Working Diagnosis & Case Discussion

ACUTE BACTERIAL MENINGITIS

Symptoms of Acute bacterial meningitis
Fever
Headache Neck stiffness Photophobia

CASE

Nausea and vomiting

Sleepiness Confusion Delirium

Coma

ACUTE BACTERIAL MENINGITIS

Bacterial meningitis is an acute purulent infection within the sub-arachnoid space.

Risk factors
Extremes of age (< 5 or >60 years) Diabetes mellitus, renal or adrenal insufficiency, hypoparathyroidism, or cystic fibrosis Immunosuppression, which increases the risk of opportunistic infections and acute bacterial meningitis

 HIV infection, which predisposes to bacterial meningitis caused by encapsulated organisms, primarily Streptococcus pneumoniae, and opportunistic pathogens Crowding (such as that experienced by military recruits and college dorm residents), which increases the risk of outbreaks of meningococcal meningitis

 Splenectomy and sickle cell disease, which increase the risk of meningitis secondary to encapsulated organisms Alcoholism and cirrhosis Recent exposure to others with meningitis, with or without prophylaxis Contiguous infection (eg, sinusitis)

 Dural defect (eg, traumatic, surgical, or congenital) Thalassemia major Intravenous (IV) drug abuse Bacterial endocarditis Ventriculoperitoneal shunt Malignancy (increased risk of Listeria infection) Some cranial congenital deformities

Epidemiology
Bacterial meningitis is the most common form of suppurative CNS infection The organisms most often responsible for community-acquired bacterial meningitis are:
Streptococcus pneumoniae (50%), Neisseria meningitidis (25%), group B streptococci (15%), Listeria monocytogenes (10%). Haemophilus influenzae (<10%)

Etiology
S. pneumoniae is the most common cause of meningitis in adults >20 years of age, accounting for nearly half the reported cases (1.1 per 100,000 persons per year). Otitis, mastoiditis, and sinusitis are predisposing and associated conditions for meningitis due to Streptococci sp., gramnegative anaerobes, S. aureus, Haemophilus sp., and Enterobacteriaceae.

S.pneumoniae/ N.meningitidis

Pathophysiology

Colonize the nasopharynx Few WBCs, Igs and complement Fluid nature of CSF

Transported to the bloodstream

Reach the intraventricular choroid plexus

Avoid phagocytosis by PMNs and complement

Prevents opsonization of bacteria

Mutiply rapidly within the CSF CSF protein

Production of inflammatory cytokines and chemokines

leukocytosis

Meningeal inflammation

Prognosis
Mortality rate is 37% for meningitis caused by H. influenzae, N. meningitidis, or group B streptococci; 15% for that due to L. monocytogenes; and 20% for S. pneumoniae. In general, the risk of death from bacterial meningitis increases with
decreased level of consciousness on admission, onset of seizures within 24 h of admission, signs of increased ICP, young age (infancy) and age >50, the presence of comorbid conditions including shock and/or the need for mechanical ventilation, delay in the initiation of treatment.

Diagnosis: CSF analysis