Meningitis

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This is inflammation of the meningeal covering of the brain or spinal cord. Common causes include bacteria (Streptococcus pneumoniae, Group B Streptococcus, E. coli, H. influenzae type b, Neisseria meningitides, Listeria, syphilis, TB), viral (e.g. coxsackie, polio, Measles, Mumps, Influenza, Herpes simplex, HIV), fungal (e.g. Cryptococcal) and non-infectious conditions such as SLE and malignancies.

Bacterial Meningitis

Description

This is inflammation of the meningeal covering of the brain or spinal cord. Common causes include Streptococcus pneumoniae, Group B Streptococcus, E. coli, H. influenzae type b, Neisseria meningitides

Signs and Symptoms

  • Headache
  • Neck stiffness/ache (common)
  • Photophobia
  • Fever
  • Vomiting
  • Seizures
  • Confusion, Drowsiness, Loss of consciousness
  • Vascular collapse characterized low blood pressure (hypotension) and (Waterhouse - Friderichsen syndrome)
  • Petechae skin rash
  • Positive Kernig or Brudzinski’s sign
  • Cranial nerve palsies (facial nerve, oculomotor nerve palsies and occasional deafness)

Investigations

  • Cerebral Spinal Fluid analysis
    • CSF color that is cloudy
    • Low CSF glucose
    • CSF positive gram stain
    • Positive culture and organism identification
    • Rapid antigen test for streptococcus
    • Multiplex PCR (if available)
  • Supportive tests
    • HIV testing should be offered to all patients whose HIV status in unknown
    • Full blood culture
    • Kidney function tests and electrolytes
    • Malaria parasite slide
    • Blood cultures
  • Imaging

A CT-scan should be done if available but should not delay starting therapy

Treatment

• Empiric: Benzylpenicillin 2.4 MU IV 4 times daily
PLUS
• Chloramphenicol IV 1g 4 times daily
OR
• Ceftriaxone IV 2g 12 hourly
OR
• Cefotaxime IV 2g 8 hourly

Specific treatment will vary depending on CSF-culture results

  • Prevention
    • Vaccination is recommended for those with hyposplenism
  • Post exposure prophylaxis
    • For those exposed or contacts of meningococcal. The contacts include:
      • Sharing same household or dormitory
      • More than 8 hours of contact or exposure
      • Exposure to secretions
  • Drug options AND dosages:
    • Ceftriaxone 250 mg intramuscular as stat dose
    • Ciprofloxacin (20 mg/kg) max 500 mg single dose
    • Azithromycin 500 mg single dose
    • Follow up for at least 10 days

Complications

  • Seizures
  • Loss of consciousness
  • Hydrocephalus
  • Thrombophlebitis
  • Cranial palsies
  • Hemiplegia and death.
  • Mental retardation
  • Hearing loss
  • Blindness
  • Epilepsy.

Referral Criteria

  • Complications such as hydrocephalus
  • Failure improves in 48-72 hours
  • Suspected atypical infection based on history
  • Resistant pathogen detected
  • Suspected TB meningitis

Cryptococcal Meningitis

Description

The causative organism is Cryptococcal neoformans. The high-risk groups most affected are those with severe immunosuppression such as Advanced HIV Disease (AHD) with low CD4 counts, and patients on cancer treatment

Signs and Symptoms

  • Headache
  • Fever
  • Nausea and projectile vomiting
  • Seizures
  • Visual impairment
  • Altered mental status with somnolence
  • Photophobia
  • Cranial nerve palsies
  • Hemiplegia or hemiparesis

Investigations

  • Lumbar puncture with measurement opening pressure for CSF analysis as above in bacterial meningitis including the following
    • Cryptococcal antigen (CrAg) assay
    • India Ink
    • Culture for Cryptococcus neoforman
  • Serum CrAg
  • Contrast enhanced CT scan of the Brain

Treatment

Induction phase:

  • Liposomal Amphotericin B 3-4 mg/kg IV daily PLUS Flucytosine 25 mg/kg PO in 4 divided doses at 6hour intervals for 7 days

OR

  • Amphotericin B deoxycholate 0.7-1 mg/kg IV daily PLUS Flucytosine 25 mg/kg PO in 4 divided doses at 6 hour intervals for 7 days
  • Amphotericin B as above PLUS Fluconazole 800-1200 mg once daily for 14 days
  • Consolidation phase: Eight-week anti-fungal regimen
    • Fluconazole 400–800 mg/day after a two-week induction with Amphotericin B regimen (6–12 mg/kg/ day up to 400–800 mg/day, if below 19 years)
    • Fluconazole 800 mg/day after induction treatment with short-course Amphotericin B or Fluconazole- based induction (Fluconazole 12mg/kg/day up to 800 mg/day, if below 19 years)
  • Maintenance Phase:

Oral Fluconazole 200 mg daily (6 mg/kg/day up to 200 mg/day, if below 19 years) until CD4 >350 cells/mL for more than 6 months or lifelong

Serial lumbar puncture is recommended to manage raised intracranial pressure

Prevention of Cryptococcal Disease
The routine use of antifungal primary prophylaxis for Cryptococcal disease in HIV-infected with a CD4 count less than 100 cells/μL and who are CrAg negative or where CrAg status is unknown is not recommended before ART initiation, unless a prolonged delay in ART initiation is likely

Viral Meningitis

Description

This is inflammation of the meningeal covering of the brain or spinal cord. Common causes include coxsackie, polio, Measles, Mumps, Influenza, Herpes simplex and HIV

Signs and Symptoms

• As for bacterial and cryptococcal meningitis

Investigations

Cerebral Spinal Fluid analysis
• Clear appearance
• Lymphocytes: 10 to 100
• Polymorphs: none
• Protein: 0.4 to 0.8 g/l

Treatment

Acyclovir 10-15mg/kg IV 3 times per day for 7 days