Bacterial Meningitis Bacterial Meningitis --

A Medical A Medical EmergencyEmergencySwartz MN

N Engl J Med

2004;351:1826-1828

Mortality Rates Associated with Community-Acquired Bacterial Meningitis

over the Past 90 Years

Swartz MN N Engl J Med 2004;351:1826-1828

Bacterial Meningitis Bacterial Meningitis --

A Medical A Medical EmergencyEmergency Fever and neurologic

symptoms

Bacterial meningitis

Aseptic meningitis

Neurologic Neurologic SymptomsSymptomsWith FeverWith Fever

Bacterial meningitis

Aseptic meningitis

EncephalitisBrain abscess

Epidural AbscessSubdural

empyemaSinus septic

thrombosisCollagen

diseases

Typical CSF Typical CSF ChangesChanges

etiology protein glucose leukocytes

bacterial meningitis 100-500 100-10000, P

viral meningitis 50-200 N <1000, MN

TB meningitis 100-500 10-500, MN

fungal meningitis 25-500 25-500, MN

brain abscess 75-500 N 0-200, MN

Bacterial Bacterial MeningitisMeningitisEtiologyEtiology

NeonatesGram (-) rodsStrep group BListeria

monocytogenesHaemophilus

influenzae b

> 3 monthsHaemophilus

influenzae bStrep

pneumoniaeN. meningitidis

Bacterial Bacterial MeningitisMeningitis

Clinical Clinical PresentationPresentation1. "Looks Bad”

2. Fever3. Headache, nausea, vomiting4. Irritability, restlessness5. Sleepy6. Confusion, mental signs7. Back pain8. Bulging fontanel / nuchal rigidity

Bacterial Bacterial MeningitisMeningitisDiagnosisDiagnosis

1. LP – mandatory (protein, glucose, cells, culture, Gram stain, antigen detection by latex, ELISA, CIE)

2. Blood culture – always

3. CT? (search for focus)

Bacterial Bacterial MeningitisMeningitisTreatmentTreatment

1. Antibiotic regimen2. Steroids3. Fluid restriction?4. Anticonvulsant medications?5. Monitoring

CSF PenetrationCSF Penetrationof Antibioticsof Antibiotics

adequate good with minimal with nil inflammation inflammationchloramphenicol ampicillin gentamicin

clindamycinsulfa cefotaxime tobramycin

benza pen TMP/SMX amikacin erythromycin

ampho Bmetronidazole vancomycin ketoconazole

polymyxinrifampin

Bacterial Bacterial MeningitisMeningitisTreatmentTreatment

1. Antibiotic regimen2. Steroids3. Fluid restriction?4. Anticonvulsant medications?5. Monitoring

Bacterial Bacterial MeningitisMeningitisSequelaeSequelae

1. Mortality: 1-5% 6. Motor abnormalities

2. Hearing loss: 10-40% 7. Seizures: 2-8%3. Language disorders 15% 8. Hydrocephalus4. Impaired vision: 2-4% 9. Cranial N palsy5. Mental retardation: 10% 10. Ataxia…

(Sell et al)

Bacterial MeningitisBacterial Meningitisfactors affecting factors affecting

prognosisprognosis1. Age2. Specific cause3. Underlying disorders4. Delay in therapy5. Focal neurologic findings6. Bacterial load (animals)

Aseptic MeningitisAseptic MeningitisBacterial – partially treated,

mycobacteria, T. pallidum, borrelia, leptospira

ViralRickettsiaFungalProtozoaParameningeal foci (abscess,

mastoiditis, sinus septic thrombosis)

Viral Meningitis - Viral Meningitis - USAUSA

Enteroviruses - 85%Arboviruses - 5%Mumps - 2%Herpes simplex 2-5%Others: adeno, VZV, CMV,

measles, rubella, influenza, parainfluenza, RSV

Herpes simplex Herpes simplex EncephalitisEncephalitis

Presentation (Kohl, Ped C N Am 1998) Fever 90-100% Altered consciousness 80-100% Headache 76-80% Seizures 40-85% Hemiparesis 33-40% Cranial N palsy 30-35% Behavioral changes 47-85%

Herpes simplex Herpes simplex EncephalitisEncephalitis

Laboratory findings (Kohl, Ped C N Am 1998)

Abnormal CSF 90-97% CSF pleocytosis 50-1000, lymph CSF RBCs 75-85% CSF protein increased CSF glucose normal Culture negative PCR (type 1, 2) positive

Herpes simplex Herpes simplex Encephalitis – Encephalitis –

OutcomeOutcome Acyclovir Vidarabine

placebo Mortality (1m) 16% 36%

70%Severe sequelae 34 72%

Moderate sequelae 10 15% Minor or no impairment 46% 13%

Recurrent Recurrent MeningitisMeningitis

Communication of SAS with: Skin - dermal sinus, meningomyelocele Paranasal sinuses, middle ear, nasopharynx

– due to fractures, cong malformationsParameningeal focus – epidural, brain,

mastoid Immune deficiencyUnknown

Thank YouThank Youfor the attentionfor the attention

Shai AshkenaziShai Ashkenazi