Meningitis

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Meningitis is an inflammation of the membranes surrounding the brain and spinal cord.

Causes

  • Viral infection (common)
  • Bacterial infections (streptococcus, pneumococcus, meningococcus, listeria)
  • Tuberculosis
  • Fungal infection e.g. Cryptococcus neoformans
  • Protozoa e.g. Toxoplasma in HIV-AIDS

Signs and symptoms

Triad of symptoms

  • Headache
  • Fever
  • Neck stiffness

Other symptoms

  • Impaired consciousness
  • Rash
  • Convulsions
  • Photophobia

Differential diagnosis

  • Subarachnoid haemorrhage
  • Tetanus
  • Brain abscess
  • Cerebral malaria

Complications

  • Cranial nerve palsies
  • Cerebral infarction
  • Empyema
  • Stroke
  • Multiple seizures
  • Ataxia
  • Syndrome of Inappropriate Anti-Diuretic Hormone (SIADH) secretion

Investigations

  • Full blood count
  • Blood film for malaria parasite
  • HIV screening
  • Mantoux test, if TB is suspected
  • Chest radiograph to exclude TB, and in cases of pneumococcal meningitis.
  • Lumbar puncture to examine the CSF.
    • High neutrophils in CSF suggest bacterial infection
    • High lymphocytes suggest viral or TB meningitis
    • Low sugar in CSF could be bacterial or TB but not viral meningitis
    • High protein in CSF in most types of meningitis
    • CSF pressure may be high.
    • CSF should also be examined and cultured for bacteria
  • Blood culture and sensitivity

Treatment objectives

  • Eradicate the infecting organism
  • Reduce intracranial pressure
  • Manage CNS and systemic complications
  • Correct metabolic derangements
  • To prevent spread to contact

Non-pharmacological treatment

  • Counsel on, and encourage good nutritional habit
  • Urgently inform local and other relevant authorities if epidemic meningitis is suspected
  • Reduce fever with tepid sponging or using water at room temperature (i.e. around 32.2°C- 35°C).
  • Keep airways clear

Pharmacological treatment

Adult:

  • Antibiotics should be given for a minimum of 14 days.
  • Empirical antibiotic treatment should be intravenous, initially for a minimum of 7 days, and should be started without delay.
  • This may be changed to oral therapy with significant clinical improvement.
  • Ceftriaxone may be administered for all types of bacterial meningitis before culture results are available.

Ceftriaxone

2 g IV every 6 hours for 7 days or more.

THEN

Amoxicillin/clavulanic acid oral

1 g orally every 6 hours for the remainder of the treatment course

 

For pneumococcal meningitis

Benzylpenicillin IV

4 mega (million) units by slow intravenous injection every 6 hours 

THEN

Chloramphenicol oral

500 mg orally every 6 hours for remainder of treatment course

Child:

  • All antibiotic treatment should be by the intravenous route for a minimum of 10 days in children, and should be started without delay.

Benzylpenicillin IV

0.2 mega (million) units/kg body weight IV every 6 hours

PLUS

Chloramphenicol oral

25 mg/kg body weight IV every 6 hours

 

Alternatively, for all types of bacterial meningitis

Ceftriaxone IV

50-60 mg/kg body weight intravenously once daily for 7 days

 

Tuberculous meningitis

4 fixed-dose combinations (FDC) RHZE for 2 months (rifampicin, isoniazid, pyrazinamide and ethambutol)

FOLLOWED BY

2 FDC (rifampicin and isoniazid) for 7-10 months depending on the age of the patients.

Adult:

4 FDC (RHZE 150/75/400/275 mg)

2 FDC (RH 150/75 mg)

Child:

3 FDC plus Ethambutol 100 mg (RHZ 75/50/150 mg)

2 FDC (RH 75/50mg)

PLUS

Prednisolone 2-4 mg/kg/day

 

Prophylaxis for meningococcal meningitis

Prophylactic treatment is recommended for patients 2 days prior to discharge and also for their close contacts

Ciprofloxacin, oral

Adult: 500 mg as a single dose (Avoid in pregnancy)

Child:             

5-12 years: 250 mg as a single dose

 

OR

Ceftriaxone IM

Adult:  250 mg as a single dose by deep IM injection

Child: 

Under 12 years: 125 mg as a single dose by deep IM injection

Prevention

Encourage the following vaccinations which are the most effective way to prevent meningitis of certain aetiologies:

  • Meningococcal vaccines (N. meningitidis)
  • Pneumococcal vaccines (S. pneumoniae)
  • Hib vaccines (H. influenzae B)

Encourage healthy habits:

  • Careful, regular hand washing with soap and water to prevent the spread of germs.
  • Cessation or avoidance of cigarette smoking, and persons who smoke
  • Avoid close contact with ill persons

Referral

Patients with meningitis not responding to treatment should be referred for specialist care.