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MeningitisCommonly Asked Questions
Stephen J. Gluckman, M.D.
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What are normal CSF findings?
• Protein– 0.45 gm/L– Elevated with Diabetes– Elevated with neuropathies of any cause– Elevated with increasing age– Elevated by bleeding into the CSF (SAH or
traumatic)• 0.01 gm/L for every 1000 RBC’s
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What are normal CSF findings?
• Glucose– 60 % of blood glucose
• In persons with hyperglycemia it takes several hours for CFS and blood glucose to equilibrate
– Low CSF glucose• Bacterial infection• Tuberculosis, cryptococcosis, carcinomatous• SAH• Sarcoidosis• Occasional viral
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What are normal CSF findings?
• Cell count– <5 WBC (all mononuclear) and < 5 RBC
considered “normal”– Traumatic tap
• WBC/RBC ratio = 1:1000
• Pressure– <20
• In patients with bacterial meningitis– wide range– 40% >30, 10% < 14
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Can the CSF reliably distinguish between a bacterial and non-bacterial cause of
meningitis?
Usually
Look at the whole pattern!
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Can the CSF reliably distinguish between a bacterial and non-bacterial cause of
meningitis?
• Glucose– <2.5 suggests bacterial– < 0.5 highly suggests bacterial
• Protein– > 2.5 suggests bacterial
• Cell count– >500 suggests bacterial– >1000 highly suggests bacterial
• % polys– >50 suggests bacterial
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Are there exceptions?
• Early viral can have a predominance of polys
• Some viral can have low CFS glucose
• Listeria can have predominance of mononuclear cells rather than polys
• TB can have predominance of polys
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How much does prior administration of antibiotics alter the CSF findings?
Not Much
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How much does prior administration of antibiotics alter the CSF findings?
• 48-72 hours of prior intravenous antibiotic treatment has little effect on glucose, protein and cell count– It will rarely change the CSF from a “bacterial”
to an “aseptic” formula
• Prior antibiotic treatment will likely make the cultures negative.
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What is the typical clinical presentation of bacterial meningitis?
• History– Headache: 75-90%– Photophobia: uncommon
• Examination– Fever: 95%– Stiff Neck: 85%– Altered mental status: 80%– All three: 40%– Any one of the three: 100%
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How “good” are Kernig and Brudzinski signs?
• Originally related to severe, advanced TB meningitis (not bacterial)
• Not studied in a prospective study until 2002 (N=297)*– Sensitivity 5%– Specificity 95%
*Thomas KE et al. Clin Infect Dis. 2002;35:46-52
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What are the common causes of bacterial meningitis?
• It depends upon age and risk factors– Age
• Neonates: listeria, group B streptococci, E. coli• Children: H. influenza• 10 to 21: meningococcal• 21 onward: pneumococcal >meningococcal• Elderly: pneumococcal>listeria
– Risk factors• Decreased CMI: listeria• S/P neurosurgery or opened head trauma: Staphylococcus,
Gram Negative Rods• Fracture of the cribiform plate: pneumococcal
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What is the proper empirical antibiotic regimen for presumed bacterial meningitis?
It depends upon the clinical situation
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What is the proper empirical antibiotic regimen for presumed bacterial meningitis?
• Neonates– 3rd generation cephalosporin and ampicillin
• Children– 3rd generation cephalosporin
• Normal adult– 3rd generation cephalosporin and vancomycin (if resistant
pneumococci)• Problems with cell mediated immunity (AIDS, steroids,
elderly)– Add coverage for listeria with ampicillin or co-trimoxazole
• S/P CNS trauma or neurosurgery– Coverage for staphylococcus and gram negative rods with
antipseudomonal beta-lactam and vancomycin
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How important is the speed of initiating antibiotics in bacterial meningitis?
It is important
But it is not the critical prognostic factor
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How important is the speed of initiating antibiotics in bacterial meningitis?
• The clinical outcome is primarily influenced by the severity of the illness at the time antibiotics are initiated– Severity based on
• Altered mental status• Hypotension• Seizures
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How important is the speed of initiating antibiotics in bacterial meningitis?
• No factors– 9% with adverse outcome
• One factor– 33% with adverse outcome
• Two or three factors– 56% with adverse outcome
Therefore, though treatment should be administered ASAP, the impact of antibiotic delay is a function of the severity of disease at the time that treatment is initiated
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Steroids or no Steroids?
Steroids
(today)
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Steroids or no Steroids?
• Reduces morbidity and mortality*
• Give before or at the same time as the first dose of antibiotics
• Dose studied– Dexamethazone 10 mg Q6H x 4 days
*Only shown for pneumococcal meningitis in adults and haemophilus meningitis in children
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Do you need to do a CT scan before an LP?
Usually not
• A CT scan should never delay therapy (obtain blood cultures)
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Do you need to do a CT scan before an LP?
• Prospective studies*– N = 412– Predictors of CNS mass lesion
• History– > 60 years old– Immunocompromised– Hx of prior CNS disease– Hx of seizure w/in 1 week prior to onset
• Examination– Focal neurological findings– Altered mental status– Papilledema
*Gopal et al. Arch Intern Med. 1999;159:2681-5 Hasbun and Abrahams. N Engl J Med 2001:345:1727-33
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How contagious is meningitis?Are we at risk when we care for a patient?
• Not really
• The only bacterial meningitis that is spread from person to person is meningococcal– The risk is very low
• Household contacts have about a 1% risk• Health care workers have not been shown to have
a risk• After 24 hours of treatment this is no risk
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What is “Aseptic” meningitis?
• It is a term used to mean non-pyogenic bacterial meningitis
• It describes a spinal fluid formula that typically has:– A low number of WBC– A minimally elevated protein– A normal glucose
• It has a much bigger differential diagnosis than viral meningitis.
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What are the treatable causes of aseptic
meningitis/encephalitis syndrome?• Infectious
– HSV 1 and 2– Syphilis– Listeria (occasionally)– Tuberculosis– Cryptococcus– Leptospirosis– Cerebral malaria– African tick typhus– Lyme disease
• Non-Infectious– Carcinomatous– Sarcoidosis– Vasculitis– Dural venous sinus
thrombosis– Migraine– Drug
• Co-trimoxazole• IVIG• NSAIDS
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What are the important things to know about AIDS- associated cryptococcal meningitis?
• Generally advanced with CD4 < 100
• Sub-acute onset: fever, headache– Stiff neck is rare
• Mortality with treatment is about 15%!– Predictors of death
• Altered Mental status, low CSF WBC count, high CSF cryptococcal antigen titer
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What are the important things to know about AIDS- associated cryptococcal meningitis?
• CSF findings– Elevated pressure is the usual (>70%)– Rest of CSF findings are often unimpressive
• WBC <50• Glucose: normal or slightly low• Protein: normal or slightly elevated• 25% have normal WBC, glucose and protein
– CSF cryptococcal antigen: 95-100% sensitive
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What are the important things to know about AIDS- associated cryptococcal meningitis?
• Treatment– Medical
• Induction: amphotericin B 0.7mg/kg x 2/52 – (flucytosine)
• Consolidation: fluconazole 400 mg x 8/52• Maintenance: fluconazole 200 mg
– Pressure• Daily LP’s to keep opening pressure <20• If LP’s are still needed after 1 month shunt
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Questions from the Audience?
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Meningitis – Who was awake?
Which of the following are true statements?
a. Early viral meningitis can have a predominance of polys
b. Some viral meningitis can have low CSF glucose
c. Listeria meningitis can have predominance of mononuclear cells rather than polys
d. All of the above
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Meningitis – Who was awake?
Which of the following are true statements?
a. Early viral meningitis can have a predominance of polys
b. Some viral meningitis can have low CSF glucose
c. Listeria meningitis can have predominance of mononuclear cells rather than polys
d. All of the above
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Meningitis – Who was awake?
To correct CSF protein concentrations for blood in the CSF the proper ratio is approximately 0.01 gm/L of protein for every 100 RBC’s
a. True
b. False
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Meningitis – Who was awake?
To correct CSF protein concentrations for blood in the CSF the proper ratio is approximately 0.01 gm/L of protein for every 100 RBC’s
a. True
b. False
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Meningitis – Who was awake?
• Which of the following are true about cryptococcal meningitis?– a. A normal CSF effectively rules out
cryptococcal meningitis– b. If the CSF pressure is elevated one should
not remove more than 10 ml at a time– c. Everyone with HIV infection is at increased
risk for cryptococcal meningitis.
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Meningitis – Who was awake?
• Which of the following are true about cryptococcal meningitis?– a. A normal CSF effectively rules out
cryptococcal meningitis– b. If the CSF pressure is elevated one should
not remove more than 10 ml at a time– c. Everyone with HIV infection is at increased
risk for cryptococcal meningitis.
None