MENINGITIS & ENCEPHALITIS

RANDA AL-HARIZY
PROF OF INTERNAL MEDICINE
 MENINGITIS
• Meningitis means inflammation but usually
implies serious infection of the meninges
• Microorganisms reach the meninges either by
direct extension from the ears, nasopharynx,
cranial injury or congenital meningeal defect,
or by bloodstream spread.
• Non-infectious causes of inflammation include
malignant cells, drugs and blood following
subarachnoid haemorrhage
INFECTIVE CAUSES OF MENINGITIS
Bacteria
• Neisseria meningitidis*
• Streptococcus pneumoniae*
• Staphylococcus aureus
• Streptococcus Group B
• Listeria monocytogenes
• Gram-negative bacilli
• Mycobacterium tuberculosis
• Treponema pallidum
Viruses
• Enteroviruses:
• ECHO
• Coxsackie
• Mumps
• Herpes simplex
• HIV
• Epstein-Barr virus
Fungi
• Cryptococcus neoformans
• Candida
• (Coccidioides immitis, Histoplasma capsulatum, Blastomyces dermatitidis)
 PATHOLOGY
• In acute bacterial meningitis, the pia-arachnoid is
congested with polymorphs. A layer of pus forms. This
may organize to form adhesions, causing cranial nerve
palsies and hydrocephalus.
• In chronic infection (e.g. TB), the brain is covered in a
viscous grey-green exudate with numerous meningeal
tubercles. Adhesions are invariable. Cerebral oedema
occurs in any bacterial meningitis.
• In viral meningitis there is a predominantly
lymphocytic inflammatory CSF reaction without pus
formation, polymorphs or adhesions; there is little or
no cerebral oedema unless encephalitis develops.
 CLINICAL FEATURES
The meningitic syndrome
• This is a simple triad: headache, neck stiffness and fever.
• Photophobia and vomiting are often present.
• In acute bacterial infection there is usually intense malaise,
fever, rigors, severe headache, photophobia and vomiting.
This develops within hours or minutes.
• Neck stiffness and positive Kernig's sign usually appear within
hours.
• In less severe cases (e.g. many viral meningitides) there are
less prominent meningitic signs, but fatal bacterial infection
may also be indolent, with a deceptively mild onset.
• In uncomplicated meningitis, consciousness remains intact,
although anyone with high fever may be delirious.
• Complications include: cerebral edema, venous sinus
thrombosis, brain abscess , septicemia, DIC and multiorgan
failure (MOFS)
SPECIFIC VARIETIES OF MENINGITIS
Acute bacterial meningitis
• Onset is typically sudden, with rigors and high fever.
Meningococcal meningitis is often associated by a
petechial or other rash. The meningitis may be part of
a generalized meningococcal septicaemia. Acute
septicaemic shock may develop in any bacterial
meningitis.
Viral meningitis
• This is almost always a benign, self-limiting condition
lasting 4-10 days. Headache may follow for some
months. There are no serious sequelae.
Chronic meningitis
 MENINGITIS
Differential diagnosis
• It may be difficult to distinguish between the sudden
headache of subarachnoid haemorrhage, migraine and
acute meningitis. Meningitis should be considered
seriously in anyone with headache and fever and in any
sudden headache. Neck stiffness should be assessed
carefully - it may not be obvious.
• Chronic meningitis sometimes resembles an
intracranial mass lesion, with headache, epilepsy and
focal signs.
• Cerebral malaria often mimics bacterial meningitis.
 Clinical clues in meningitis

Clinical feature Probable cause

Petechial rash Meningococcal infection
Skull fracture
Ear disease Pneumococcal infection
Congenital CNS lesion
Immunocompromised patients HIV opportunistic infection
Rash or pleuritic pain Enterovirus infection
International travel Poliomyelitis
Malaria
Occupational history (working in drains, Leptospirosis
anals, polluted water, ecreational
swimming): rostration, myalgia,
onjunctivitis, jaundice
 MANAGEMENT
• Recognition and immediate treatment of acute
bacterial meningitis is vital. Minutes save lives.
Bacterial meningitis is lethal. Even with optimal
care, mortality is around 15%.
• The immediate management of suspected
meningococcal infection is benzylpenicillin 1200
mg (adult dose) either by slow i.v. injection or
intramuscularly, prior to investigations.
Cefotaxime 1 g i.v. is an alternative in cases of
penicillin allergy. In meningitis, minutes count:
delay is unacceptable.
 INVESTIGATIONS
• On arrival in hospital, routine tests including
blood cultures should be carried out
immediately, and a close lookout kept for the
emergence of septicaemic shock.
• lumbar puncture is performed if there is no
clinical suspicion of a mass lesion. If the latter
is suspected an immediate CT scan must be
performed because coning of the cerebellar
tonsils may follow.
 CSF in meningitis

Normal Viral Pyogenic Tuberculosis

Appearance Crystal-clear Clear/turbid Turbid/purulen Turbid/viscous
t
Mononuclear < 5 mm3 10-100 mm3 < 50 mm3 100-300 mm3
cells
Polymorph Nil Nil* 200-300/mm3 0-200/mm3
cells
Protein 0.2-0.4 g/L 0.4-0.8 g/L 0.5-2.0 g/L 0.5-3.0 g/L
Glucose ⅔ > ½ blood > ½ blood < ½ blood < ½ blood
glucose glucose glucose glucose
 PROPHYLAXIS
• Meningococcal infection should be notified to public health
authorities, and advice sought about immunization and prophylaxis
of contacts, e.g. with rifampicin or ciprofloxacin.
• MenC, a meningococcal C conjugate vaccine, is part of childhood UK
immunization and often given to case contacts.
• A combined A and C meningococcal vaccine is sometimes used
prior to travel to endemic regions, e.g. Africa, Asia; and a
quadrivalent ACWY vaccine for specific events, e.g. Hajj and Umrah
in Mecca.
• There is no vaccine for Group B. A polyvalent pneumococcal vaccine
is used after recurrent meningitis, e.g. after a CSF leak following
skull fracture.
• Hib (Haemophilus influenzae) vaccine is given routinely in childhood
in the UK, virtually eliminating a common cause of fatal meningitis.
 CHRONIC MENINGITIS
• Tuberculous meningitis (TBM) and cryptococcal
meningitis commence typically with vague headache,
lassitude, anorexia and vomiting. Acute meningitis can
occur but is unusual. Meningitic signs usually take
some weeks to develop. Drowsiness, focal signs (e.g.
diplopia, papilloedema, hemiparesis) and seizures are
common. Syphilis, sarcoidosis and Behçet's syndrome
also cause chronic meningitis. In some chronic
meningitis an organism is never identified.
• Treatment with anti-TB drugs - rifampicin, isoniazid and
pyrazinamide - must commence on a presumptive
basis and continue for at least 9 months. Ethambutol
should be avoided because of its eye complications.
 ENCEPHALITIS
• Encephalitis means inflammation of brain
parenchyma, usually viral. Brain inflammation
also develops in bacterial and fungal
meningitis.
• Acute viral encephalitis: The usual organisms
are herpes simplex, ECHO, Coxsackie, mumps
and Epstein-Barr viruses. Adenovirus, varicella
zoster, influenza, measles and other viruses
are rarer.
 CLINICAL PICTURE
• Many encephalitides are mild and recovery
occurs.
• In a minority, serious illness develops with
high fever, headache, mood change and
drowsiness over hours or days.
• Focal signs, seizures and coma ensue. Death,
or brain injury follows.
 INVESTIGATIONS
• CT and MR imaging show diffuse areas of
oedema, often in the temporal lobes. EEG
shows characteristic slow waves, which are
useful in some cases; a normal EEG is
exceptional. CSF shows a raised cell count.
Viral serology (blood + CSF) is helpful. Brain
biopsy is occasionally performed.
 TREATMENT
• Suspected herpes simplex encephalitis is
treated immediately with intravenous
aciclovir.
• Supportive measures are required for
comatose patients; seizures are treated with
anticonvulsants.
• Prophylactic immunization against Japanese
encephalitis is advised for travelers to
endemic areas in Asia.