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Updated: Dec 30 2021

Meningitis

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  • Snapshot
    • A 19-year-old man presents to the emergency department with a headache. His headache was initially mild but then subsequently worsened over the course 2 days. His headaches are associated with fevers, chills, photophobia, and neck stiffness. His temperature is 101°F (38.3°C), blood pressure is 124/95 mmHg, pulse is 118/min, and respirations are 22/min. Physical examination is notable for nuchal rigidity and petechieal hemorrhages in the skin. An emergent lumbar puncture is performed and blood cultures are obtained. Immediately after, he is started on intravenous vancomycin and ceftriaxone. (Meningococcal meningitis)
  • Introduction
    • Definition
      • inflammation of the meninges that can be caused by
        • infection (bacterial, viral, and fungal)
        • autoimmune disease
        • malignancy
        • medications
    • Etiology
      • infection
        • bacterial
        • viral
        • fungal
      • autoimmune disease
        • neurosarcoid
        • Behcet syndrome
      • malignancy
        • leptomeningeal carcinomatosis
        • hemotologic malignancy
      • medications
        • trimethoprim-sulfamethoxazole
        • non-steroidal anti-inflammatory drugs
        • intravenous immunoglobulins
        • inflixamab
    • Epidemiology
      • incidence
        • aseptic meningitis is more common than bacterial meningitis
        • enteroviruses are the most common cause of viral meningitis
    • Prognosis
      • bacterial meningitis is a medical emergency requiring prompt antibiotic treatment
  • Presentation
    • Symptoms
      • headache
      • confusion
      • photophobia
    • Physical exam
      • nuchal rigidity
      • positive Kernig sign
        • patient supine
        • knee extension while hips are 90° flexed → resistance/pain
      • positive Brudzinski sign
        • patient supine
        • passive neck flexion → involuntary knee flexion
      • petechial rash
        • may suggest Neisseria meningitidis infection
  • Studies
    • Lumbar puncture
      • helps suggest which type of meningitis the patient has
      • studies must include
        • opening pressure
        • cell count
        • protein
        • glucose
        • Gram stain
        • culture
      • other tests depend on the clinical scenario
        • e.g., acid fast bacillus (AFB) stain in patients who are likely to have tuberculosis
    • Serum studies
      • blood cultures
        • especially helpful in patients who urgently require antibiotics but are unable to get a lumbar puncture immediately
      • Cerebrospinal Fluid Analysis
      • Test
      • Normal
      • Bacterial
      • Viral
      • Fungal/TB
      • Opening pressure
      • ≤ 20 cm H
      • 2O
      • Normal or slightly ↑
      • Color
      • Clear
      • Cloudy
      • Clear
      • Cloudy
      • Cell count
      •   0-5 cells/µL
      • ↑ PMN
      • ↑ (Lymphocytes)
      • ↑ (Lymphocytes)
      • Protein
      •   < 45 mg/dL
      • Slighty ↑
      • CSF:Serum glucose
      •   > 0.6
      • Normal
  • Treatment
      • Bacterial
      • Population
      • Causative Organism
      • Treatment
      • Infants (<1 month)
      • Streptococcus agalactiae (group B streptococcus)
      • Listeria monocytogenes
      • Escherichia coli
      • other gram-negative bacilli
      • Ampicillin and cefotaxime
      • 1-23 months of age
      • Streptococcus pneumoniae
      • Neisseria meningitidis
      • S. agalactiae
      • Haemophilus influenzae
      • E. coli
      • Vancomycin and ceftriaxone
      • In cases of streptococcal pneumoniae, patients can benefit from dexamethasone
      • 2-50 years of age
      • N. meningitidis
      • S. pneumoniae
      • Vancomycin and ceftriaxone
      • > 50 years of age of immunocompromised
      • S. pneumoniae
      • Listeria monocytogenes
      • N. meningitidis
      • aerobic gram-negative bacilli
      • Vancomycin, ceftriaxone, and ampicillin
    • Viral meningitis
      • supportive treatment
    • Meningococcal prophylaxis
      • indication
        • roomates or intimate contacts
        • child care center workers
        • direct exposure (e.g., kissing and endotracheal intubation)
        • sitting next to the affected person for ≥ 8 hours
      • medication
        • rifampin
          • interacts with oral contraceptives and other medications that use the cytochrome P450 system
        • ceftriaxone
        • ciprofloxacin
    • Cryptococcal meningitis
      • treatment
        • amphotericin with flucytosine followed by fluconazole
  • Complications
    • Neurological sequela (e.g., cognitive deficit)
    • Septic sinus thrombosis
    • Subudural effusion or empyema
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