meningitis final november 4

8/14/2019 MENINGITIS Final November 4

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PROMPT recognition of Meningitis Rapid Diagnostic testing to identify the

etiologic pathogen and adjust therapy Rapid Initiation of appropriate Empiric

Antimicrobial therapy Targeted Antimicrobial therapy Dos and Donts for the Boards


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1805-1900s: ~100% fatal 1913: Flexner: intrathecal meningococcal

antiserum. Prevented some deaths 1930s: Antibiotics. Improved survival Current data:

Adults: 25% mortality, 21-28% neurologic

sequelaeBacterial meningitis remains a

medical emergency!


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RECOGNIZE Clinical picture is often unimpressivewhen the patient is first seen

aLTERED mENTAL sTATUS

FEVER HEADACHE

URIinterruptedby one of the

meningeal

symptoms:vomiting,

headache,

lethargy,

confusion, stiffneck


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1. AGE 2.SEASON 3.Geography 4.Predisposing factors

(immunocompromised state; basilar skullfracture with CSF leak; head trauma; post

neurosurgical procedures ~wound and FB) 5.Onset and duration of illness (acute;

subacute and chronic) ~community aquiredor nosocomial


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6.Travel,occupational and recreationalexposures( insect and animal contact)

7. Vaccination history and current meds (ABX) 8.Parameningeal foci or septic emboli from IE 9. Imaging before Lumbar puncture 10. Gram stain and Interpretation of the CSF

formula


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14-year-old male with no significant PMH isadmitted to the hospital with acute onset ofhigh fever, chills, sore throat, stiff neck, and

lethargy T 1040F, P 120, RR 32, BP 70/30 mmHg On examination, he was oriented only to person, and had evidence of nuchal rigidity WBC 25,000/mm3with 20% bands CSF WBC 1,500/mm3(98% neutrophils), glucose

20 mg/dL, and protein 200 mg/dL


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A Haemophilus influenzae type b B Neisseria meningitidis C Streptococcus pneumoniae D Enterovirus 71 E Cryptococcus neoformans


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LOOK @ AGE/ARMYRECRUITS/COLLEGE

STUDENTS/Rash


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Affects mostly children and young adults; mortality 3-13% (SPORADIC 98% cases B) Epidemics usually caused by serogroups A and C Group Y strains associated with pneumonia Serogroup C disease increasing in the US Nasopharyngeal acquisition of infection Predisposition in those with congenital

deficiencies in terminal complementcomponents (C5-C9) and properdindeficiencies


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PEN G and AMPICILLIN are DRUGS OFCHOICE

Empiric therapy with Third GenerationCephalosporins recommended

Nasopharyngeal carrier state 10 to 15%

Infection control DROPLET precautions~surgical mask


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21-year-old male without significant PMH was founddifficult to arouse by his roommate in his collegedormitory. Patient taken via fire rescue to ER

On exam, he was lethargic, febrile to 1030

F,tachycardic, tachypnec, and hypotensve. His neckwas stiff and he had a petechial rash on the lowerextremities

CSF revealed a neutrophilic pleocytosis, low glucose,and elevated protein. Grams stain showed gram-negative diplococci

The patient received IV penicillin G and made a fullrecovery. Blood and CSF grew Neisseria meningitidis


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For which of the following persons isantimicrobial chemoprophylaxis

recommended? The Dean of the college The ambulance driver The emergency room physician The triage nurse The patient


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Household members Day care center contacts Persons directly exposed to patients oral

secretions - kissing, mouth-to-mouthresuscitation - endotracheal intubation or endotracheal tube

management Index patient if not treated with a third

generation cephalosporin Chemoprophylactic regimens - rifampin - ceftriaxone - ciprofloxacin - azithromycin


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Immunocompromised

patients H/O CNS disease

New onset SEIZURE Focal neurological

signs Altered consciousness

Papilledema

Delay in performing LP

Do Blood Cx STAT Dexamethasone and

empiric antimicrobials CT scan

LP if CT negative


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Normal Bacterial Viral TBCells 0-5 >1000


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Gram stain Positive in 60-90%

Culture CSF Positive in 70-85%**

Blood Culture Positive in 50%

** Beware of partially treated meningitis with abx for2-3 days this may give you negative Cx although CSFremains abnormal; Shift from PMN to polys andlymphs or lymphocytic predominance

Do NOT assume this is NOT a bacterial infection


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Gram negative:Diplococci: Meningococcus

Bacilli: E. coli

Coccobacilli: H influenzae(small, pleomorphic)

Gram Positive:

Diplococci: Pneumococcus

Chains: Strep Group B

Clusters: Staph

Rods & cocobacilli: Listeria


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56-year-old female with a 2-day history offever, chills, headache, and confusion. Sawher physician 5 days earlier with complaintsof earache; received ciprofloxacin

T 1030F, P 140, RR 32, BP 90/60 mmHg Obtunded, stiff neck, purpuric rash on lower

extremities CSF showed opening pressure of 280 mm

H2O, WBC 2,500/mm3(99% neutrophils),glucose 15 mg/dL, protein 400 mg/dL


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Which of the following regimens should beinitiated?

A Dexamethasone + Penicillin G B Dexamethasone + Ceftriaxone C Dexamethasone + Vancomycin + Ampicillin D Dexamethasone + Vancomycin +

Ceftriaxone E Vancomycin + Ceftriaxone


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Most common etiologic agent in US Mortality of 19-26%

Associated with other suppurative foci ofinfection ~ Pneumonia (25%) Otitis media or mastoiditis (3 0%) Sinusitis (10-15%) Endocarditis (


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PCN MIC g/ml Antimicrobial therapy

1.0 Vancomycin + third generationcephalosporin*

>2.0 Vancomycin + third generationcephalosporin **

*Cefotaxime or ceftriaxone

!! REMEMBER SUSCEPTIBILITIES ARENOT ROUTINELY DONE

**Consider addition of Rifampin ifCeftriaxone MIC > 2


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Microorganism Antimicrobial Therapy S. pneumoniae Vancomycin + a third generation cephalosporina,b

N. meningitidis Penicillin G, ampicillin, or a third generation cephalosporina

H. influenzae type b Third generation cephalosporina

L. monocytogenes Ampicillin or penicillin G*

S. agalactiae Ampicillin or penicillin G*

E. coli Third generation cephalosporina

acefotaxime or ceftriaxone

baddition of rifampin may be considered, especially if dexamethasone given

*addition of an aminoglycoside may be considered


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Attenuates subarachnoid space inflammatory response resulting fromantimicrobial-induced lysis

Recommended for infants and children with Haemophilus influenzaetype b meningitis and considered for pneumococcal meningitis in

childhood, if commenced with or before parenteral antimicrobialtherapy

Clinical trials (predominantly in infants and children) have demonstratedreduction in neurologic and/or audiologic sequelae

Recommended in adults with pneumococcal meningitis

Administer at 0.15 mg/kg every 6 hours for 2-4 days concomitant with orjust before first antimicrobial dose


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Tuberculous Meningitis Corticosteroids (extreme neurologic

compromise, elevated ICP, impending

herniation, impending or established spinalblock;

CT/MR evidence of hydrocephalus or basilarmeningitis)

Cryptococcal MeningitisReduction in intracranial pressure (frequenthigh- volume lumbar punctures, VP shunts)


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60-year-old male with acute myelogenous leukemiapresented with fever, headache, ataxia, and alteredmental status. Recently traveled to an outdoor familypicnic in rural Virginia. He is allergic to penicillin

(anaphylaxis) T 102oF, P 120, RR 24, BP 100/60 On examination, he was obtunded and had nuchal

rigidity. Funduscopic exam revealed no papilledema.Babinski responses were positive bilaterally

WBC was 25,000/mm3(30% bands) LP revealed a WBC 1500/mm3(50 neutrophils, 50%

lymphocytes), glucose 30 mg/dL, and protein 200mg/dL


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Which of the following antimicrobialregimens should be initiated?

A Vancomycin administered intravenouslyand intrathecally B Vancomycin + rifampin C Chloramphenicol D Trimethoprim-sulfamethoxazole E Erythromycin


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http://upload.wikimedia.org/wikipedia/commons/c/c9/Enterococcus_histological_pneumonia_01.png


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Mortality 15-29% Rare cause of bacterial meningitis in US (8%) Outbreaks associated with consumption of

contaminatedcoleslaw, raw vegetables, milk,cheese, processed meats Common in neonates (~20% of cases) Disease in adults associated with: Elderly Alcoholism Malignancy Immune suppression Diabetes mellitus Hepatic and renal disease Iron overload Collagen-vascular disorders


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CASE #2 46-year-old male executive from Phoenix,Arizona

presents to the ER with recent history of going on acruise to Jamaica. One week after returning, he

developed headaches, stiff neck, and vomiting. He had no significant PMH and was sexually active

with multiple partners. Physical exam revealed low-grade fever and

meningismus, but was otherwise negative. CSF examination revealed a WBC count of 300/mm3

with 60% eosinophils, glucose of 45 mg/dL andprotein 150 mg/dL.

Gram stain was negative.


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Which of the following is the most likelycause of this patients illness?

Treponema pallidum Mycobacterium tuberculosis Coccidioides immitis Angiostrongylus cantonensis Lymphoma


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Most common cause of eosinophilic meningitis

Reported from many countries of the world (Thailand,Malaysia, Vietnam, Indonesia, Papua New Guinea,

Taiwan, Pacific Islands); recent outbreak in Jamaica Rat infection rate in urban Bangkok ~40% May spread as rats move freely from port to port on ships Symptoms begin 6-30 days after ingestion of raw

mollusks or other sources of the parasite.

Clinical findings are headache (90%), stiff neck (56%),paresthesias (54%), and vomiting (56%) CSF reveals a moderate pleocytosis with 16-72%

eosinophils; larvae are occasionally found in CSF


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Usually self limited course and recover

completely

Analgesics

Corticosteroids

Frequent but careful LPs if increasedintracranial pressure


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May present acutely, although usually subacute tochronic

Patients generally complain of headache, low-gradefever, weight loss, and mental status changes;

signs of meningeal irritation are usually absent Serumcomplement-fixing antibody titers >1:32 to

1:64 suggest disseminated disease CSF examination may occasionally reveal a prominent

eosinophilia; CSF protein is almost always elevated Only 25-50% of patients have positive CSF cultures CSFcomplement-fixing antibodies present in at least

70% of cases; titers parallel course of meningealdisease


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60 year old male with ESRD immigrated fromBrazil to US and underwent a cadaveric renaltransplant. Prior to transplant, he had

recurrent epigastric pain. WBC 6,500 with 15% eosinophils After transplant received Prednisone and

Azathioprine Presented 1 month later with T 39C,headache, meningismus and altered mentalstatus


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Lumbar puncture showed

WBC 2500/mm

(98% neutrophils) Glucose 20 mg/dl

Protein 450mg/dl Placed on Empiric Vancomycin, Ampicillin

and Ceftriaxone

Blood cultures and CSF Cx grew E.coli


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Which of the following diagnostic test wouldmost likely establish the pathogenesis ofE.colimeningitis in this patient?

A. CT scan of the head and sinuses B. Bronchoscopy with transbronchial lung

biopsy C. Serial stool examinations D. Meningeal Biopsy E. Metrizimide cisternography


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Klebsiella species, Escherichia coli, Serratiamarcescens, Pseudomonas aeruginosa,Salmonella species

Isolated from CSF of patients following headtrauma or neurosurgical procedures

Cause meningitis in neonates, the elderly,immunocompromised patients, and in patients

with gram- negative septicemia Associated with disseminated strongyloidiasis

in the hyperinfection syndrome


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An 80-year-old male is brought to the hospital by hisfamily because of personality changes and olfactoryhallucinations

On exam, T 1010

F, P 90, RR 16, BP 120/90 mmHg He is confused and oriented only to person. There is

no meningimus or evidence of focal neurologicdeficits

CT of head without contrast is negative; CSF reveals aWBC of 90/mm3(95% lymphocytes), glucose of 80mg/dL (serum 100 mg/dl), and protein of 70 mg/dL


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Which of the following is the best test forestablishing the diagnosis in this patient?

A Electroencephalogram B MRI of head with gadolinium C Brain biopsy D CSF polymerase chain reaction E CSF antibody studies


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50-year-old man evaluatedfor obtundation and fever

Brain MRI with gadoliniumreveals swelling and

enhancement of the lefttemporal lobe; CSFanalysis reveals a WBC of10/mm3, normal glucoseand elevated protein

Intravenous acyclovir isinitiated CSF PCR for HSV 1 and

HSV 2 are negative


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Which of the following is the appropriatemanagement for this patient?

A. Discontinue acyclovir B. Perform a brain biopsy C. Begin ganciclovir + foscarnet D. Send CSF for HHV6 PCR E. Perform HSV PCR on a new CSF specimen


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Neuroimaging MRI is procedure of choice (AFTER LP)

Edema and hemorrhage in temporal lobesBilateral temporal lobes (pathognomonic) CSF Analysis Lymphocytes, increased protein, normal

glucose Polymerase chain reaction EEG Periodic lateralizing epileptiform discharges


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Published reports have found that falsenegatives can occur due to testing

Too early or too late,

improper sample transport, or low volumes of CSF tested. HSVE is frequently fatal untreated. Therefore, if

MRI shows compatible temporal lobe findingsand no alternative diagnosis is established,

continued treatment with acyclovir should bestrongly considered.

A second spinal tap with repeat CSF PCR or abrain biopsy may be indicated.


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75 year old woman from Colorado presentswith acute onset of altered mental status and

fever Neurological examination reveals bilateral

tremors of theextremities and cogwheelrigidity

Brain MRI reveals T1 hypodense lesions in thethalamus and basal ganglia that arehyperintense on T2 images


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CSF Analysis reveals a WBC of 300/mmglucose of 70 and protein of 105.

Which of the following tests is most likely toconfirm the diagnosis in this patient?

A. Serum Ig M antibody

B. Serum Ig G antibody C. CSF IgM antibody D. CSF PCR E. Brain Biopsy


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First US cases reported in 1999 in New YorkCity

Birds are main reservoirs Transmission

-mosquito vector

-transfusion

-transplantation

-Breast feeding


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Age >50 years~ increased incidence 1/150 develop neuroinvasive disease Tremors and Myoclonus Parkinsonism Poliomyelitis like flaccid paralysis Serum IgM and IgG capture ELISA

(cross reactivity with otherflaviviruses)

CSF IgM antibodies (diagnostic ofneuroinvasive disease)

CSF PCR (positive in


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Etiologies of Viral

encephalitis

THERAPY FOR ENCEPHALITIS Etiology Therapy HSV Acyclovir VZV Acyclovir CMV Ganciclovir + foscarnet HHV-6 Ganciclovir or

foscarnet HIV HAART JC virus HAART

Echo virusCoxsakie and

EnterovirusesHerpes SimplexWest Nile virus

Un identified etiology32- 75%

Herpes Encephalitisis

NOT SEASONALsporadic

**Clues !!!epidemiological

factors


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56 year old man s/p Kidney transplant in 2006s/p Left mastectomy for a painful mass onSept 1st 2009 discharged POD # 3

re-admitted a week later with urinaryretention and rectal bleeding.

Unclear cause of urinary retention relieved

after foley catheter insertion Rectal bleeding attributed to constipationand a bowel regimen ordered by generalsurgery


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Day 4 of admission patient began to have somehallucinations and beginning confusion.

Agitation increased gradually over the next few

days. CT Brain No acute abnormality MRI ( X AICD ) Day 7 after admission; after a bowel movement

patient is turned back to supine position turnsgray codes and is intubated ( ?Aspiration)

Day 14 ID is consulted for a persistent fever onVancomycin and Cefepime with a RLLPneumonia


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Patient was on Haldol round the clock forsevere agitation attributed to ICUdelirium..initially sleep deprivation

WHAT ARE WE MISSING?

Fever, altered mental statusin an Immuno-compromised host ???????CONFOUNDERS pneumonia with

Achromobacter Xylosoxidans I to cefepime


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Noninvasive testing was ordered and so wasand LP

Serum Cryptococcal Antigen was 1:1024!!!! CSF CrAG was 1:2084 Protein was 594 Glucose was 37 CSF wbc Neutrophils Lymphocytes


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Patient was initiated on High doseFluconazole and 5 Flucytosine withoutreversal of neurological status.

He underwent trach and peg and died 2weeks after initiation of therapy.


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CSF parameter NON AIDS(%) AIDS(%)

Blood cultures - 30- 63%

Serum CrAG 66% 99%

Opening pressure>200 mmH2O

72% 62- 66%

CSF Glucose < 40mg/dl 73% 33%

CSF protein>45mg/dl 89% 58%

CSF Leukocytes > 20/mm 70% 13 -31%

CSF Culture 96% 95%

CSF CrAG 86% 91-100%


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Septic Emboli with Infective Endocarditis Brain Abscess Secondary Syphilis Parameningeal focus

Rocky mountain Spotted fever ~ Doxycycline Aspetic Meningitis like picture Leptospirosis~ water rodent exposure Hepatitis/ meningitis

LYME disease

Lymphocytic choriomeningitis ~grip like illness Influenza like

2000-3000 lymphocytes / winter peak Mumps~ peaks in winter with orchitis and parotitis

Brucellosis Midline tumors craniopharyngiomas MEDS NSAIDs ( afebrile)


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Tunkel AR, Hartman BJ, Kaplan SL, et al.Practice guidelines for the management ofbacterial meningitis. Clin Infect Dis2004;39:11267-84.

Spanos A, Harrell FE Jr, Durack DT.Differential diagnosis of acute meningitis:

an analysis of the predictive value of initialobservations. JAMA 1989;262:2700-7.

meningitis final november 4

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