Meningitis

Adapted from
source
 Mr B J - 24yr old male
0900hrs – 1st Presentation with 48 hrs of Right earache

History = spontaneous onset

had seen GP day prior / had ear syringed
prescribed otodex drops

PHx of previous wax impaction otherwise healthy

Nil Medications and Nil Allergies

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

Exam : no discharge / no mastoid tenderness

 Signs in keeping with otitis externa

 Refused analgesia

Plan - discharged with no change in management

but advised to return if worsening
1826hrs returns to ED

Pc : headache + ongoing ear ache

HPc: after discharge earlier had gone to work

- later at 1500hrs developed some generalised headache
but mostly focused to right ear and right side face

- pain despite Paracetamol + Nurofen alternating

- Associated with some nausea but no vomiting

- No photophobia + walked into department

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

Exam
 slightly unwell looking + ? dehydrated
 Alert / Orientated / Not in obvious distress

 Warm / well perfused / No lymphadenopathy

 No rashes / No neck stiffness / Kernigs negative

 Throat erythematous but no pus or exudate evident

 Left ear completely normal

 Right ear canal sloughy + unable to fully visualise drum

 ? Small perforation / ? Discharge or otodex drops

 No mastoid tenderness

 Other systems normal

Impression : Febrile illness ? viral / ? Bacterial

(comment )

Plan : iv access + analgesia + bloods

Trial of fluid rehydration + analgesia

Observe for 2 hours in ED

2135hrs ( department very busy and patient moved )

Reviewed : girlfriend says ‘he keeps dropping off’

 Temp 39.6 / HR 86 / RR 18 / Sats 100% / BP 149 / 78

 Looking ‘ more sick ’ / pale / sweating

 Drowsy but rouses + says headache has intensified

 Remains orientated + cooperative

 Neck stiffness ++ / now holding vomit bag

Immediately taken into Resusciation

 Given hydrocortisone 200mg iv stat

 Given 4 gram Cetriaxone iv stat

 Unable to contact CT radiographer

 ABG ph 7.44 / PCO2 33 / PO2 128 / BE -3

 Blood Glucose 8 / istat electrolytes normal

Discussed with neurology consultant in RBWH

Agrees that LP can be done if fundoscopy ok

Post LP increasingly uncooperative

CT Head arranged + admission to ICU

Post CT agitated Anaesthetics notified ( located by security )

Addition of Vancomycin 1 gram iv

 Investigations …
WCC 14.6 / neut 11.3 / CRP 75

Lumbar puncture
 Glucose 1.8 ( 2.2 -3.9 )protein 2500 ( 150 – 500 )
 WCC 12150 / RCC 80 ( 94% polymorphs )
 Gram + cocci

Culture Streptococcus pneumoniae

 ( Sensitive to Cetriaxone /MIC 0.016 Penicillin G )

CT Head No signs raised intracranial pressure

Opacification of mastoid air cells and middle ear

on right side consistent with collection
Gram stain CSF …
Gram stain CSF …
CT head
 Progress …
 Remained combative overnight with special required
 Eventually intubated for GCS 6/15 in morning prior to
transfer to RBWH by retrieval team

 Middle Ear washed out surgically by ENT

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

 Day 5 – 24 hours post extubation full neurological recovery

 Remains on dexamethasone / Benzylpenicillin Q4hrly via
PICC
 Questions …

1. Does ‘headache + fever’ mean LP ?

2. Whose responsibility is ‘isolation’ in this hospital ?

3. Should Anaesthetics have intubated this patient ?

 GCS documented by ICU nurse as fluctuating 4/15 to 9/15
 Mannitol infusion started + glucose infusion
 GCS documented by Schmidt 7/15
 Intubated by retrieval team
 Complications of LP …

 Pain
 Failure
 PDPH
 Site related bruising / ‘back ache’
 Leg pain … normally brief ( 10 %)
 Lower limb weakness ( 1 in 10 000 temporary vs
permanent )
 Bleeding ( rare situation can be serious )
 Infection
 Brain herniation
The triad of fever, nuchal rigidity, and change in mental status is
found in only two thirds of patients. In a meta-analysis of 845
patients, the sensitivity and specificity of these classic symptoms
were poor

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

and headache are less common

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

absence of fever, neck stiffness, or altered mental status
eliminates the diagnosis of meningitis in 99-100% of cases)

Signs of meningeal irritation are observed in only approximately

50% of patients with bacterial meningitis, and their absence
certainly does not rule out meningitis
 Mortality/Morbidity
 The mortality rate for viral meningitis (without
encephalitis) is less than 1%

 Bacterial meningitis was uniformly fatal before the

antimicrobial era. With the advent of antimicrobial
therapy, the overall mortality rate from bacterial
meningitis has decreased but remains alarmingly high. It is
reported to be approximately 25%

 Among the common causes of acute bacterial meningitis,

the highest mortality rate is observed with pneumococcus

 The reported mortality rates for each specific organism

are 19-26% for S pneumoniae meningitis, 3-6% for H
influenzae meningitis, 3-13% for N meningitidis meningitis,
and 15-29% for L monocytogenes meningitis
 S pneumoniae
Gram-positive coccus, remains an important bacterial
pathogen in humans

It is a common colonizer of the human nasopharynx (5-10% of healthy

adults and 20-40% of healthy children)

It causes meningitis by escaping the local host defense and phagocytic

mechanisms, either through choroid plexus seeding from bacteremia
or through direct extension from sinusitis or otitis media

 Presently, it is the most common bacterial cause of

meningitis, accounting for 47% of cases

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

among the bacterial agents that cause meningitis (19-26%)
 S pneumoniae
 It is the most common bacterial agent in meningitis
associated with basilar skull fracture and CSF leak

 It may be associated with other foci of infection, such as

pneumonia, sinusitis, or endocarditis

 Patients with hyposplenism, hypogammaglobulinemia,

multiple myeloma, glucocorticoid treatment, defective
complement (C1-C4), diabetes mellitus, renal insufficiency,
alcoholism, malnutrition, and chronic liver disease are at
increased risk
 Antibiotic(s)
Gram-positive cocci = Vancomycin plus ceftriaxone
or cefotaxime

Gram-negative cocci = Penicillin G*

Gram-positive bacilli = Ampicillin plus an

aminoglycoside

Gram-negative bacilli = Broad-spectrum cephalosporin

plus an aminoglycoside
 S pneumoniae
 The increasing incidence of penicillin-resistant strains has
changed the management of pneumococcal meningitis

 The third-generation cephalosporins (ceftriaxone 2-4 g/d

or cefotaxime 8-12 g/d) with vancomycin (2-3 g/d,
adjusted to therapeutic serum levels) are first-line empiric
therapy, depending on the resistance patterns in the
community

 The use of corticosteroids such as dexamethasone as

adjunctive treatment for pneumococcal meningitis is now
supported by recent studies demonstrating significant
benefit with regards to reduction in case-fatality rate and
neurologic sequelae

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

for penicillin-susceptible strains.
 Long-term neurologic sequelae

Can be grouped into 3 categories :

 Hearing impairment

 Obstructive hydrocephalus

 Brain parenchymal damage: This is the most important

feared complication of bacterial meningitis. It could lead to
sensory and motor deficits, cerebral palsy, learning
disabilities, mental retardation, cortical blindness, and
seizures.
 Prognosis
 Patients with viral meningitis usually have a good
prognosis for recovery

 The prognosis is worse for patients at the extremes of age

(ie, <2 y, >60 y) and those with significant comorbidities
and underlying immunodeficiency

 Patients presenting with an impaired level of

consciousness are at increased risk for developing
neurologic sequelae or dying

 A seizure during an episode of meningitis also is a risk

factor for mortality or neurologic sequelae
 Take home …

 Acute bacterial meningitis is a medical

emergency and delays in instituting effective
antimicrobial therapy result in increased
morbidity and mortality

 Don’t forget steroids prior to antibiotics and

do not delay treatment for investigations