1. NERVOUS SYSTEM
INFECTIONS
MENINGITIS
Acute infection of the meninges presents
with the characteristic combination:
pyrexia Headache Meningism

2. CAUSES OF MENINGITIS
Infective
Bacteria
Viruses: Enteroviruse,Mumps,
Influenza Herpes simplex
Protozoa & parasites:Toxoplasma
Amoeba
Fungi:Cryptococcus neoformans,

3. Fever,Headache,Nuchal rigidity
Altered mental status
Yes No
Encephalitis,ADEM,Abscess Meningitis
Brain imaging CSF
Imaging,CT or MRI. CSF

4. Bacterial causes of meningitis
•Age of onset •Common •Less common
• Neonate •G-negative •Listeria
bacillia,Group B monocytogenes
•streptococci
•Pre-school child •H-influenzae •Mycobacterium
•N-meningitidis •tuberculosis
•St-pneumonia
•Older child •N-Meningitidis •L –m,T.B,Crypto

5. Neonate
G-negative bacilli Group B streptococci

6. Pre-school child
Haemophillus ifluenza
Neisseria meningitidis
Streptococcus pneumonia

7. Older child
adult &
Neisseria Streptococcus Listeria
meningitidis pneumoniae monocytogenes

8. CSF INDICES IN MENINGITIS
Conditi CELl CELL Glucose protein -G
on Type Count stain
Normal Lymp 0-4 Normal -
>60%
B-G
Viral Lymp 10-2000 normal -
normal
Bacteri Poly 1000 Low /N +
al 5000 Increase
TB L/P,M 50-5000 Low Increase often

9. CHEMOTHERAPY OF BACTERIAL
MENINGGITIS
N-meningitidis Benzylpenicillin
Strep.pneumoniae Cefotaxime
Sensitive to B-lactams Ceftriaxone
Resistant +Vancomycin
H.Influenzae Cefotaxime
Ceftriaxone

10. Treatment of pyogenicmeningitis
unknown cause of
1-patients with a typical meningococcal rash
Benzylpenicillin 2.4 gIV.6-hourly
2-Adult aged 18-50 years without meningococcal rash
Cefotaxime 2 g IV.6-hourly
Ceftriaxone 2g IV.12-hourly
3-Patient in whome pencillin-resistant pneumococcal infection is
suspected
As 2 but add-Vancomycin 1g Iv,12-hourly or Rifampicin 600 mg
IV.12-hourly
4-Adult aged over 50 years and those in whome Listeria
monocytogees infection is suspected
As for 2 but add Ampicillin 2g IV.4-jourly or Co-trimoxazole
5-Patients with a clear history of anaphylaxis to B-lactams
Chloramphenicol 25 mg/kg IV.6-hourly plus Vancomycin 1g
IV.12-hourly

11. Recommendations for Empirical
antimicrobial therapy in adult with
community-acquired meningitis
Predisposing factor pathogen Drugs
16-50 yr N-St-pn Vancomycin +
3rd cephalosporin
>50 yrٍ St-pn, N, List Van+3rd Ceph+
Ampicillin
Presence of a risk St-pn, list, Van+3rd ceph+
H-infuenzae Ampicillin
www.NEJM.ORG ,N ENGL ,Jan-2006

12. Chemoprophylaxis for meningococcal
infection
Dose it reduce the incidence of clinical disease
among contact?
Observational data suggest that antibiotic
reduce the risk of disease
In adults a single dose of 500 mg ciprofloxacin
or oral rifampicin 600mg(12-hourly) for 2
days.
Vaccines for groups A&C but not B menigococci.

13. COMPLICATIONS
OF MININGOCOCCAL SEPTICEMIA
• Menigitis
• Rash
• Shock
• Intravascular coagulation
• Renal failure
• Gangrene
• Arthritis
• Pericarditis

14. Major intracranial complications in
Bacterial meningitis in adult
-----------------------------------------
1-Transtentorial herniation
2-Hydrocephalus
3-Infarction
4-Seizures

15. CLINICAL FEATURES OF TB MENINGITIS
• Vomiting • Depression
• Low-grade • Confusion
fever • Behavior
• lassitude changes

16. Signs
Meningism (may be absent)
Ocular palsies
Papilloedema
Depression of conscious level
Focal hemispher signs

17. Viruses causing acute encephalitis
Common
Arboviruses
Enterovirsuses
HSV
Less common
CMV
EBV
HIV
Mumps

18. Viruses causing acute meningitis
Enterviruses =75-90
Echo 30% Coxsa-A 10% Coxsac-B 40%
Mumpsvirus 15%

19. Practical points
• The typical profile is lymphocytic
pleocytosis(25-500 cells/uL.)
• A normal or slightly elevated protein
• A normal glucose concentration.
• PMN pleocytosis should always promt an
alternative diagnosis
• In both enterovirus &HSV,PCR is the
diagnostic procedure of choice

20. Differential diagnosis
Bacterial menigitis:
Mycoplasma,lasteria,brucella
Parameningeal infection
Partially treated bacterial meningitis
Tb,fungal, parasitic, Syphilitic disease
Neoplastic meningitis
Sarcoid, Behcets disease

21. Chronic & recurrent meningitis
Characteristic neurological syndrome for>4weeks
&
Persistent inflammation in CSF (WBC>5/Ul)
Causes:1-Meningeal infection
2-Malignancy
3-Noninfectious inflammatory disorder
4-Chemical meningitis
5-Parameningeal infections

22. Symptoms & signs of chronic
meningitis
Symptom Sign
Chronic headache Sign of Meningeal irritation
Change in personality Altered mental status
Facial weakness Crainal nerve palsy
Double visions Papilledema,optic atrophy
Weakness Myelopathy,radiculopathy
Sensory symptoms Frontal lobe dysfunction
Sphincter dysfunction Ataxia