questions 9

Meningitis

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Topic updated on 09/12/17 2:51pm

Snapshot
  • A 34-year-old man is brought to the ER by his wife because she believes her husband is very ill. The patient initially had a headache that progressed to neck stiffness and an inability to look at bright lights.  His temperture is 103.1 deg F (39.5 deg C), blood pressure is 130/85 mmHg, and respirations are 20/min. Extreme pain is elicited upon flexion of the patient's neck and the patient's legs.  
Introduction
 
Neonates
Causative Agent Facts Treatment
Group B Strep (agalactiae)
  • #1 cause in neonates
  • Acquired at birth
  • Ampicillin
E. coli
  • Common in neonates
  • Aquired at birth
  • Cefotaxime
Listeria monocytogenes
  • Occurs in AIDS patients, neonates, elderly, diabetics, patients taking steroids
  • Difficult to see on Gram stain
  • Ampicillin
Children
Neisseria meningitidis (meningococcal meningitis)
  • Occurs in children > 1 yr old or adults
  • Symptoms include petechiae on trunks, legs, conjunctivae
  • 3rd generation cephalosporin such as
    • ceftriaxone
    • cefotaxime
  • Rifampin prophylaxis
H. influenzae
  • Former #1 cause in children
  • Cefotaxime
Enteroviruses
  • Viral meningitis in children of all ages
  • Often prodromal illness
  • Supportive
Adults, Elderly, and Immunocompromised
Streptococcus pneumoniae
  • #1 cause in adults, elderly, asplenic patients
  • Can progress from otitis media, sinusitis, bacteremia
  • Penicillin G or cefotaxime
Fungal (Cryptococcus, Coccidioides)
  • AIDS
  • India ink show cryptococcus in CSF
  • Cocci blastocysts seen in CSF
  • IV amphotericin 
  • 5-flucytosine (cryptococcus)
  • fluconazole (cryptococcus)
    • ppx for life or until CD4 count rises
Staphylococcus aureus
  • Trauma/neurosurgery
  • Wound infection from skin
  • Oxacillin
  • Vancomycin
TB
  • Elderly
  • Reactivation
  • Can use PCR to confirm presence of TB in CSF
  • RIPE (Rifampin, INH, Pyrazinamide, Ethambutol, extended duration)
  • corticosteroids
 
Presentation
  • Presents with
    • fever
    • neck stiffness (meningismus - can't touch chin to chest)
    • photophobia
    • altered mental status
    • seizures
  • Physical exam shows
    • positive Kernig and Brudzinski signs
  • Classic signs of menigitis may be absent in an infant less than 2 years of age
Evaluation
  • CBC may or may not reveal leukocytosis
  • Blood cultures 
  • LP for CSF studies
    • LP contraindicated if papilledema or focal neurological deficits
    • LP labs show low glucose
  • Imaging studies to rule out other etiologies
  • Order of management for Step 2/3
    • CT scan if focal neurologic deficits prior to lumbar puncture
    • best initial step: lumbar puncture
      • get cell count, stain, glucose levels
      • send for culture
    • next step: broad spectrum antibiotics
      • begin these prior to getting culture results
      • should include ceftriaxone and vancomycin
        • add ampicillin if patient is elderly or neonate/infant and steroids
      • adjust treatment based on culture results
 

Bacterial TB/Fungal Virus
Protein normal to ↑
Glucose normal
Pressure normal
Cells ↑ neutrophils
↑ lymphs
↑ lymphs
 
Treatment
  • Treat with IV antibiotics if bacterial (ceftriaxone and vancomycin for healthy adults)  
    • add dexamethasone if S. pnemonia is suspected 
  • Supportive care if non-bacterial
    • HSV and HIV can be treated
  • Treat seizures with benzodiazepine or phenytoin
  • Treat cerebral edema (loss of oculophalic reflex) with IV mannitol
  • Subdural effusions (especially common with H. influenzae meningitis) can be followed
  • Subdural empyema (presents as intractable seizures), and brain abscesses must be treated surgically
  • Prophylactic abx in close contacts 
    • rifampin
    • ciprofloxacin
Prognosis, Prevention, and Complications
  • Hyponatremia
  • Seizures
    • IV mag for for seizure prophylaxis along with benzos
  • Cerebral edema
    • presents with a loss of oculocephalic reflex
  • Subdural effusions
    • may be seen on CT
    • Occurs in 50% with H. influenzae meningitis
    • No treatment is neccesary
  • Subdural empyema
    • presents with intractable seizures
    • requires surgical evacuation
  • Brain abscess
    • requires surgical drainage
  • Control HTN with hydralazine
Snapshot
  • A 35-year-old man presents to the ED with a fever.  He states that he has a severe headache, as well as that his neck is very stiff.  When you examine the patient you see a young man in distress sitting in a dark room.  On physical exam, flexion of the patients leg or neck induces severe discomfort and pain.
Bacterial Meningitis
  • Presentation
    • suspect bacterial meningitis with the classic, cornerstone symptoms of meningitis:
      • fever
      • photophobia
      • headache
      • stiff neck
    • best initial step/best initial test
      • lumbar puncture with CSF analysis
        • decreased glucose, elevated protein, increased neutorphils
        • do not wait for culture results to begin treatment
    • next step in management/best initial therapy
      • treat with vancomycin, ceftriaxone and steroids prior to obtaining culture results
      • adjust treatment based on culture results
    • important considerations
      • do not confuse with encephalitis that presents with the same symptoms with the exception of neck stiffness → it is managed differently
Snapshot
  • A 20-year-old college student is brought to student health by his roommate who is concerned that his friend is not doing well.  The patient is minimally responsive.  You learn from the roommate that the patient has been complaining of a stiff neck and a headache recently and that he has kept to himself in his room with the lights off.  On physical exam you are alarmed when you find a diffuse petechial rash and a blood pressure of 80/40 mmHg.
Neisseria Meningitidis Meningitis
  • Presentation
    • a young college student or military recruit presents with neck stiffness, photophobia and headache
  • Best initial test/next step in management
    • lumbar puncture
      • send for CSF analysis (cell count, glucose) and culture
  • Next step in management
    • begin broad spectrum antibiotic treatment with ceftriaxone, vancomycin and corticosteroids
    • update antibiotic treatment pending culture results
      • treatment of choice is ceftriaxone
  • Unique information for N. meningitidis
    • C5-C9 deficiency and asplenia are associated
    • respiratory isolation for the patient
    • ppx with rifampin, ciprofloxacin or ceftriaxone for close contacts
    • Waterhouse-Friderichsen Syndrome
      • disseminated N. meningitidis that affects adrenal glands
      • stabilize the patient first with fluids, corticosteroids and vasopressors and begin treatment immediatley
Snapshot
  • A 77-year-old dairy salesman presents with a headache, stiff neck, and photophobia.  He is currently treated for polyarteritis nodosa with high doses of prednisone.  His past medical history is notable for mononucleosis that resulted in splenic rupture at a football game.  On physical exam you see an uncomfortable old man who has his eyes closed.
Listeria Meningitis
  • Presentation
    • patient who is elderly, a neonate, immunocompromised (HIV, steroid use, chemotherapy) presents with headache, fever, stiff neck and photophobia
  • Best initial/next step in management
    • lumbar puncture
      • send for CSF analysis (cell count, glucose) and culture
  • Next step in management
    • begin broad spectrum antibiotics with vancomycin, ceftriaxone, ampicillin and steroids
    • antibiotic of choice pending culture results is ampicillin
Snapshot
  • A 32-year-old male presents with a slow progression of symptoms.  Several days ago he had a headache, however in the past few hours he has also noticed that his neck is stiff and bright lights hurt his eyes.  Patient has a past medical history of HIV with a CD4+ count of 5 T-cells.
Cryptococcal Meningitis
  • Presentation
    • gradual onset of symptoms (headache, fever, neck stiffness, photophobia) in a HIV patient with low CD4+ count
  • Best initial test
    • India ink of the CSF
  • Most accurate test
    • cryptococcal antigen or latex particle agglutination
  • Treatment
    • intrathecal amphotericin + 5-flucytosine
    • once the patient is treated → fluconazole for life or until T-cell rises
Snapshot
  •  A 12-year-old boy presents with neck stiffness, photophobia, fever and headache.  His symptoms began the day after he returned from a boyscout trip where he was out in the wilderness for a week drawing pictures of beavers for his beaver badge.
Lyme Meningitis
  •  Presentation
    • classic meningitis symptoms in a patient that has been in the outdoors, in particulary camping
    • specific mention of exposure to a tick is not necessary for diagnosis
  • Best initial test
    • lumbar puncture and CSF analysis (cell count, glucose)
  • Most accurate test
    • serology of the CSF
    • Western blot of the CSF
  • Treatment
    • ceftriaxone is best
    • penicillin can be used
    • doxycycline and amoxicillin (children) are used for lyme disease, not lyme meningitis!
  • Unique information for Lyme disease
    • suspect Lyme meningitis if signs of meningitis + outdoor exposure or FAKE symptoms
      • facial nerve palsy (CN VII)
      • arthritis
      • kardiac block
      • erythema migrans (target rash)
Snapshot
  • A 12-year-old boy presents with a low grade fever as well as a minor headache, neck stiffness and photophobia.  A lumbar puncture is performed and demonstrates a normal glucose, a slightly elevated protein, and an increase in CSF lymphocytes.
Viral Meningitis
  • Presentation
    • suspect in a patient with classic signs and symptoms meningitis that seem more mild than usual
    • this is a diagnosis of exclusion
  • Best initial step
    • lumbar puncture and CSF analysis
    • normal glucose, elevated protein, lymphocyte predominant
  • Treatment
    • supportive therapy assuming you have ruled out other potential causes
    • do not confuse this with HSV encephalitis which must be treated with acyclovir ASAP
Snapshot
  • A 27-year-old immigrant who was just released from prison presents with symptoms that have progressed slowly over the past few months.  He currently complains of neck stiffness, photophobia and a headache that have very slowly been worsening.  Past medical history is not known, though he does state that he had a cough in his home country of Uzbekistan that was succesfully treated by his grandmother with goats milk.  On presentation he currently still has a cough.
Tuberculosis Meningitis
  • Presentation
    • suspect in immigrants and prisoners who have very slow onset of classic meningitis symptoms
    • suspect even further if there is concern for TB infection or improperly treated TB
  • Best initial step
    • lumbar puncture and CSF analysis with acid fast stain and culture
      • very high protein level, low glucose
      • acid fast stain positive (though this test is not very sensitive at all so do not rely on it)
      • culture is very difficult to perform
  • Treatment
    • RIPE therapy + steroids for an extended length of time as compared to pulmonary TB (6+ months)
      • rifampin
      • isoniazid
      • pyrazinamide
      • ethambutol
Snapshot
  • A 55-year-old man presents to the emergency department with altered mental status, a headache and a fever.  These symptoms began a few hours ago and progressed rapidly. On physical exam the patient experiences no pain when his leg is flexed or his neck is bent.
Encephalitis
  • Presentation
    • fever, confusion, focal neurologic findings without neck stiffness with or without a history of HSV
  • Best initial step in management
    • acyclovir
  • Best initial test
    • CT of the head
  • Most accurate test
    • lumbar puncture and PCR
  • Treatment
    • acyclovir is first line
    • foscarney if acyclovir resistant
  • Important points to consider
    • for Step exams an important differentiating factor from meningitis is neck stiffness
    • begin with therapy right away if you suspect encephalitis with acyclovir


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Qbank (5 Questions)

TAG
(M3.NE.15) A 62-year-old male is prescribed chemoprophylaxis following exposure to an infectious agent. He takes warfarin daily. Which of the following matches an organism with a prophylactic antibiotic appropriate for this patient? Topic Review Topic

1. Neisseria meningitidis and ciprofloxacin
2. Neisseria meningitidis and rifampin
3. Pneumocystis jiroveci and fluconazole
4. Mycobacterium avium complex and ceftriaxone
5. Treponema pallidum and azithromycin

PREFERRED RESPONSE ▶
TAG
(M3.NE.62) A 21-year-old returns home for winter vacation. A few days later she experiences severe headaches, nausea, vomiting, and neck stiffness. In the emergency department, a lumbar puncture reveals elevated intracranial pressure. Cerebrospinal fluid analysis reveals elevated protein, elevated neutrophil count, and decreased glucose. A microorganism is identified on pathology slide (Image A). The patient is admitted to the hospital and initiated on intravenous ceftriaxone and vancomycin. Her family members ask if they should also be treated. Which of the following is the best course of action if all remain asymptomatic? Topic Review Topic
FIGURES: A          

1. Close observation without immediate medical management
2. Initiate intravenous vancomycin and ceftriaxone
3. Initiate intravenous ceftriaxone without vancomycin
4. Initiate ampicillin and cefotaxime
5. Initiate oral rifampin

PREFERRED RESPONSE ▶
TAG
(M2.NE.12) A 66-year-old male presents to the emergency department with complaints of fevers, altered mental status, neck stiffness and headaches over the past 2 days. Vital signs are as follows: T 39.2, HR 101, BP 144/88, RR 18, O2 Sat 97% RA. Physical exam is significant for involuntary flexion of the bilateral hips and knees in response to passive neck flexion. He reports being treated with antibiotics for sinusitis 8 days ago. Other medical history includes a remote splenectomy and hypertension. A gram stain of the patient's cerebrospinal fluid is shown in Figure A. Of note, the patient's serum glucose at this visit is 120 mg/dL. Which of the following findings would be expected on further analysis of this patient's cerebrospinal fluid? Topic Review Topic
FIGURES: A          

1. Glucose 40 mg/dL
2. WBC count 500 cells/mm^3
3. Protein 20 mg/dL
4. Opening CSF pressure 160 mm H2O
5. 20% polymorphonuclear leukocytes

PREFERRED RESPONSE ▶
TAG
(M2.NE.58) An 18-year-old female college student is brought to the emergency department by ambulance for headache and altered mental status. The patient is accompanied by her boyfriend, who lives with her, and states she had not been feeling well for the past day. He states she has vomited several times in the past 12 hours. Lumbar puncture is performed in the emergency room, and the patient is admitted with contact precautions. Microorganisms are seen on Gram stain (Figure A), and appropriate treatment is initiated. Who of the following requires antibiotic prophylaxis? Topic Review Topic
FIGURES: A          

1. Patient’s boyfriend
2. Paramedics in ambulance
3. Neurologist who performed lumbar puncture
4. Nurses on the floor of the patient
5. None of the above

PREFERRED RESPONSE ▶
TAG
(M2.NE.204) A 21-year-old female college student presents with headache, malaise, and fever of 3 hours duration. Past medical history is unremarkable and the patient does not take medications. She denies recent alcohol or drug use. Temperature is 39°C, blood pressure is 110/70 mmHg, pulse is 76/min and respirations are 17/min. Physical examination is notable for a petechial rash present in the lower extremities bilaterally. Extension of the knee when both the hip and thigh are flexed produces pain. Which of the following is the most appropriate next step in management? Topic Review Topic

1. MRI of the head
2. Ampicillin
3. Blood cultures
4. Head CT
5. Ceftriaxone

PREFERRED RESPONSE ▶
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e Gans J, van de Beek D; European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators.
Lancet. 2001 May;357(9266):1391-6. PMID: 12432041 (Link to Pubmed)
6/4/2013
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