QUESTIONS

MENINGITIS
- inflammation of the arachnoid & pia mater associated with the presence of bacteria,
viruses, fungi or protozoa in the CSF,
- inflammation of the meninges which cover/line the brain or spinal cord

1. Discuss viral meningitis; causing pathogens, signs & symptoms, treatment &
management.

Viruses; Signs & symptoms; Treatment;

- echoviruses, • acute onset of low grade fever, headache, • Usually require no
coxsackie, photophobia & neck stiffness. Remain alert & specific tx
mumps or orientated unless develop encephalitis. • Symptomatic tx is
herpes virus • Headache >severe feature than meningism the usual tx and bed
• CSF exam shows an increase in lymphocytes rest
& proteins but still appear clear • Recovery occurs
Usually benign & self-limiting within a few days

2. Discuss bacterial meningitis; causing pathogens & signs & symptoms.

Bacteria; Signs & symptoms;

-In older children & adults;
neisseria meningitidis (gram –
ve) & strep pneumoniae (gram
+ve)
-in non-vaccinated young
children, H. influenzae type B
(Hib). (gram +ve)
-In neonates & infants <3/12;
strep agalactiae (group B strep)
& aerobic Gram –ve rods
(E.coli, proteus sp)
-Listeria monocytogenes (gram • Other signs of cerebral dysfunction are present;
+ve) now very uncommon &
occurs mainly in
immunocompromised,
diabetics, alcoholics &
pregnant women
-In skull fracture or post
surgery, staph sp
• Acute onset of headache
• Neck stiffness (meningism)
• Photophobia
• Fever
• Vomiting
• Weakness
• +ve Kernig sign (meningism)
• If left untreated, pt deteriorate rapidly, develop
seizures, cranial nerve palsies, loss of sensory
capabilities, LOC, death
• If complicated by septicaemia may lead to septic
shock
• May have haemorrhagic rash (Meningococcal?)
confusion, delirium, declining level of consciousness
ranging from lethargy to coma
• Focal neurological deficits; visual field deficits,
dysphasia
• Cranial nerve palsies; weakness/paralysis of the areas
the sp cranial nerve affected supply

3. Detail the antibiotic treatment of bacterial meningitis; empirical & directed

antibiotic treatment.

- Prompt & early therapy is important

 - if suspect meningococcaemia on clin grounds (fever + rash +headache) give stat
parenteral benzylpenicillin or ceftriaxone b4 transfer to hosp
- In hosp, if pt has not received high-dose penicillin & all tests incl a lumbar puncture
will be delayed >20min, give dexamethasone & empirical a/biotic
- a/biotics should not be w/held while awaiting a computerised tomography (CT) scan
or PCR testing
- LP should be performed asap as CSF microscopy & culture are vital in directing tx
and the possible use of corticosteroids
- Blood culture & throat swab culture (for meningococci) should be collected asa pt
arrives in hosp to maximize the chance of culturing the org
- Empirical tx;
o Should cover the most common pathogen
o In pt >3 months y/o, use:
1. ceftriaxone 4g IV d or ceftriaxone 2g IV bd
2. cefotaxime 2g IV q6h
plus;
{dexamethasone 10mg IV, starting b4 or with the 1st dose of a/biotic,
then q6h for 4 days}
o A/biotic should not be delayed if cortocosteroids are not available
o Listeria monocytogenes is resistant to cephalosporins. If pt is
immunosuppressed or Listeria infection is suspected, ADD to the
above regimen;
{benzylpenicillin 2.4 g IV q4h}

o Once the org has been identified & susceptibility results are
available, choose the appropriate directed regimen
o If no pathogen is isolated, continue the empirical a/biotics for a
total minimum of 10 days, depending on response
o Dexa should be continued for a total duration of 4 days

Neisseria H. Strep pneumoniae Listeria

meningitidis influenza monocytogenes
type b
{benzylpenicillin 1.ceftriaxo For penicillin- susceptible {benzylpenicillin
1.8g IV q4h for 3- ne 4g IV d strain(MIC<0.125 mg/L) 2.4g IV q4h}
5 days} for 7 days {benzylpenicillin 2.4g IV, q4h for
or 10-14 days} Hypersensitivity;
In hypersensitivity ceftriaxon {trimethoprim +
(excl immediate) e 2g IV bd For ceftriaxone/cefotaxime-susc str sulfamethoxazole
use; for 7 days (MIC<1mg/L): 160+800mg IV
{ceftriaxone 4g IV or 1.ceftriaxone 4g IV d for 10-14 days q6h}
d for 3-5 days or or
ceftriaxone 2g IV 2.cefotaxi ceftriaxone 2g IV bd for 10-14 days Usual duration of tx
bd for 3-5 days} me 2g IV or is 3 weeks, w
q6h for 7 2.cefotaxime 2g IV q6h for 10-14 extension to 6
in immediate days days weeks in
hypersensitivity, immunocompromise
use; For str w pen MIC>0.125mg/L & d pt.
{ciprofloxacin ceft/cefo MIC 1-2 mg/L, use;
400mg IV bd for {ceftr/cefo + vanco} Oral tx w co-
3-5 days} trimoxazole may be
Immediate hypersensitivity; use used to complete
{vanco + ciprofloxacin} the course after
Or {moxifloxacin} initial 3 weeks if
there has been a
Severely ill pt may req tx for up to 3 good response to IV
weeks tx

4. Detail the chemoprophylaxis for bacterial meningitis, according to the causing

pathogens.

Neisseria meningitidis Haemophilus influenzae type b

1. ceftriaxone 250mg IM {rifampicin 600mg d for 4 days}
stat (preferred for Or, if deemed unsuitable, use
pregnant women) {ceftriaxone 1g IM d for 2 days}
1. ciprofloxacin 500mg stat
(preferred opt for women Pt < 2y/o commence a full course of Hib vaccination
taking ocp) asap after recovery, regardless of any previous Hib
1. rifampicin 600mg bd for vaccination
2 days (preferred for
children) Unvaccinated contacts <5y/o should be immunized
asap

5. Discuss encephalitis; definition, causing pathogen, signs & symptoms, treatment &
management.

• An acute inflammatory disease of the brain substance (cortex, white matter, basal
ganglia)
• Usually caused by direct viral invasion or to hypersensitivity initiated by a virus or
other foreign protein
Pathogen: Signs & symptoms: Treatment:
-very rarely caused by; o Progressive headache o Specific a/viral, a/fungal,
o Protozoa & fungi eg o Fever a/biotic tx should be
toxoplasma gondii & o Alterations in cognitive initiated where
cyptococcus state (confusion, appropriate
neoformans behavioral change or o a/convulsant tx for seizure
o Bacteria dysphasia), disoriented o a/pyretic prn
o But likely pathogen o Consciousness may range o support in an ICU is often
dramatically from drowsiness to coma req to
influenced by o Focal neurological sx; -maintain ventilation (b/c
geograpgic location, - paresis or seizures (focal decreased conscious
history of travel, or generalized) state)
animal exposure & - aphasia (loss of speech) -protect airway
vaccination o Upper motor signs -manage complications eg
-In Aus, HSV the most (hyperreflexia & extensor- cerebral oedema &
common cause of non- plantar responses) are hypoglycaemia
seasonal encephalitis often present, but flaccid o fluid restriction
-In the absence of paralysis & bladder sx may o monitoring of intracranial
particular risk factor, occur if the spinal cord is pressure (cerebral
other common causes involved oedema)
are o Assoc movt disorders o in Herpes simplex
o Enteroviruses (ataxia, myoclonic jerks) or encephalitis; for adults &
o Influenza virus the syndrome of children in suspected or
o Mycoplasma inappropriate antidiuretic proven cases, use
pneumoniae hormone secretion may be {acyclovir 10mg/kg IV q8h
seen for at least 14 days – adjust
o Cerebral oedema dose for renal fn}