Global Issue

• Meningitis kills or disables around 1.2 million people worldwide each year.

• Bacterial meningitis, which is the most severe and common form of meningitis, causes around 120,000 deaths globally every year.

Definition“Meningitis is a disease caused by the inflammation of the protective membranes covering the brain and spinal cord known as the meninges.”

Facts Of Meningitis• Meningitis may develop in response to a number of causes,

usually bacteria or viruses but meningitis can also be caused by physical injury, cancer or certain drugs.

• Viral meningitis is often less severe than bacterial meningitis and usually resolves without specific treatment.

• Those surviving meningitis can have their lives devastated as a result of long-term effects, such as deafness, brain damage, learning difficulties, seizures, difficulties with physical activities and when septicemia is involved loss of limbs.

• Meningitis can be hard to recognize in the early stages. Symptoms can be similar to those of the common flu, including: fever, vomiting, headache, stiff neck, sensitivity to light, drowsiness, muscle and leg pain.

Nasopharyngeal colonization

Local invasion

Bacteremia

Meningeal invasion

Bacterial replication in the subarachnoid space

Release of bacterial components (cell wall, LOS)

Cerebral micro vascular endothelium

Macrophages, neutrophils, other CNS Cells

Cytokines

Subarachnoid space inflammationCerebral vasculitisIncreased CSF outflow resistance

Hydrocephalus

Interstitial edema

Increased intracranial pressure

Decreased cerebral blood flow and loss of cerebro vascular auto regulation

Cytotoxic edema

Cerebral infarction

Increased BBB permeability

Vasogenic edema

Classification of MeningitisBased on duration:• Acute: symptoms present within a period of 0-24 hours.• Sub acute: symptoms lasting from 1-7 days.• Chronic: symptoms lasting over 7 days.Based on etiology:• Bacterial meningitis • Viral Meningitis• Fungal Meningitis• Parasitic Meningitis• Non infectious Meningitis Trauma, cancer or certain drugs

Bacterial Meningitis Causative agents varies

according to age:• Newborn to 3 months: Escherichia Coli, Group B Streptococci, Listeria Monocytogenes, Streptococcus

Pneumoniae, Haemophilus Influenzae type b, Neisseria Meningitides.

• Age 3 months to Adolescence: Neisseria meningitis, Streptococcus

Pneumoniae, Haemophilus Influenzae type b.

Mycobacterium Tuberculosis is most common in young children of any age.

• Adolescence to Young adults: Neisseria Meningitides, Streptococcus

Pneumoniae

• Older Adults: Streptococcus Pneumoniae, Neisseria Meningitides, Listeria Monocytogenes• Streptococcus Pneumoniae is the

most common type of Meningitis. Approximately 6,000 cases/yr

• Haemophilus Meningitis incidence has declined about 95% due to the introduction of Haemophilus Influenza b vaccine

Viral MeningitisCausative agents:• Enteroviruses• Adenovirus• Herpes Simplex Virus• Varicella-Zoster Virus• Mumps Virus• Measles Virus• Viral Meningitis is often less severe than Bacterial Meningitis.• Duration of illness approx 7 to 10 days.• Viral Meningitis occurs mostly in children younger than age 5.• There are certain diseases and medications that may weaken the immune

system and increase risk of Meningitis. For example, Chemotherapy and recent organ or Bone Marrow Transplant.

Fungal MeningitisCausative agents:• Cryptococcus Neoformans • Coccidioides Immitis • Histoplasma Capsulatum• Aspergillus Fumigatus • Candida Albicans (Yeast)

Occurrence: Rare

Mode of Transmission: • Fungal Meningitis is not contagious, usually

the result of spread of a fungus through blood to the spinal cord and also potentially contaminated medication injected into the body..

• Fungal Meningitis, people with weakened immune systems, like those with HIV infection or Cancer are at higher risk.

Treatment: Fungal Meningitis is treated with long

courses of high dose Anti-Fungal medications.

Parasitic Meningitis

Causative pathogens• Angiostrongylus Cantonensis• Cystic Echinococcosis• Naegleria FowlerOccurrence: Very rareTransmission: Spread through Warm Freshwater ( Lake, River &

Swimming Pool )

Non Infectious Meningitis

Causes:• Cancers• Systemic Lupus Erythematosus (Lupus)• Certain Drugs• Head Injury• Brain SurgeryMode of Transmission:• This type of Meningitis is not spread from person to person. Non-

Infectious Meningitis can be caused by Cancers, Systemic Lupus Erythematosus (Lupus), Certain Drugs, Head Injury and Brain Surgery.

Clinical Presentation Young Infants <3 months:• Fever or Hypothermia• Bulging Fontanel• Convulsion/Seizures• High-pitched cry and Irritability• Lethargy and Altered Mental

State• Apnea• Poor Feeding and Vomiting

Children >3 months to Adolescent:• Fever (50% of patients)• Headache, Photophobia, Stiff

Neck, Irritability, Lethargy, Vomiting and Altered Level of Consciousness

• Papilledema

Physical ExaminationKerning's Sign• It is an assessed with patient lying in Supine Position

with Hip Joint and Knee Joint flexed to 90 degree. In a patient with Positive kerning's sign pain limits passive Extension of the Knee.

Physical ExaminationBrudzinski`s Sign• A Positive Brudzinski`s sign occurs when flexion of

the Neck causes involuntary flexion of the Knee and Hip Joints.

Physical Examination

Skin Findings:• Non Specific Erythmatous,

Macular, Papular rash to a

Petechial or Purpuric rash.• TUMBLER TEST is Positive

Investigations

• Lumber Puncture (LP)• CSF Culture• Polymerase Chain

Reaction (PCR)• Blood Counts• Blood Culture• X-ray Chest• CT Scan

• Latex Agglutination• Gram Staining

CSF Normal Bacterial Meningitis

Viral Meningitis Fungal Meningitis Parasitic Meningitis

Appearance Clear Opale-scant to Purulent

Clear Normal or Cloudy Normal

Glucose(mg/ dL) 40-85mg/ dL

Normal to Marked Decrease. <40 mg/ dL

Normal (> 40 mg/dL.)

<40 mg/dL (Low) Normal or Minimal Low

Protein(mg/ dL) 15-45mg/dL

(Marked Increase) > 250 mg/dL.

<100 mg/dL (Moderate Increase)

(Moderate to Marked Increase) 25 -500 mg/ dL

Slightly Elevated

WBCs(cells/ µL) 0–5/µL (Adults / Children); 30/µL(Newborn)

>500 (Usually > 1000). Early: May be < 100.

< 100 cells/µL Variable (10 -1000 cells/µL) <500cells/µL

Increased no. of Esinophils

CSF Culture Sterile Positive Negative Positive Mostly NegativeGram`s/ZN Staining Not Seen Gram +ve Cocci

(Pneumococcai),Gram –ve Cocci(Meningococci),Gram –ve Bacilli(H.Influenzae)

No organisms are seen

No organisms are seen

No organisms are seen

Detection of Micro Organism

Negative Latex Agglutination Test, Blood Culture

CSF for PCR is the Diagnostic procedure of choice

Blood Culture Blood Culture

Management

• Monitor vital sign hourly (B.P,R/R, Pulse rate, temperature)

• Monitor input and output• Give treatment as prescribed• Keep proper ventilation• Turn patient at every 2 hours• Monitor the child's state of

consciousness and pupil size at every after hours during the first 24 hours ( thereafter every 6 hours)

• Assess for increased ICP (Intra cranial pressure)

• Measure and records the head circumference of infants

• Document the characteristics of seizure activity and duration

• On discharge ,assess all children for neurological problems, especially hearing loss

Treatment: AntibioticsAmpicillin In neanate:100-200mg/kg/day, every 6

hours

In children:200-400mg/kg/day, every 6 hours

Cefotaxime In neonate: 100-150 mg/kg/day, every 6-8 hours

In children 200mg/kg/day, every 6-8 hours

Ceftriaxone 100mg/kg, every after 12 hours or 24 hours

Gentamicin In neonate:5 mg/kg/day, every 8 hours

In children:60mg/kg/day, every 6 hours

Vancomycin In neonate:45mg/kg/day, every 8 hours

Benzyl penicillin In neonate: 100,000 units/kg/day, every 6-12 hours according to age

In children: 400,000 units/kg/day every 4 to 6 hours

Chlor-amphenicol 100mg/kg/day I/V every 6 hours (max dose 4 g/day)

Supportive Treatment

• Give Paracetamol 15mg/kg 6-8 hourly for fever (>38.5 M).• IV fluids: isotonic fluids at maintenance rate(250 ml/24hrs).• Feeding according to age requirement (75-100 kcal/kg/day).• Give anticonvulsant if convulsing.• Correct hypoglycemia if present.• NGT for feeding.• Physiotherapy.

Complication

• Increased intracranial pressure(ICP)

• Cranial nerve palsy• Seizures• Stroke• Ataxia• Inappropriate ADH secretion• Rapidly increasing head

circumference• Subdural Effusions

• Blindness• Cerebral Infarcts• Anemia• Cerebral or Crebeller Herniation• Deafness• Spasticity• Visual Handicap or Squint• Epilepsy

Meningitis According to Tibb (Unani Medicine)

MENINGIES• Dura matter (Supportive and as an

infrastructure)• Arachanoid matter(Bilious)• Pia matter(Atrabilious)• Brain( Phlegmatic)

Pia Matter Arachanoid Matter Brain

Atrabilious (Cold & Dry) Bilious (Hot & Dry) Phlegmatic (Cold & Moist)

Fever Pale eyes Papilledema

Nausea Vomiting Nausea & Vomiting

Neck Stiffness Bitter Taste Chills and Rigors

Seizures Seizures Nasal Discharge

Headache Headache Headache

Perspiration Photophobia Vertigo & Lethargy

Irritability

Rod shape Cocci shape Spiral shape

Emollient, Atrabilious Concoctive & Purgative

Exhilarant, Sedative & Hypnotics, Brain Tonic, Bilious Purgative

Phlegmatic Purgative, Emollient

Khisanda-e- Astokhuddoos, Jawarish-e-Anareen & Jawarish-e- Ood-e-tursh

Luab bahidana, sharbat- e-neelofer, mufarah-e- barid

Aab anar-e-Tursh

Sharbat-e-Badyan,Roghan-e-Kafoor

Sharbat-e-Deenar,Roghan-e-Khashkhash

Sharbat-Allu-Bukhara, Sikanjbeen-e-Sadah & Roghan-e-Gul

DIFFERENTIAL DIAGNOSIS ACCORDING TO TIBB (Unani medicine)

Sign & Symptoms

Herbal treatment

Causative pathogens

Prognosis

• It depends on patient`s age and disease severity.Mortality rate • 5% Neisseria Meningitis• 8% in Haemophillus Influenza • 25% in Streptococcal Pneumoniae• 35% of survivors have permanent deficit e.g. Deafness, Learning

Disabilities, Blindness, Seizures and Hydrocephalous.

PREVENTION

• Haemophilus vaccine (Hib vaccine) in children.• The pneumococcal conjugate vaccine is now a routine childhood

immunization and is very effective at preventing pneumococcal meningitis.

• Household members and other in close contact with people who have meningococcal meningitis should receive preventive antibiotics.

REFERENCES

• www.slideshare.net• News health(2010) management

of acute bacterial meningitis in infants and children clinical practice guidelines.

• Who (2005) pocket book of hospital care for children guidelines for the management of common illnesses with limited resources.

• www.cdc.gov• Basis of pediatrics( 8th Edition)• Tarteeb ul Adwiya