphotericin 5-flucytosine (cryptococcus) fluconazole (cryptococcus) ppx for life or until CD4 count rises Staphylococcus aureus Trauma/neurosurgery Wound infection from skin Oxacillin Vancomycin TB Elderly Reactivation Can use PCR to confirm presence of TB in CSF RIPE (Rifampin, INH, Pyrazinamide, Ethambutol, extended duration) corticosteroids Presentation Presents with fever neck stiffness (meningismus - can't touch chin to chest) photophobia altered mental status seizures Physical exam shows positive Kernig and Brudzinski signs Classic signs of menigitis may be absent in an infant less than 2 years of age Evaluation CBC may or may not reveal leukocytosis Blood cultures LP for CSF studies LP contraindicated if papilledema or focal neurological deficits LP labs show low glucose Imaging studies to rule out other etiologies Order of management for Step 2/3 CT scan if focal neurologic deficits prior to lumbar puncture best initial step: lumbar puncture get cell count, stain, glucose levels send for culture next step: broad spectrum antibiotics begin these prior to getting culture results should include ceftriaxone and vancomycin add ampicillin if patient is elderly or neonate/infant and steroids adjust treatment based on culture results Bacterial TB/Fungal Virus Protein ↑ ↑ normal to ↑ Glucose ↓ ↓ normal Pressure ↑ ↑ normal Cells ↑ neutrophils ↑ lymphs ↑ lymphs Treatment Treat with IV antibiotics if bacterial (ceftriaxone and vancomycin for healthy adults) add dexamethasone if S. pnemonia is suspected add dexamethasone and ampicillin (Listeria) if immunosuppressed or elderly Supportive care if non-bacterial HSV and HIV can be treated Treat seizures with benzodiazepine or phenytoin Treat cerebral edema (loss of oculophalic reflex) with IV mannitol Subdural effusions (especially common with H. influenzae meningitis) can be followed Subdural empyema (presents as intractable seizures), and brain abscesses must be treated surgically Prophylactic abx in close contacts rifampin ciprofloxacin Prognosis, Prevention, and Complications Hyponatremia Seizures IV mag for for seizure prophylaxis along with benzos Cerebral edema presents with a loss of oculocephalic reflex Subdural effusions may be seen on CT Occurs in 50% with H. influenzae meningitis No treatment is neccesary Subdural empyema presents with intractable seizures requires surgical evacuation Brain abscess requires surgical drainage Control HTN with hydralazine Snapshot A 35-year-old man presents to the ED with a fever. He states that he has a severe headache, as well as that his neck is very stiff. When you examine the patient you see a young man in distress sitting in a dark room. On physical exam, flexion of the patients leg or neck induces severe discomfort and pain. Bacterial Meningitis Presentation suspect bacterial meningitis with the classic, cornerstone symptoms of meningitis: fever photophobia headache stiff neck best initial step/best initial test lumbar puncture with CSF analysis decreased glucose, elevated protein, increased neutorphils do not wait for culture results to begin treatment next step in management/best initial therapy treat with vancomycin, ceftriaxone and steroids prior to obtaining culture results adjust treatment based on culture results important considerations do not confuse with encephalitis that presents with the same symptoms with the exception of neck stiffness → it is managed differently Snapshot A 20-year-old college student is brought to student health by his roommate who is concerned that his friend is not doing well. The patient is minimally responsive. You learn from the roommate that the patient has been complaining of a stiff neck and a headache recently and that he has kept to himself in his room with the lights off. On physical exam you are alarmed when you find a diffuse petechial rash and a blood pressure of 80/40 mmHg. Neisseria Meningitidis Meningitis Presentation a young college student or military recruit presents with neck stiffness, photophobia and headache Best initial test/next step in management lumbar puncture send for CSF analysis (cell count, glucose) and culture Next step in management begin broad spectrum antibiotic treatment with ceftriaxone, vancomycin and corticosteroids update antibiotic treatment pending culture results treatment of choice is ceftriaxone Unique information for N. meningitidis C5-C9 deficiency and asplenia are associated respiratory isolation for the patient ppx with rifampin, ciprofloxacin or ceftriaxone for close contacts Waterhouse-Friderichsen Syndrome disseminated N. meningitidis that affects adrenal glands stabilize the patient first with fluids, corticosteroids and vasopressors and begin treatment immediatley Snapshot A 77-year-old dairy salesman presents with a headache, stiff neck, and photophobia. He is currently treated for polyarteritis nodosa with high doses of prednisone. His past medical history is notable for mononucleosis that resulted in splenic rupture at a football game. On physical exam you see an uncomfortable old man who has his eyes closed. Listeria Meningitis Presentation patient who is elderly, a neonate, immunocompromised (HIV, steroid use, chemotherapy) presents with headache, fever, stiff neck and photophobia Best initial/next step in management lumbar puncture send for CSF analysis (cell count, glucose) and culture Next step in management begin broad spectrum antibiotics with vancomycin, ceftriaxone, ampicillin and steroids antibiotic of choice pending culture results is ampicillin Snapshot A 32-year-old male presents with a slow progression of symptoms. Several days ago he had a headache, however in the past few hours he has also noticed that his neck is stiff and bright lights hurt his eyes. Patient has a past medical history of HIV with a CD4+ count of 5 T-cells. Cryptococcal Meningitis Presentation gradual onset of symptoms (headache, fever, neck stiffness, photophobia) in a HIV patient with low CD4+ count Best initial test India ink of the CSF Most accurate test cryptococcal antigen or latex particle agglutination Treatment intrathecal amphotericin + 5-flucytosine once the patient is treated → fluconazole for life or until T-cell rises Snapshot A 12-year-old boy presents with neck stiffness, photophobia, fever and headache. His symptoms began the day after he returned from a boyscout trip where he was out in the wilderness for a week drawing pictures of beavers for his beaver badge. Lyme Meningitis Presentation classic meningitis symptoms in a patient that has been in the outdoors, in particulary camping specific mention of exposure to a tick is not necessary for diagnosis Best initial test lumbar puncture and CSF analysis (cell count, glucose) Most accurate test serology of the CSF Western blot of the CSF Treatment ceftriaxone is best penicillin can be used doxycycline and amoxicillin (children) are used for lyme disease, not lyme meningitis! Unique information for Lyme disease suspect Lyme meningitis if signs of meningitis + outdoor exposure or FAKE symptoms facial nerve palsy (CN VII) arthritis kardiac block erythema migrans (target rash) Snapshot A 12-year-old boy presents with a low grade fever as well as a minor headache, neck stiffness and photophobia. A lumbar puncture is performed and demonstrates a normal glucose, a slightly elevated protein, and an increase in CSF lymphocytes. Viral Meningitis Presentation suspect in a patient with classic signs and symptoms meningitis that seem more mild than usual this is a diagnosis of exclusion Best initial step lumbar puncture and CSF analysis normal glucose, elevated protein, lymphocyte predominant Treatment supportive therapy assuming you have ruled out other potential causes do not confuse this with HSV encephalitis which must be treated with acyclovir ASAP Snapshot A 27-year-old immigrant who was just released from prison presents with symptoms that have progressed slowly over the past few months. He currently complains of neck stiffness, photophobia and a headache that have very slowly been worsening. Past medical history is not known, though he does state that he had a cough in his home country of Uzbekistan that was succesfully treated by his grandmother with goats milk. On presentation he currently still has a cough. Tuberculosis Meningitis Presentation suspect in immigrants and prisoners who have very slow onset of classic meningitis symptoms suspect even further if there is concern for TB infection or improperly treated TB Best initial step lumbar puncture and CSF analysis with acid fast stain and culture very high protein level, low glucose acid fast stain positive (though this test is not very sensitive at all so do not rely on it) culture is very difficult to perform Treatment RIPE therapy + steroids for an extended length of time as compared to pulmonary TB (6+ months) rifampin isoniazid pyrazinamide ethambutol Snapshot A 55-year-old man presents to the emergency department with altered mental status, a headache and a fever. These symptoms began a few hours ago and progressed rapidly. On physical exam the patient experiences no pain when his leg is flexed or his neck is bent. Encephalitis Presentation fever, confusion, focal neurologic findings without neck stiffness with or without a history of HSV Best initial step in management acyclovir Best initial test CT of the head Most accurate test lumbar puncture and PCR Treatment acyclovir is first line foscarney if acyclovir resistant Important points to consider for Step exams an important differentiating factor from meningitis is neck stiffness begin with therapy right away if you suspect encephalitis with acyclovir