Meningitis

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Clinical Description

Clinical syndrome characterized by inflammation of the meninges.

Causes:

  • Viruses: Herpes simplex Virus, enteroviruses
  • Bacteria: Streptococcus Pneumoniae, Staphylococcus Aureus, Haemophilus Influenza, Meningococcal TB
  • Fungal: Cryptococcus Neoformans

Clinical FeaturesSIGNS AND SYMPTOMS

  • Headache, Photophobia, Fever, Neck stiffness, Seizures, Altered mental status, Positive Babinski, Positive Kernig’s sign

INVESTIGATIONS

  • FBC, Blood glucose, HIV status, Lumbar Puncture, Microscopy, chemistry and culture (CSF for gene X-pert if suspect TB meningitis), India ink and Cryptococcal antigen, Blood culture

 

TreatmentPHARMACOLOGICAL

  • Assess and manage Airway, Breathing, Circulation and Disability
  • Treat seizures as per protocol
  • Neuroprotective measures
  • Analgesia as per WHO pain ladder
  • Bacterial meningitis
    • Ceftriaxone 100mg/kg IV q24h (maximum dose 2g) for 10 to 14 days
      • Adjust treatment as guided by culture results
  • Viral encephalitis
    • Acyclovir 10mg/Kg IV 8 hourly for 10 days if suspecting Herpes Simplex or Varicella encephalitis
  • Cryptococcal meningitis
    • Induction Phase
      • Option 1: Liposomal Amphotericin B + Flucytosine for 7 days
        • Amphotericin B 6mg/kg IV over 6 hours daily
        • Flucytosine 100mg/kg/day PO divided into 4 doses
      • Option 2: Fluconazole + Flucytosine for 14 days
        • Fluconazole 12mg/kg (max 800mg) q24h
        • Flucytosine 100mg/kg/day PO divided into 4 doses
      • Option 3: Liposomal Amphotericin B + Fluconazole for 14 days
        • Amphotericin B 3-4 mg/kg IV over 6 hours daily. Use up to 6 mg/kg for treatment failure or serious disease
        • Fluconazole 12mg/kg (max 800mg) q24h
    • Consolidation Phase 
      • Fluconazole 12mg/kg PO (maximum 800mg) daily for 8 weeks
    • Maintenance Phase
      • Fluconazole 6mg/kg PO daily, life long
  • TB meningitis
    • Intensive treatment HRZE for 2 months
    • RH for 10 months
    • Prednisolone 2-4mg/kg/day for 3 weeks, taper dose over 3 weeks
    • Pyridoxine 25mg daily

 

NON-PHARMACOLOGICAL

  • Hearing assessment
  • Refer for Intensive Medical rehabilitation Services.
  • Serial head circumference measurement

Complications:

Brain abscess, Cranial nerve palsies, Seizures, SIADH, Stroke, Learning disability, Developmental regression, Hearing loss, Hydrocephalus 

Referral

  • Suspected brain abscess
  • Signs of raised intracranial pressure
  • Not responding to treatment