Case-based discussion: 1 History A 20-year-old medical student - - PowerPoint PPT Presentation

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Case-based discussion: 1 History A 20-year-old medical student - - PowerPoint PPT Presentation

Oct 20, 2022 109 likes •511 views

Case-based discussion: 1 History A 20-year-old medical student presents to the Emergency Department feeling generally unwell. He is wearing sunglasses and complains of a stiff neck with a pounding headache. He has vomited twice.

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History

A 20-year-old medical student presents to the Emergency Department feeling generally unwell. He is wearing sunglasses and complains of a stiff neck with a ‘pounding headache’. He has vomited twice. On examination, he is Kernig's sign positive.

Observations

HR 121, BP 101/77, RR 20, SpO2 98%, Temp 38.3

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Case-based discussion: 1

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3

Question: 1

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History

A 20-year-old medical student presents to the Emergency Department feeling generally unwell. He is wearing sunglasses and complains of a stiff neck with a ‘pounding headache’. He has vomited twice. On examination, he is Kernig's sign positive.

Observations

HR 121, BP 101/77, RR 20, SpO2 98%, Temp 38.3

4

Case-based discussion: 1

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Definition

Inflammation of the meninges due to infective (bacterial, viral, or fungal) or non-infective causes

  • S. pneumoniae and N.meningitidis are the most common

bacterial causes

  • Enteroviruses are the most common viral cause

Epidemiology

  • 5 per 100,000 population (NICE)
  • Bacterial meningitis mortality: 25% in adults
  • Viral meningitis mortality: <1%

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Introduction

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Introduction

Risk factors

  • Age
  • Immunocompromised
  • Non-immunised
  • Smoking
  • Crowded environment
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Bacteria

  • Haematogenous spread (most common)
  • Direct extension from a contiguous site
  • Release of inflammatory mediators in the CSF
  • Inflammation
  • Cerebral oedema
  • Raised ICP

Virus

  • Enteroviruses spread via faecal-oral route
  • Enter the CNS through haematogenous spread
  • See above for the inflammatory response

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Pathophysiology

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Aetiology

Bacterial meningitis Viral meningitis Fungal meningitis

Rare, but potentially fatal

  • Neonatal
  • Children
  • Adults
  • Elderly

More common, but self-limiting

  • Enteroviruses:
  • Coxsackievirus
  • Echovirus
  • Herpes simplex virus (HSV):
  • HSV-2
  • HSV-1
  • Varicella-zoster virus (VZV)

Rarely affects immunocompetent patients

  • Cryptococcus neoformans
  • Candida
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Question: 2

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Aetiology by age

Age Organism 0 to 3 months

  • Group B streptococcus
  • E. Coli
  • Streptococcus pneumoniae
  • Listeria monocytogenes

3 months to 6 years

  • Streptococcus pneumoniae
  • Neisseria meningitides
  • Haemophilus influenzae b

6 months to 60 years

  • Neisseria meningitidis
  • Streptococcus pneumoniae

> 60 years

  • Streptococcus pneumoniae
  • Neisseria meningitidis
  • Listeria monocytogenes
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Aetiology

Neisseria meningitidis (Meningococcal meningitis)

  • Colonises the nasopharynx – asymptomatic carriers
  • Droplet spread of respiratory secretions
  • Vaccination:
  • Men B and Men C
  • Men ACWY
  • Mortality: 10%
  • Typically causes a non-blanching purpuric rash
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Aetiology

  • S. pneumoniae

(Pneumococcal meningitis)

  • Droplet spread
  • Poorer outcomes compared to N.meningitidis
  • Vaccination: PCV
  • Mortality: 25%
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Aetiology

Group B streptococcus (Streptococcus agalactiae)

  • Most common cause of neonatal meningitis,

pneumonia, and sepsis

  • Colonises the vagina and transmitted during birth
  • Currently not routinely screened for
  • Intrapartum antibiotics

Risk factors

  • Prolonged membrane rupture
  • Low birthweight
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Streptococci

Beta-haemolytic Alpha-haemolytic Gamma-haemolytic

Group A streptococcus

  • S.pyogenes

Group B streptococcus

  • S.agalactiae

S.pneumoniae S.viridans Group D streptococcus

  • Enterococcus

Classified according to pattern of haemolysis on blood agar

  • Alpha-haemolytic (partial haemolysis)
  • Beta-haemolytic (complete haemolysis)
  • Gamma-haemolytic (no haemolysis)
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History

A 20-year-old medical student presents to the Emergency Department feeling generally unwell. He is wearing sunglasses and complains of a stiff neck with a ‘pounding headache’. He has vomited twice. On examination, he is Kernig's sign positive.

Observations

HR 121, BP 101/77, RR 20, SpO2 98%, Temp 38.3

15

Question: 3

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Question: 3

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Clinical features

Symptoms Signs

Meningism

  • Headache
  • Photophobia
  • Neck stiffness

Kernig’s sign

  • When the hip is flexed and the knee is

at 90°, extension of the knee results in pain Fever Brudzinski sign

  • Severe neck stiffness causes the hips

and knees to flex when the neck is flexed Nausea and vomiting Purpuric non-blanching rash

  • Meningococcal disease

Seizures Pyrexia Reduced GCS

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Clinical features

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Clinical features

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20

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Differentials

Viral meningitis Bacterial meningitis Tuberculous meningitis Encephalitis

  • Acute onset
  • Meningism
  • Usually self limiting
  • Acute onset
  • Meningism
  • May be fatal
  • Chronic onset
  • Prodromal malaise

and fever

  • Abnormal cerebral

function

  • +/- meningism
  • CSF interpretation
  • CSF interpretation
  • CSF interpretation
  • PCR and Ziehl-

Neelsen stain

  • CXR
  • CSF profile may be

similar to viral meningitis

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History

A 20-year-old medical student presents to the Emergency Department feeling generally unwell. He is wearing sunglasses and complains of a stiff neck with a ‘pounding headache’. He has vomited twice. On examination, he is Kernig's sign positive.

Observations

HR 121, BP 101/77, RR 20, SpO2 98%, Temp 38.3

22

Question: 4

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Question: 4

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Investigations

Bedside

  • Blood glucose: required to compare to CSF glucose

Bloods

  • FBC: leukocytosis
  • CRP: raised inflammatory markers
  • Coagulation profile: sepsis and DIC
  • Blood culture
  • PCR for N. meningitidis

Imaging

  • CT head: meningeal enhancement. May be conducted prior to an LP

Specialist tests

  • Lumbar puncture (LP): MCS and PCR
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Investigations

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Question: 5

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CSF interpretation

Viral Bacterial Fungal/TB

Pressure Normal/elevated Elevated Elevated Appearance Clear Cloudy Cloudy Fibrin web WCC <1000/mm

3

Lymphocytes 10-5000/mm

3

Neutrophils <1000/mm

3

Lymphocytes Glucose >60% serum glucose <50% serum glucose <50% serum glucose Protein <1g/L >1g/L >1g/L

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History

A 20-year-old medical student presents to the Emergency Department feeling generally unwell. He is wearing sunglasses and complains of a stiff neck with a ‘pounding headache’. He has vomited twice. On examination, he is Kernig's sign positive.

Observations

HR 121, BP 101/77, RR 20, SpO2 98%, Temp 38.3

28

Question: 6

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Question: 6

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Management

Antibiotics

  • Secondary care: IV cephalosporin (cefotaxime or ceftriaxone) +/- amoxicillin
  • Primary care: IV or IM benzylpenicillin if there is evidence of a non-blanching rash

Steroids

  • Dexamethasone: administered before or at the same time as antibiotics
  • Should be given within 12 hours of antibiotics
  • If pneumococcal meningitis is confirmed, continue steroid

Anti-viral

  • Aciclovir: if viral meningitis is suspected. Used to treat HSV and VZV

Adjunct

  • IVF
  • Analgesia and anti-pyretic
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History

A 20-year-old medical student presents to the Emergency Department feeling generally unwell. He is wearing sunglasses and complains of a stiff neck with a ‘pounding headache’. He has vomited twice. On examination, he is Kernig's sign positive.

Observations

HR 121, BP 101/77, RR 20, SpO2 98%, Temp 38.3

31

Question: 7

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Question: 7

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Contact tracing

Meningitis is a notifiable disease Meningococcal meningitis

  • Prolonged close contact in a household setting in the preceding 7 days before onset of

illness

  • Exposure to respiratory droplets
  • Ciprofloxacin 500mg one off dose to anyone who meets the above criteria
  • Rifampicin is an alternative

Pneumococcal meningitis

  • Prophylaxis is not usually required
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Complications

System Complication

Neurological

  • Sensorineural hearing loss
  • Seizures
  • Cerebral oedema
  • Long-term cognitive and behaviour

deficit

  • Abscess
  • Hydrocephalus

Endocrine

  • Waterhouse-Friderichsen syndrome

Other

  • Sepsis
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Top-decile question

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Top-decile question

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Recap

  • Meningitis is relatively rare but carries a high mortality
  • The most common cause are enteroviruses
  • S.pneumoniae and N.meningitidis is the most common bacterial cause
  • The definitive investigation is with CSF analysis
  • Management depends on the aetiology and involves:
  • Antibiotics
  • Antivirals
  • Corticosteroids
  • Ciprofloxacin prophylaxis is indicated for contacts of patients with meningococcal disease
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References

1. SVG by Mysid, original by SEER Development Team [1], Jmarchn / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0) 2. Microman12345 / CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0) 3.

  • Doc. RNDr. Josef Reischig, CSc. / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)

4. CDC / CC BY (https://creativecommons.org/licenses/by/2.5) 5. GrahamColm / CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0) 6.

  • R. G. Wiener, Harlem Hospital / Public domain

7. Pam Cleverley, Perry Bisman, http://babycharlotte.co.nz / CC BY-SA (http://creativecommons.org/licenses/by-sa/3.0/) 8. Blausen.com staff (2014). &quot;Medical gallery of Blausen Medical 2014&quot;. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436. / CC BY (https://creativecommons.org/licenses/by/3.0) 9. Amadalvarez / CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0)

All other images were made by BiteMedicine or under the basic license from Shutterstock and not suitable for redistribution

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