meningitis edited

8/8/2019 Meningitis Edited

http://slidepdf.com/reader/full/meningitis-edited 1/26

Meningitis Meningitis

Adapted from source Adapted from source



Observations : temp 37.5 / HR 87 / RR18 /Sats 99 %Observations : temp 37.5 / HR 87 / RR18 /Sats 99 %

Exam : no discharge / no mastoid tendernessExam : no discharge / no mastoid tenderness

Signs in keeping with otitis externaSigns in keeping with otitis externa

Refused analgesiaRefused analgesia

PlanPlan -- discharged with no change in managementdischarged with no change in management

but advised to return if worseningbut advised to return if worsening



1826hrs returns to ED1826hrs returns to ED

Pc :Pc : headache + ongoing ear acheheadache + ongoing ear ache

HPc: after discharge earlier had gone to work HPc: after discharge earlier had gone to work

-- later at 1500hrs developed some generalised headachelater at 1500hrs developed some generalised headachebut mostly focused to right ear and right side facebut mostly focused to right ear and right side face

-- pain despite Paracetamol + Nurofen alternating pain despite Paracetamol + Nurofen alternating

-- Associated with some nausea but no vomiting Associated with some nausea but no vomiting

-- No photophobia + walked into departmentNo photophobia + walked into department



Observations: temp 38.9 / HR 109 / RR 20 / Sats 97%Observations: temp 38.9 / HR 109 / RR 20 / Sats 97%

ExamExam

slightly unwell looking + ? dehydratedslightly unwell looking + ? dehydrated

Alert / Orientated / Not in obvious distress Alert / Orientated / Not in obvious distress

Warm / well perfused / No lymphadenopathy Warm / well perfused / No lymphadenopathy No rashes / No neck stiffness / Kernigs negativeNo rashes / No neck stiffness / Kernigs negative

Throat erythematous but no pus or exudate evident Throat erythematous but no pus or exudate evident

Left ear completely normalLeft ear completely normal

Right ear canal sloughy + unable to fully visualise drumRight ear canal sloughy + unable to fully visualise drum ? Small perforation / ? Discharge or otodex drops? Small perforation / ? Discharge or otodex drops

No mastoid tendernessNo mastoid tenderness

Other systems normalOther systems normal



Impression : Febrile illness ? viral / ? BacterialImpression : Febrile illness ? viral / ? Bacterial

(comment )(comment )

Plan : iv access + analgesia + bloodsPlan : iv access + analgesia + bloods

Trial of fluid rehydration + analgesia Trial of fluid rehydration + analgesia

Observe for 2 hours in EDObserve for 2 hours in ED



2135hrs ( department very busy and patient moved )2135hrs ( department very busy and patient moved )

Reviewed : girlfriend says ¶he keeps dropping off·Reviewed : girlfriend says ¶he keeps dropping off·

Temp Temp 39.639.6 / HR 86 / RR 18 / Sats 100% / BP 149 / 78/ HR 86 / RR 18 / Sats 100% / BP 149 / 78

Looking ¶ more sick · / pale / sweatingLooking ¶ more sick · / pale / sweating

Drowsy but rouses + says headache has intensifiedDrowsy but rouses + says headache has intensified

Remains orientated + cooperativeRemains orientated + cooperative

Neck stiffness ++ / now holding vomit bagNeck stiffness ++ / now holding vomit bag



Immediately taken into ResusciationImmediately taken into Resusciation

Given hydrocortisone 200mg iv statGiven hydrocortisone 200mg iv stat

Given 4 gram Cetriaxone iv statGiven 4 gram Cetriaxone iv stat

Unable to contact CT radiographerUnable to contact CT radiographer

ABG ph 7.44 / PCO2 33 / PO2 128 / BE ABG ph 7.44 / PCO2 33 / PO2 128 / BE --33

Blood Glucose 8 / istat electrolytes normalBlood Glucose 8 / istat electrolytes normal



Discussed with neurology consultant in RBWHDiscussed with neurology consultant in RBWH

Agrees that LP can be done if fundoscopy ok Agrees that LP can be done if fundoscopy ok

Post LP increasingly uncooperativePost LP increasingly uncooperative

CT Head arranged + admission to ICUCT Head arranged + admission to ICU

Post CT agitated Anaesthetics notifiedPost CT agitated Anaesthetics notified ( located by security )( located by security )

Addition of Vancomycin 1 gram iv Addition of Vancomycin 1 gram iv



Gram stain CSF «Gram stain CSF «



CT headCT head



Progress «Progress «

Remained combative overnight with special requiredRemained combative overnight with special required

Eventually intubated for GCS 6/15 in morning prior to transferEventually intubated for GCS 6/15 in morning prior to transfer

to RBWH by retrieval teamto RBWH by retrieval team

Middle Ear washed out surgically by ENTMiddle Ear washed out surgically by ENT

Remained in ICU with fluctuating GCS < 13 for 48 hoursRemained in ICU with fluctuating GCS < 13 for 48 hours

Day 5Day 5 ² ² 24 hours post extubation full neurological recovery24 hours post extubation full neurological recovery

Remains on dexamethasone / Benzylpenicillin Q4hrly viaRemains on dexamethasone / Benzylpenicillin Q4hrly via

PICCPICC



QuestionsQuestions ««

1. Does ¶headache + fever· mean LP ?1. Does ¶headache + fever· mean LP ?

2. Whose responsibility is ¶isolation· in this hospital ?2. Whose responsibility is ¶isolation· in this hospital ?

3. Should Anaesthetics have intubated this patient ?3. Should Anaesthetics have intubated this patient ? GCS documented by ICU nurse as fluctuating 4/15 to 9/15GCS documented by ICU nurse as fluctuating 4/15 to 9/15

Mannitol infusion started + glucose infusionMannitol infusion started + glucose infusion

GCS documented by Schmidt 7/15GCS documented by Schmidt 7/15

Intubated by retrieval teamIntubated by retrieval team



Complications of LP «Complications of LP «

PainPain

FailureFailure

PDPHPDPH

Site related bruising / ¶back ache·Site related bruising / ¶back ache·

Leg pain « normally brief ( 10 %)Leg pain « normally brief ( 10 %)

Lower limb weakness ( 1 in 10 000 temporary vsLower limb weakness ( 1 in 10 000 temporary vs

permanent ) permanent )

Bleeding ( rare situation can be serious )Bleeding ( rare situation can be serious )

InfectionInfection

Brain herniationBrain herniation



The triad of fever, nuchal rigidity, and change in mental status is The triad of fever, nuchal rigidity, and change in mental status is

found in only two thirds of patients. In a metafound in only two thirds of patients. In a meta--analysis of 845analysis of 845

patients, the sensitivity and specificity of these classic symptoms patients, the sensitivity and specificity of these classic symptoms

were poor were poor

Fever is the most common manifestation (95%), while stiff neck Fever is the most common manifestation (95%), while stiff neck

and headache are less commonand headache are less common

The negative predictive value of these symptoms is high (ie, the The negative predictive value of these symptoms is high (ie, the

absence of fever, neck stiffness, or altered mental statusabsence of fever, neck stiffness, or altered mental status

eliminates the diagnosis of meningitis in 99eliminates the diagnosis of meningitis in 99--100% of cases)100% of cases)

Signs of meningeal irritation are observed in only approximatelySigns of meningeal irritation are observed in only approximately

50% of patients with bacterial meningitis, and their absence50% of patients with bacterial meningitis, and their absence

certainly does not rule out meningitiscertainly does not rule out meningitis



Mortality/MorbidityMortality/Morbidity

The mortality rate for viral meningitis (without The mortality rate for viral meningitis (withoutencephalitis) is less than 1%encephalitis) is less than 1%

Bacterial meningitis was uniformly fatal before theBacterial meningitis was uniformly fatal before theantimicrobial era. With the advent of antimicrobial therapy,antimicrobial era. With the advent of antimicrobial therapy,

the overall mortality rate from bacterial meningitis hasthe overall mortality rate from bacterial meningitis hasdecreased but remains alarmingly high. It is reported to bedecreased but remains alarmingly high. It is reported to beapproximately 25%approximately 25%

Among the common causes of acute bacterial meningitis, Among the common causes of acute bacterial meningitis,the highest mortality rate is observed with pneumococcusthe highest mortality rate is observed with pneumococcus

The reported mortality rates for each specific organism are The reported mortality rates for each specific organism are1919--26% for26% for S pneumoniae S pneumoniae meningitis, 3meningitis, 3--6% for6% for H influenzae H influenzae meningitis, 3meningitis, 3--13% for13% for N meningitidis N meningitidis meningitis, and 15meningitis, and 15--29%29%forfor L monocytogenes L monocytogenes meningitismeningitis



S pneumoniae S pneumoniae

GramGram--positive coccus, remains an important bacterial positive coccus, remains an important bacterial pathogen in humans pathogen in humans

It is a common colonizer of the human nasopharynx (5It is a common colonizer of the human nasopharynx (5--10% of healthy10% of healthyadults and 20adults and 20--40% of healthy children)40% of healthy children)

It causes meningitis by escaping the local host defense and phagocyticIt causes meningitis by escaping the local host defense and phagocyticmechanisms, either through choroid plexus seeding from bacteremia ormechanisms, either through choroid plexus seeding from bacteremia orthrough direct extension from sinusitis or otitis mediathrough direct extension from sinusitis or otitis media

Presently, it is the most common bacterial cause of Presently, it is the most common bacterial cause of meningitis, accounting for 47% of casesmeningitis, accounting for 47% of cases

It is also associated with one of the highest mortality ratesIt is also associated with one of the highest mortality rates

among the bacterial agents that cause meningitis (19among the bacterial agents that cause meningitis (19--26%)26%)




It is the most common bacterial agent in meningitisIt is the most common bacterial agent in meningitisassociated with basilar skull fracture and CSF leak associated with basilar skull fracture and CSF leak

It may be associated with other foci of infection, such asIt may be associated with other foci of infection, such as pneumonia, sinusitis, or endocarditis pneumonia, sinusitis, or endocarditis

Patients with hyposplenism, hypogammaglobulinemia,Patients with hyposplenism, hypogammaglobulinemia,multiple myeloma, glucocorticoid treatment, defectivemultiple myeloma, glucocorticoid treatment, defective

complement (C1complement (C1--C4), diabetes mellitus, renal insufficiency,C4), diabetes mellitus, renal insufficiency,alcoholism, malnutrition, and chronic liver disease are atalcoholism, malnutrition, and chronic liver disease are atincreased risk increased risk



Antibiotic(s) Antibiotic(s)

GramGram--positive cocci = Vancomycin plus ceftriaxone positive cocci = Vancomycin plus ceftriaxoneor cefotaximeor cefotaxime

GramGram--negative cocci = Penicillin G*negative cocci = Penicillin G*

GramGram--positive bacilli = Ampicillin plus an positive bacilli = Ampicillin plus anaminoglycosideaminoglycoside

GramGram--negative bacilli = Broadnegative bacilli = Broad--spectrum cephalosporinspectrum cephalosporin plus an aminoglycoside plus an aminoglycoside




The increasing incidence of penicillin The increasing incidence of penicillin--resistant strains hasresistant strains haschanged the management of pneumococcal meningitischanged the management of pneumococcal meningitis

The third The third--generation cephalosporins (ceftriaxone 2generation cephalosporins (ceftriaxone 2--4 g/d4 g/dor cefotaxime 8or cefotaxime 8--12 g/d) with vancomycin (212 g/d) with vancomycin (2--3 g/d,3 g/d,adjusted to therapeutic serum levels) are firstadjusted to therapeutic serum levels) are first--line empiricline empirictherapy, depending on the resistance patterns in thetherapy, depending on the resistance patterns in thecommunitycommunity

The use of corticosteroids such as dexamethasone as The use of corticosteroids such as dexamethasone asadjunctive treatment for pneumococcal meningitis is now adjunctive treatment for pneumococcal meningitis is now

supported by recent studies demonstrating significantsupported by recent studies demonstrating significantbenefit with regards to reduction in casebenefit with regards to reduction in case--fatality rate andfatality rate andneurologic sequelaeneurologic sequelae

Penicillin G (24 million U/d) remains the drug of choicePenicillin G (24 million U/d) remains the drug of choice

for penicillinfor penicillin--susceptible strains.susceptible strains.



Long Long--term neurologic sequelaeterm neurologic sequelae

Can be grouped into 3 categories :Can be grouped into 3 categories :

Hearing impairmentHearing impairment

Obstructive hydrocephalusObstructive hydrocephalus

Brain parenchymal damage: This is the most importantBrain parenchymal damage: This is the most important

feared complication of bacterial meningitis. It could lead tofeared complication of bacterial meningitis. It could lead to

sensory and motor deficits, cerebral palsy, learningsensory and motor deficits, cerebral palsy, learning

disabilities, mental retardation, cortical blindness, anddisabilities, mental retardation, cortical blindness, and

seizures.seizures.



PrognosisPrognosis

Patients with viral meningitis usually have a goodPatients with viral meningitis usually have a good prognosis for recovery prognosis for recovery

The prognosis is worse for patients at the extremes of age The prognosis is worse for patients at the extremes of age(ie, <2 y, >60 y) and those with significant comorbidities(ie, <2 y, >60 y) and those with significant comorbiditiesand underlying immunodeficiencyand underlying immunodeficiency

Patients presenting with an impaired level of Patients presenting with an impaired level of

consciousness are at increased risk for developingconsciousness are at increased risk for developingneurologic sequelae or dyingneurologic sequelae or dying

A seizure during an episode of meningitis also is a risk A seizure during an episode of meningitis also is a risk factor for mortality or neurologic sequelaefactor for mortality or neurologic sequelae



Take home « Take home «

Acute bacterial meningitis is a medical Acute bacterial meningitis is a medical

emergency and delays in instituting effectiveemergency and delays in instituting effectiveantimicrobial therapy result in increasedantimicrobial therapy result in increased

morbidity and mortalitymorbidity and mortality

Don·t forget steroids prior to antibiotics andDon·t forget steroids prior to antibiotics and

do not delay treatment for investigationsdo not delay treatment for investigations

meningitis edited

Documents