1. MENINGITIS
Dr. Opiro Keneth

2. • Definition:
- Inflammation of the leptomeninges
• Importance:
- Significant cause of morbidity and mortality among
children. 426,000 children are affected annually, with
85,000 deaths.
Overall mortality rate is 5 – 10%: 15 – 20% in
neonates, 3 -10% in older children.
Mortality rate from S.pneumoniae is 26.3 – 30%, H.
influenza type B is 7.7 – 10.3, N. meningitidis is 3.5 –
10.3%

3. - High frequency of neurologic sequelae: up to
30%, highest with S pneumonia.
- Classical symptoms and signs may not be
present in neonates and infants
- The most important causes are preventable
through immunisation (S. pneumonia, Hib, N.
meningitidis, Mtb, and some viral causes e.g
Measles, Rubella)

4. Aetiology
• Bacterial:
a) 0 - 2 months
- Escherichia coli
- Group B streptococci
- Listeria monocytogenes
- Others: Klebsiella, Salmonella
b) 2 months – 2 years
- Streptococcus pneumoniae
- Haemophilus influenza type b
- Neisseria meningitidis

5. c) 3 years and above
- S. pneumonia
- N. meningitis
- Hib
- Mycobacterium tuberculosis
d) Unusual bacteria
- Staphylococcus aureus
- Pasteurella multocida
- Mycoplasma

6. • Viruses:
- Enterovirus
- Paramyxoviruses
- Herpes simplex
- Cytomegalovirus
- Influenza
- Rubella
- Adenovirus
- Polio
• Fungal
- Cryptococcus
neoformans
- Candida albicans
• Drugs and Chemicals
- NSAIDs
- IVIG
- Antibiotics

7. Predisposing/ Risk factors
• Age: prematures, neonates
• Intrauterine infection
• Maternal infection and pyrexia at delivery
• Open head trauma (with skull fracture or CSF leakage)
• Contiguous focus of infection e.g. sinusitis, otitis media,
mastoiditis, osteomyelitis of skull, periorbital and facial cellulitis,
septic arthritis,
• Open neural tube defects
• Neurosurgical procedures and patients with ventriculoperitoneal
shunts
• Immune deficiency (primary or secondary)
• Sickle cell anaemia or asplenia
• Overcrowding
• Immunisation status

8. Pathogenesis
• Acquisition:
Aerosol or droplet, nasopharyngeal
colonisation, replication and invasion
• Spread:
- Haematogenous: from nasopharynx, skin, or
following pneumonia, infective endocarditis;
bacteremia then meningeal seeding
- Direct: Otitis media, mastoiditis, sinusitis,
open head injury

9. • Local immune response
• Endothelial cells, macrophages, neutrophils
• Inflammation, increased blood brain barrier
permeability, cerebral edema, increased ICP
• Local thrombosis, infarction

10. Clinical features
• History: Brief & fulminant Vs slow gradual
a) Bacterial meningitis:
Neonate:
- Maternal infection or pyrexia at delivery
- Non specific symptoms: change in feeding or
sleeping habits, irritability, lethargy, vomiting,
high pitched cry, seizures, paradoxical
irritability (quiet at rest, cries when moved or
comforted)
Infants:
- Fever, lethargy, irritability, change in

11. After 2 - 3 years:
- Headache, irritability, nausea, vomiting,
anorexia, nuchal rigidity, photophobia,
confusion, back pain, seizures, coma
b) Viral:
- Onset variable; fever, general malaise,
anorexia, vomiting
- features of pharyngitis, conjunctivitis, myositis
- seizures and evidence of encephalitis

12. c) Tuberculous meningitis
- occurs 3 – 6 months following primary
infection
- sudden or insiduous presentation
- 3 stages:
- First stage: 1 -2 weeks of fever, headache,
malaise, irritability
- Second stage: typical meningeal signs
- Third stage: worsening neurological
condition, coma and death
d) Fungal meningitis:
- Immunesuppressed patients, variable
presentation

13. Physical Examination
• Young infant:
- Irritable, unconscious
- Febrile, hypothermic
- Bulging fontanelle
- Diastasis of the sutures
- +/- Nuchal rigidity
• Older child:
- Meningeal signs: Neck stiffness, +ve Kernig
and Brudzinski signs,

14. - Bulging fontanelle
- Ptosis, Sixth nerve palsy, diplopia
- Bradycardia, hypertension and apnea =
Cushing’s triad – brain herniation
- Focal neurological signs in 15% of patients
- Seizures in up to 30% patients
- Altered consciousness and coma 15 – 20%

15. Signs and Symptoms of Bacterial MeningitisSigns and Symptoms of Bacterial Meningitis
Hemi paresis, ptosis,
deafness, facial nerve palsy,
optic neuritis
Hemiparesis, ptosis, facial
nerve palsy
FocalFocal
neurologicneurologic
signssigns
Headache, bulging fontanel,
diastasis of sutures in infants,
papilledema, mental
confusion, altered state of
consciousness
Bulging fontanel, diastasis of
sutures, convulsions,
opisthotonus
IncreasedIncreased
intracranialintracranial
pressurepressure
Neck rigidity, Kernig and
Brudzinski sign
Neck rigidity,MeningealMeningeal
inflammationinflammation
Fever, anorexia, confusion,
irritability, photophobia,
nausea, vomiting, headache,
seizure
Fever or hypothermia,
abnormally sleepy or lethargic,
disinterest in feeding, poor
feeding, cyanosis, grunting,
apneic episodes, vomiting
NonspecificNonspecific
Older infants and childrenOlder infants and childrenNeonatesNeonatesSigns andSigns and
symptomssymptoms

16. Investigations
• Blood:
- Complete blood count
- Blood cultures
- Blood glucose
- Serum electrolytes
- Bacterial antigen studies
- Coagulation studies
- Sickle cell screening test

17. • CSF examination:
- Most important
- Lumbar puncture: anatomical markings,
opening and closing pressures
- Analysis:
- Cell counts; total and differential,
- Gram stain (
- ZN stain
- Indian ink stain
- Glucose
- Protein
- Antigen tests
- Culture and sensitivity (even with ‘normal csf’)

18. - Latex agglutination tests
• Contraindications to LP:
- Infection at LP site
- Signs of increased ICP (other than a bulging
fontanelle)
- Suspicion of a mass lesion
- Extreme patient instability
CSF findings in various conditions are attached;
Interpretation of CSF from a traumatic LP

19. • Imaging studies:
- Rarely required
- May be needed to rule out other pathology
before LP, or when focal nerological signs are
present
- Helpful in abscesses, subdural effusions,
empyema, hydrocephalus
- CT Scan, MRI: Normal findings do not rule out
increased ICP
- Cranial Ultrasound Scan

20. DDx: Bacterial Meningitis
• Tuberculous meningitis
• Fungal meningitis
• Brain abscess
• Intracranial or spinal epidural abscesses
• Encephalitis
• Bacterial endocarditis with embolism
• Subdural empyema
• Subarachnoid hemorrhage
• Brain tumors

21. Management
• Airway, Breathing, Circulation
• Management of seizures
• Empiric and specific antibiotic therapy
• Supportive treatment
- ABC
- Fluid: 2/3 of maintenance
- Feeding
- Antipyretics
- Physiotherapy, occupational therapy
- Counseling and support to attendants

22. Empiric Therapy for BacterialEmpiric Therapy for Bacterial
MeningitisMeningitis
Bacterial meningitis is a medical emergency,
delay in treatment may lead to increased
sequelae or death
Drug of choice must be bactericidal for pathogen
involved
Must achieve adequate levels in the CSF
Initial regimen should cover most likely
pathogens for specific age groups, and reach
bactericidal levels in the CSF
Knowledge of local susceptibility patterns is
essential

23. Empiric Therapy for Bacterial MeningitisEmpiric Therapy for Bacterial Meningitis
Cefotaxime or
Chloramphenicol
Benzyl penicillin
&
Ceftriaxone
H. influenzae
S. pneumoniae
N. meningitidis
2mos – 5 yrs
Chloramphenicol
Or Ceftriaxone
Penicillin GS. pneumoniae
N. meningitidis
>5 yrs
Ampicillin +
Cefotaxime or
Ceftriaxone
Ampicillin or
Penicillin +
Aminoglycoside
E. coli
Gram (-) bacilli
S. pneumoniae
0-2 mos
AlternativePrimary
Antimicrobial choiceLikely etiologyPatient
group

24. Duration of Therapy of
Bacterial Meningitis*
Pathogen Suggested duration
of therapy (days)
H. influenzae 10-14
S. pneumoniae 10 -14
N. meningitidis 10 - 14
Grp. B. streptococci 14-21
G(-) bacilli 21
*Quagliarello, et al, NEJM 1997, 336(10):708-716

25. Supportive management
IV Fluids and hydration
maintain normal blood pressure, watch out
for SIADH
Control of increased intracranial pressure
Nutritional support
Prevention- chemoprophylaxis,
immunizations, infection control

26. Complications
• Fits/ Epilepsy
• Hydrocephalus
• Cranial nerve palsies: CN 3 – 6
• Subdural effusions ( common with Hib)
• Brain abscess
• Encephalitis/ Cerebritis
• Hearing loss
• Blindness
• Cognitive dysfunction
• SIADH secretion
• Ventriculitis
• Cerebral edema
• Learning disabilities
• Cerebral palsy
• Paresis, ataxia

27. Persistent fever
• Inadequate drug doses
• Organism not sensitive to drug
• Drug fever
• Complications: cerebral abscess, ventriculitis,
subdural effusion
• Another focus of infection
• Hib infection
• Pericardial or joint effusions

28. Poor prognosis
• Young age: Prematures, neonates
• Long duration of illness prior to effective
antibiotic therapy
• Late onset seizures
• Coma and other coplications at presentation
• Shock
• Low or absent CSF WBC count in the presence
of visible bacteria on CSF Gram stain
• Immunocompromised status
• Positive CSF culture
• Organism: Strep pneumoniae

29. Look out for:
• Role of immunisation in the prevention and
control of meningitis
• Role of steroids in the management of
meningitis
• TB and fungal meningitis

30. and