Acute Pyogenic Meningitis
~ Acute Meningitis ( Over Hrs And Days ) ~ Chronic Meningitis ( Persisting More Than 4 Weeks ) PARTIALLY Treated PM may present as chronic meningitis. May cause meningoencephalitis ( Meningoencephomyelitis ) √ Three Patterns Of Onset :- • Fulminant - Seriously Ill Patient ( Within 24 Hrs W/O Antecedent RTI ) • Meningitis Development ( Over 1-7 Days /S RS Symptoms ) • Meningitis Symptoms ( After 1-3 Weeks Of RS Symptoms ) √ Signs Of Meningeal Irritation :- • Neck Stiffness - ( Passive Flexion Of Neck ) Unable to put chin on chest - Spasm Of Neck Muscle. • Kernig's Sign - ( Thigh is flexed at 90 ° from abdomen ) Impossible for patient to straighten knee to more than 135 ° passively - Spasm Of Hamstrings. •Brudzinski's Neck Sign - ( Hand at back of head is raised and other hand restraining chest of supine patient ) Automatic Flexion at both the hip and knee is a positive sign. •Brudzinski's Leg Sign - ( On passively flexing one leg ) Other leg gets flexed automatically. √ Investigations :- • Biopsy Of Skin Lesions, If Present ( Meningococci ) • Blood Urea - Increased ( Due To Dehydration ) • Blood Culture - Positive ( Organisms ) • Culture Of Pus ( Middle Ear/Sinuses ) • CT-Scan ( Commonest Finding - Increased Contrast Enhancement Of Meninges ) - Cerebritis, Hydrocephalus And Brain Abscess •CSF Finding :- ~Turbid Appearance ~ Culture Of CSF ( Grows Pathogen ) ~ Cell Count - Raised ~ Protein Level - Elevated ~ Sugar Level - Decreased • Hyponatremia ( Due To SIADH ) • Total Leukocytes, ESR And PMNL - Increased • Radiography :- ~ Chest - Pneumonia And Lung Abscess ~ Mastoids - Mastoiditis ~ Paranasal Sinuses - Sinusitis ~ Skull - Chronic Osteomyelitis And Fracture • Lumbar Puncture ( Safe in patients who are suspected with meningitis, conscious and have no papilloedema or focal deficits ) Treatment :- ~ Initial Management - Airway Protection, Oxygenation, Volume Resuscitation, Prevention Of Hypoglycemia, Control Of Seizures, Reduction Of Hypothermia And Measures To Reduce ICP And Maintain CBF. ~ Latter Management - Elevation Of Heat, Fluid Restriction, Mannitol And Hyperventilation. ~ Steroids - Given in emergency room, Reduces incidence of hearing impairment in children with Hemophilus Influenzae, Useful in adults with Pneumococcal Meningitis, Not Used In Impaired Cell-Mediated Immunity Patients. ( Dexamethasone - 0.15/kg/6hr for 4 Days , Adjunctive Dexamethasone avoided if patient already received Antimicrobial Therapy ) ~ Antimicrobial Therapy - Administered Immediately in suspected meningitis, Duration Of Treatment - 10-14 Days. DOC - Ceftriaxone • Neonates - Ampicillin ( 100 - 150 mg/kg ) + Ceftriaxone ( 50 mg/kg ) Or Cefotaxime ( 50-100 mg/kg ) • Children ( < 12 Yrs ) And Adults - Ceftriaxone ( Cefotaxime ) + Vancomycin ( 40 mg/kg ) •Elderly And Immunocompromised Patients - Ampicillin ( 100 - 150 mg/kg ) + Ceftriaxone ( 50 mg/kg ) Or Cefotaxime ( 50-100 mg/kg ) + Vancomycin
