CHAPTER I
INTRODUCTION
1.1. Background
Monitoring infectious diseases,
especially the central nervous system infections, has become one of the
important priorities in health care system. In this regard, various
epidemiological, serological, and bacteriological studies have been carried out
to determine causative agents. The results of recent investigation have shown
that more than 80% of bacterial meningitis are caused by 4 bacteria, including:
Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae and Listeria monocytogenes. However, exact
information is not available for other bacteria causing meningitis infection.
In addition, in recent years, Coagulase Negative Staphylococci (CoNS) have been increasingly recognized as causative
agents of various infections, especially in immunocompromised patients and also
related to implanted foreign body materials.
Furthermore, the results of recent
researches show that the pathogenesis of CoNS infections depends on their
ability to form biofilms on polymer surfaces. It is important to know that CoNS
that have been historically viewed as contaminants have been recovered from
clinical specimens, and are now recognized as opportunistic pathogens of
increasing importance in the hospital-acquired infections. However, in patients
without implants or other external device, the pathogenesis and virulence
factor of CoNS may be controversial.
1.2. Problem Formulation
·
What
is the history of meningitis?
·
What is the definition
of meningitis?
·
What
are types of meningitis?
·
How
the demographics of meningitis?
·
What
are the causes and transmission of meningitis?
·
Who
are have risk factors of meningitis?
·
How
the meningitis mechanism?
·
What
are the symptoms of meningitis?
·
How
to diagnose the meningitis?
·
How
to treatment person with meningitis?
·
How
to prevention body from meningitis?
·
What
is the prognosis of meningitis?
1.3. Purpose
·
To
know about history of meningitis.
·
To
know about the definition of meningitis.
·
To
know about types of meningitis.
·
To
know about demographics of meningitis.
·
To
know about causes and transmission of meningitis.
·
To
know about person who have risk factors of meningitis.
·
To
know about meningitis mechanism.
·
To
know about the symptoms of meningitis.
·
To
know about the diagnose of meningitis.
·
To
know about treatment to person with meningitis.
·
To
know about the prevention from meningitis.
·
What
is the prognosis of meningitis.
CHAPTER II
DISCUSSION
2.1. History
of Meningitis
Meningitis
has been described in ancient texts. Hippocrates described meningitis in his
work. Tuberculous meningitis was first described by Edinburgh physician Sir
Robert Whytt in a posthumous report that appeared in 1768. However, the link
with Tubercle bacilli that also causes tuberculosis took another 100 years to
discover.
v
History of the organisms causing
meningitis
Meningitis
outbreak was first recorded in Geneva in 1805. Gaspard Vieusseux (1746-1814)
and Andre Matthey (1778-1842) in Geneva, and Elisa North (1771-1843) in
Massachusetts, described epidemic (meningococcal) meningitis. Several other
epidemics in Europe and the United States were described shortly afterward.
In
Africa the first outbreak was described in 1840. African epidemics became much
more common in the 20th century. The first major one was reported in Nigeria
and Ghana in 1905–1908. In early reports large number of people died of the
disease.
The
first evidence that linked bacterial infection as a cause of meningitis was
written by Austrian bacteriology Anton Vaykselbaum who described meningococcal
bacteria in 1887.
Heinrich
Quincke (1842-1922) utilized his new technique of lumbar puncture (1891) to
provide an early analysis of cerebrospinal fluid (CSF). William Mestrezat
(1883-1929), and H. Houston Merritt (1902-1979) compiled large series of CSF
profiles in meningitis.
Organisms
causing meningitis were identified in the late 19th century including:
·
Streptococcus pneumonia
·
Neisseria meningitidis
·
Haemophilus influenzae
v
History of clinical features of
meningitis
By
the end of 19th century more symptoms of the condition were described. The
symptoms of meningitis were described in 1884 by Russian physician Vladimir
Kernig (1840-1917) in 1899 and by Polish physician Jozef Brudzinski
(1874-1917). The signs were thus called Kernig’s sign and Brudzinski sign in
1882 and 1909 respectively.
By
the second half of the 20th century influenza viruses A and B, adenovirus were
found to be linked to meningitis as well.
In
1968, AA Smorodintsev proved that there are more than 200 different viruses and
their serotypes that may cause meningeal infections. Armstrong and Lilly in
1934 isolated the virus from the cerebrospinal fluid of patients.
v
History of vaccines
It
was in 1906 that researchers noted that horses could be used to create
antibodies against meningococcal bacteria. This was developed further by the
American scientist Simon Flexner and markedly decreased mortality from
meningococcal disease.
The
introduction in the late 20th century of ''Haemophilus'' vaccines led to a
decline in meningitis due to Hemophillus influenza type b.
v
History of antibiotics
In
1944, penicillin was first reported to be effective in meningitis. The first
successful treatment of meningitis began with the introduction of serum therapy
for meningococcal meningitis by Georg Joachmann (1874-1915) in Germany and
Simon Flexner (1863-1946) in America.
Antibiotic
therapy began in the 20th century with the use of sulfonamides by Francois
Schwentker (1904-1954) and penicillin by Chester Keefer (1897-1972).
v
Other advances in the treatment of meningitis
In
2002, evidence emerged that treatment with steroids could improve the prognosis
of bacterial meningitis. This also revolutionized therapy of meningitis and
improved long term outcome of the condition.
In
2000, an Advisory Committee on Immunization Practices (ACIP), a part of the
Centers for Disease Control and Prevention (CDC), recommended that colleges and
universities inform all students and their parents about the risk of
meningococcal disease and the availability of a vaccine.
Between
2005 and 2010 FDA licenses additional meningococcal disease vaccines to protect
against 4 of the 5 major disease-causing serogroups, A, C, Y, and W-135. In
2007 the ACIP recommends routine vaccination for preteens against meningococcal
disease at the 11- to 12-year-old checkup.
2.2. Definition
of Meningitis
Meningitis is a serious inflammation of
the meninges, the membranes (lining) that surround the brain and spinal cord. Meninges are 3
connective tissue layers. They consist of the pia mater (closest to the central
nervous system organs), the arachnoid, and the dura mater (farthest from the
brain and spinal cord). They also include blood vessels and contain
cerebrospinal fluid. These are the structures involved in meningitis, an
inflammation of the meninges, which, if severe, may become encephalitis, an
inflammation of the brain.
The infection may be caused by bacterial,
viral, or fungal origin, and it leads to the meninges becoming inflamed
(swollen). This can cause serious damage to the nerves, brain, and the spinal
cord.
2.3. Types
of Meningitis
a. Bacterial
Meningitis
Bacterial meningitis is aggressive,
develops quickly and can lead to permanent disability or death in a matter of
hours. It is fatal in approximately 50% of cases and accounts for around
170,000 deaths around the world each year.
Bacterial meningitis is caused by any
one of several bacteria. The most common bacteria causing meningitis in
children and adults are Neisseria
meningitidis (meningococcus), Streptococcus pneumoniae (pneumococcus) and in older patients with
decreased immunity, Listeria
monocytogenes. Haemophilus influenzae type b (Hib) was a common cause of
meningitis in infants and young children until the Hib vaccine was introduced
for infants. Vaccines are available for both Neisseria meningitidis and Streptococcus
pneumoniae. They're recommended for all children and adults at special
risk.
There are different types of meningococcus (called serogroups), of
which serogroups A, B, C, Y and W135 are responsible for over 95% of meningitis
and septicaemia cases. Meningitis caused by meningococcus is called
meningococcal meningitis. Similarly, meningitis due to Streptococcus pneumoniae is also called pneumococcal meningitis.
Septicaemia (blood poisoning) is a
potentially life-threatening infection that occurs when the bacteria that cause
meningitis get into the bloodstream. The infection may be seen alone or in
addition to meningitis.
Other bacteria that can cause meningitis
include E.coli and Group B Strep
(common causes of neonatal meningitis) and Mycobacteria
tuberculosis [TB]. It is believed that 10-20% of the population carries the
meningitis bacteria at any one time, but it will only develop into the disease
in susceptible people.
The infection spreads from person to
person through respiratory droplets (kissing, coughing, sneezing, sharing food,
or utensils). Children who attend day-care or preschool are at greater risk of
contracting bacterial meningitis. There are vaccines available for many types
of bacterial meningitis. So, if we are around someone who has bacterial meningitis, contact our health care provider to ask what steps we need to take to avoid
infection.
In many instances, bacterial meningitis develops when
bacteria get into the bloodstream from the sinuses, ears, or other part of the
upper respiratory tract. The bacteria then travel through the bloodstream to
the brain.
b. Viral
Meningitis
Viral
meningitis also called aseptic meningitis is more common than the bacterial
form and generally ‘but not always’ less serious. It can be triggered by a
number of viruses, including several that can cause diarrhea. Almost all
patients recover without any permanent damage (most will recover completely),
although full recovery can take many weeks.
Some
examples of known viruses can cause meningitis are:
·
Enteroviruses
: usually causes abdominal infections
·
The
herpes simplex virus : causes genital herpes
·
The
chickenpox virus
·
Measles
virus
·
The
influenza virus
·
The
mumps virus ( Mumps )
It
is most often spread through respiratory droplets (kissing, coughing, sneezing,
sharing food or utensils) or faecal contamination. Elderly people and those
with conditions that affect their immune system are more at risk.
There are no vaccines available for
viral meningitis, but washing hands thoroughly and keeping surfaces clean can
help prevent the disease.
Viral meningitis is generally less
severe and often disappears without specific treatment, while bacterial meningitis
can be quite serious and may result in brain damage, hearing loss, or learning
disabilities in children. The infection may even cause death.
c. Fungal
/ Environmental Meningitis
Fungal meningitis causes severe
infections but occurs much less frequently. A common cause of fungal meningitis
is Cryptococcus. The fungus may
spread into the bloodstream and into the spinal cord. It is not contagious and
spreads by inhaling fungal spores from the environment.
Fungus-related meningitis is rare in
healthy people. However, someone who has an impaired immune system such as a
person with AIDS is more likely to become infected with this form of
meningitis.
d. Other
Types of Meningitis
It is also possible to contract
meningitis from parasites or through non-infectious means like cancers, AIDS, lupus,
certain drugs, head injuries, brain surgery, or an existing condition of the
skull or spine. Meningitis parasites or primary amebic meningoencephalitis are
usually caused by amoebas and deadly. Naegleria
fowleri is a type of amoeba parasite commonly cause meningitis.
2.4. Demographics
According
to the National Institute of Neurological Disorders and Stroke (NINDS), some
6,000 cases of pneumococcal meningitis are reported in the United States each
year. Meningococcal meningitis is common in minors ages two to 18. Each year
about 2,600 people get this highly contagious disease. High-risk groups include
infants under the age of one year, people with suppressed immune systems,
travelers to foreign countries where the disease is endemic, and college
students and Army recruits who reside in dormitories and other close quarters.
Between 10 and 15 percent of cases are fatal, with another 10 to 15 percent
involving brain damage and other serious side effects.
2.5. Causes
and Transmission
Meningitis
can be caused by bacteria or a virus. While bacterial meningitis is more
dangerous, viral meningitis is more common and runs a milder course. Meningitis
also can be caused by fungal/environmental, parasites, and several other
diseases such as cancers, AIDS, lupus, certain drugs, head injuries, brain
surgery, or an existing condition of the skull or spine.
a. Bacterial
Meningitis Causes
There
are currently a number of bacteria that can lead to meningitis. Some of these
include:
·
Neisseria meningitidis bacteria or Meningococcal bacteria
Ä There are several different types of meningococcal bacteria called groups A,
B, C, W135, Y, and Z. At present there is a vaccine available that provides
protection against group C meningococcal
bacteria. Most cases of meningococcal meningitis, however, are caused by
the group B bacteria.
·
Streptococcus pneumoniae bacteria or pneumococcal bacteria
Ä These bacteria tend to affect babies
and young children and the elderly because their immune system is weaker than
other age groups.
·
Staphylococcus
Ä Those who have a CSF shunt or have
dural defects are likely to get meningitis caused by Staphylococcus.
·
Pseudomonas sp.
Ä Patients having spinal procedures (eg
spinal anaesthetia) are at a risk of meningitis caused by Pseudomonas sp.
·
Syphilis
and Tuberculosis leading to meningitis as well as fungal meningitis are rare
causes but are seen in HIV positive individuals and those with a suppressed
immunity.
According
to age group of the patient the most likely bacterial causes of meningitis
include:
·
In
new-borns - Pneumococcal bacteria or group B streptococci, Listeria monocytogenes, Escherichia coli
·
Infants
and young children - H. influenzae
type b, in children less than 4 years and being unvaccinated raises risk of
meningitis due to Neisseria meningitidis,
Streptococcus pneumonia
·
Older
children and adults - S. pneumoniae, H. influenzae type b, N. meningitidis, Gram-negative bacilli, Staphylococci, Streptococci, and
L. monocytogenes.
·
Elderly
and those with a suppressed immunity - S.
pneumoniae, L. monocytogenes, tuberculosis (TB), Gram-negative
organisms
·
After
head injury or infection acquired after a hospital stay or procedure - includes
infection with Klebsiella pneumoniae,
E.coli, Pseudomonas aeruginosa, Staphylococcus
aureus
b. Transmission
of Bacterial Meningitis
The
Meningococcal bacteria that cause
meningitis are usually spread through prolonged, close contact. Spread is
possible by being in proximity of an infected person who passes on the bacteria
by sneezing, coughing, kissing, sharing personal possessions like toothbrushes,
cutlery, utensils, etc.
Pneumococcal bacteria are also spread by close contact with
an infected person and by coughing, sneezing, etc. However, in most cases they
only cause mild infection, such as a middle ear infection (otitis media). Those
with a poor immune system may develop a more severe infection such as
meningitis.
c. Viral
Meningitis Causes
There
are several viruses that may lead to viral meningitis. Vaccinations against
many of these viruses have led to the decline in the incidence of several viral
meningitis cases. For example measles, mumps, and rubella (MMR) vaccine
provides children with immunity against mumps, which was once a leading cause
of viral meningitis in children. Viruses
that may cause meningitis include:
·
herpes
simplex virus – this may lead to genital herpes and cold sores
·
enteroviruses
– stomach flu virus - these have been responsible for causing polio in the past
as well
·
Mumps
virus
·
Echovirus
·
Coxsackie
virus
·
Herpes
zoster virus
·
Measles
virus
·
Arbovirus
·
Influenza
virus
·
HIV
·
West
Nile virus
d. Transmission
of the Virus
Viral
meningitis infection may be spread by close contact with the infected person
and being exposed when the person sneezes and coughs.
Hand
washing after they are contaminated with the virus – for example, after
touching a surface or object that has the virus on it can prevent the spread.
e. Other
Causes of Meningitis
Other
causes of meningitis include:
·
Fungal
meningitis – Caused by Cryptococcus,
Histoplasma, and Coccidioides species and seen in AIDS patients
·
Parasites
causing meningitis – includes examples of eosinophilic meningitis caused by
angiostrongyliasis
·
Other
organisms like atypical tuberculosis, syphilis, Lyme disease, leptospirosis,
listeriosis and brucellosis, Kawasaki's disease and Mollaret's meningitis
·
There
may be no infection and only inflammation of the meninges leading to
non-infective meningitis. This is caused by tumors, leukemia, lymphomas, drugs
and chemicals given spinally or epidurally during anesthesia or other
procedures, diseases like Sarcoidosis, Systemic lupus erythematosus and
Behçet's disease etc.
2.6. Risk
Factors of Meningitis
Risk
factors of getting meningitis include:
·
Those
living in close quarters like schools, colleges, military base, day care
centers, student housings etc. are more at risk of getting meningococcal
infections.
·
Those
with CSF shunts placed in their brain for another pathology
·
those
with defects in the dura
·
use
of spinal procedures (eg spinal anaesthetics)
·
diabetics
·
those
with bacterial endocarditis
·
alcoholism
and liver cirrhosis
·
intravenous
drug abuse
·
renal
insufficiency
·
thalassemia
·
cystic
fibrosis
·
hypoparathyroidism
·
splenectomy
·
sickle
cell disease
2.7. Meningitis
Mechanism
The
meninges are the three membranes that along with the cerebrospinal fluid,
enclose and protect the structures of the nervous system like the brain and the
spinal cord. These consist of the pia mater (closest to the central nervous
system organs), the arachnoid, and the dura mater (farthest from the brain and
spinal cord).
They
also include blood vessels and contain cerebrospinal fluid. These are the
structures involved in meningitis, an inflammation of the meninges, which, if
severe, may become encephalitis, an inflammation of the brain.
v The
meninges
The
pia mater is a very delicate impermeable membrane. It is firmly attached to the
surface of the brain and follows all the contours of the brain. The arachnoid mater has a spider web
like appearance, hence its name. It loosely fits on top of the pia mater. The
space between the arachnoid and pia mater membranes is called the subarachnoid
space and is filled with cerebrospinal fluid. The outermost membrane, the dura mater, is a thick durable
membrane, which is attached to both the arachnoid membrane and the skull.
v The
infective organism reach the meninges
The
bacteria or infective organism spreads through the blood. They reach the
meninges by one of two main routes: through the bloodstream or through direct
contact between the meninges and either the nasal cavity or the skin. The
infection begins in one part of the body – e.g. throat or lungs and spreads to
the brain.
v Blood
brain barrier
Normally
the brain is protected by the blood brain barrier that is a thick membrane that
filters out impurities from blood and does not allow entry into the brain. In
some persons with decreased immunity the infection crosses the blood brain
barrier.
v The
subarachnoid space
Once
bacteria have entered the bloodstream, they enter the subarachnoid space in
places where the blood-brain barrier is vulnerable—such as the choroid plexus. Meningitis
occurs in 25% of newborns with bloodstream infections due to group B
streptococci; this phenomenon is less common in adults.
v Swelling
of the meninges
This
leads to activation of the immune system that leads to swelling of the meninges
to stop the spread of the infection. This swelling damages the brain and the
nervous system.
v Cerebrospinal
fluid
The
organism may also affect the cerebrospinal fluid (CSF). This adds to the injury
and there is increased pressure on the brain and on the skull. This is called
raised intracranial pressure. Direct contamination of the cerebrospinal fluid
may arise from indwelling devices, skull fractures, or infections of the
nasopharynx or the nasal sinuses.
v The
immune response
With
the inflammation, the immune system identifies the bacteria by its cell wall.
The immune cells of the brain (astrocytes and microglia), respond by releasing
large amounts of cytokines that are hormone-like mediators that recruit other
immune cells. This stimulates other tissues to participate in an immune
response.
The
blood-brain barrier becomes more permeable, leading to "vasogenic"
cerebral edema (swelling of the brain due to fluid leakage from blood vessels).
The blood vessels are also inflamed leading to cerebral vasculitis which leads
to a decreased blood flow another type of edema, "cytotoxic" edema.
2.8. Symptoms
of Meningitis
Meningitis
can be hard to recognise in the early stages. Symptoms can be similar to those
of the common flu and can develop quickly, over a matter of hours. The main symptoms
to look out for are fever or high fever, vomiting, severe headache, stiff neck,
sensitivity to light, skin rash, and drowsiness or altered consciousness. The
signs and symptoms do not appear in a definite order and some may not appear at
all.
This
symptoms list does not include every possible sign and symptom of meningitis.
We must to contact our local healthcare professional to ask about the most
common symptoms in a country. It’s important to know the warning signs and to
get medical treatment fast. Until the cause of meningitis is known, it should
be regarded as a medical emergency.
Know the
Symptoms
·
Arching
of the back (infants)
·
Behavioural
changes
·
Blank,
staring expression
·
Bulging
fontanelle (infants)
·
Cold
hands and feet
·
Diarrhoea
·
Dislike
of being handled (infants)
·
Drowsy
or difficult to wake
·
Fever
·
Irritability
·
Listless,
less responsive
·
Loss
of appetite, refusing food (infants)
·
Muscle,
leg or joint pain
·
Neck
retraction with arching of the back (infants)
·
Pale
or blotchy skin
·
Rash
or spots that don’t fade with pressure (also called purpure or petechiae)*
·
Rapid
breathing
·
Seizures,
fits or convulsions
·
Sensitivity
to light
·
Severe
headache
·
Stiff
neck
·
Unusual
high-pitched cry (infants)
·
Vomiting
*Not everyone
who contracts meningitis will get a rash. Don’t wait for a rash to appear
before getting help.
a. Bacterial Meningitis Symptoms
Bacterial
meningitis is the more serious form of the condition. Symptoms begin suddenly
and worsen rapidly. Meningitis commonly affects children and elderly but may
affect all age groups.
v
Initial Warning Symptoms
Some of the
initial warning symptoms include:
·
body ache and
muscle pain in limbs and joints
·
shivering and
cold hands and feet
·
bluish lips and
pale skin
·
high fever
v
Early Symptoms
Early symptoms
of bacterial meningitis include:
·
feeling
generally unwell
·
severe
unrelenting headache
·
usually a very
high fever
·
nausea and
vomiting
v
Later Symptoms
As the disease
progresses the symptoms include:
·
drowsiness
·
confusion
·
seizures or fits
·
being unable to
tolerate bright lights (photophobia) – this is less common in young
children
·
stiff neck
– less common in young children - the neck becomes stiff and it is
difficult to bend the neck forwards
·
rapid breathing
rate, rapid heart rate, respiratory distress, altered mental state (confusion
and delirium), poor urine output and extremely low blood pressure – this is a
symptom of septicaemia and shock
·
blotchy red rash
which is characteristic and does not fade or change colour when pressed with a
glass slide. This is not always present - a rash is strongly suggestive of
meningococcal septicaemia and should lead to urgent treatment and referral
·
Kernig's sign
refers to pain and resistance on straightening the knees with the hips folded -
this detects back stiffness and is characteristic of meningitis
·
Brudzinski's
sign refers to pain and resistance on bending the head forward with the hips
folded
·
focal paralysis
and neurological deficits and abnormal pupils
v
Bacterial Meningitis Symptoms in Young Children
Young children
and infants have some different symptoms that indicate meningitis. These
include:
·
initial symptoms
are those of irritability and refusal to be held or fed
·
becoming floppy
and unresponsive
·
the baby may be
stiff with jerky movements
·
unusual crying,
shrill cry or unusual moaning
·
vomiting and
refusing feeds
·
pale and blotchy
skin
·
staring
expression
·
very sleepy or
drowsy with a reluctance to wake up
·
swelling of the
soft part on the top of the head called the fontanelle
b. Viral meningitis symptoms
Viral meningitis
is more common than bacterial meningitis. The illness appears much like flu and
may have milder symptoms.
v
Common symptoms
Common symptoms
of viral meningitis include:
·
Headaches
·
Fever
·
Generally not
feeling very well
v
More severe symptoms
In more severe cases of viral
meningitis symptoms may be:
·
nausea and
vomiting
·
neck stiffness
·
muscle or joint
pain
·
diarrhoea
·
photophobia
(sensitivity to light)
2.9. Meningitis
Diagnosis
Meningitis
is inflammation of the meninges and can be diagnosed using laboratory and
imaging studies.
v
Ruling out other conditions
There
are several clinical signs and symptoms that may raise the suspicion of
meningitis. However, before diagnosing meningitis other conditions that have
similar clinical presentation need to be ruled out. These include:
·
fever
for other infections
·
abscess
within the brain
·
other
causes of confusion and altered mental state like brain infection
(encephalitis), bleeding within the brain or stroke (subarachnoid haemorrhage),
brain tumors etc.
Whatever
may be the cause, symptoms of meningitis should be dealt with as a priority and
on an emergency basis since the course of the disease may turn rapidly life
threatening and fatal.
Investigations
suggested for diagnosis of meningitis include lumbar puncture, complete blood
count and so forth. Lumbar puncture performed immediately providing there are
no signs of raised intracranial pressure. This includes bad headache, raised
fontanelle among babies, seizures, loss of consciousness etc.)
Samples
of cerebrospinal fluid taken from the lumbar puncture are sent to the
laboratory for staining with special dyes that reveal the organism leading to
meningitis. The common stains and
tests used are:
·
Gram
stain (to diagnose gram negative Meningococci,
E. coli, Pseudomona and gram positive Staphylococci
and Pneumococci)
·
Ziehl-Neelsen
stain (for diagnosing tuberculosis)
·
cytology
(for abnormal cells)
·
virology
(for causative viruses)
·
glucose,
protein, culture (to check for growth of specific bacteria)
·
rapid
antigen screen or polymerase chain reaction (PCR) if available
·
India
ink for Cryptococci (fungal
infection)
During
early stages the CSF may be normal.
v
Other methods used to diagnose
meningitis
These
include:
·
Complete
blood count to detect anemia and infection (by raised WBC counts)
·
Blood
culture for diagnosing infection and septicaemia
·
Blood
glucose to compare it with CSF glucose
·
Renal
and liver function tests
·
Tests
to check adequate blood clotting ability
·
Chest
X ray to detect lung pathologies like lung abscess, tuberculosis etc.
·
Urine
culture to detect organisms
·
Nasal
swab and stool for virology if viral meningitis is suspected
·
Whole
blood real-time PCR testing (EDTA sample) for N. meningitidis to confirm a
diagnosis of meningococcal disease
·
CT
scan or computed tomography scan and MRI scan (Magnetic resonance imaging scan)
to check for brain tumors, abscesses and other pathologies.
·
Blood
antigen tests for Cryptococcus and India ink and CSF cryptococcal antigen
·
Blood
tests for syphilis if syphilis involvement of meninges is suspected.
2.10. Treatment
of Meningitis
Those
with meningitis, especially due to bacterial causes, have a high risk of blood
infection or septicaemia. Immediate hospital admission is required for these
patients.
v
Treatment of bacterial meningitis
·
Urgent
hospital admission. With severe infections, treatment in the intensive care
unit (ICU) is recommended.
·
Diagnosis
of the causative organism is made. Specific bacteria and its sensitivity to
antibiotics needs to be determined before targeted antibiotics may be given.
·
Antibiotics
are used to treat the infection. Initial empirical or “blind” antibiotics are
begun without delay and these may be continued or changed to a more specific
antibiotic once the causative organism is confirmed by laboratory tests. The
antibiotics are commonly given via injections into a vein over the forearm.
·
Blind
antibiotic therapy includes third generation cephalosporins like cefotaxime or
ceftriaxone and Amoxicillin if listeriosis is suspected.
·
Benzylpenicillin
is given if meningococcal infection is suspected (usually for 7 days) and
Rifampicin or ciprofloxacin for 2 days if nasal colonization is suspected.
·
Meningitis
suspected to be caused by pneumococci or hemophilis influenza type b needs
cefotaxime for 10-14 days or benzylepenicillin. Rifampicin is usually given for
four days prior to discharge for patients with hemophillus infections.
·
Benzylpenicillin
and gentamicin, or cefotaxime alone are given for 14 days for meningitis caused
by group B streptococcal infections.
·
In
addition Amoxicillin and gentamicin for 10-14 days are usually given for
listeriosis.
·
Vital
support including oxygen, intravenous fluids, nutritional support etc. need to
be begun upon admission.
·
Corticosteroids
are administered to reduce the edema, swelling and inflammation of the
meninges. Steroids like dexamethasone have shown to prevent hearing loss and
other complications of meningitis. Dexamethasone or a similar corticosteroid
needs to be started just before the first dose of antibiotics is given, and
continued for four days.
·
General
measures such as anti-emetics for the nausea and vomiting and anti-seizure
medications or anticonvulsants for seizures are recommended.
·
Usually
a week or so of hospital stay is needed if the patient responds well to
antibiotics. Those with more severe illness may need to stay in the hospital
longer.
v
Treatment of viral meningitis
·
Severe
viral meningitis requires hospital admission.
·
Treatment
is begun with vital support with oxygen and intravenous fluids and antibiotics.
·
Once
diagnosis is made and causative virus identified, antibiotics are withdrawn
since they are infective against viruses. However, intravenous fluids will be
continued.
·
Some
severe infections may require antiviral medications. Aciclovir is considered
beneficial in treating herpetic viral infections but only if given very early
in the course of the infection. Patients need to be given Aciclovir injections
immediately if there is suspicion of herpes encephalitis or brain infection.
Ganciclovir is effective for cytomegalovirus (CMV) infections.
·
Those
with a mild viral meningitis will not require hospital treatment. These
patients need bed rest, plenty of fluids and painkillers for headache and
anti-emetics for nausea and vomiting.
·
Recovery
is usually within a week or two
2.11. Prevention
Meningitis,
especially caused by certain bacteria and viruses, is preventable with
vaccinations and prophylactic or preventable antibiotics and medications among
those who have been exposed to the infection.
Vaccinations
may be against routine infections as part of the child’s immunization programme
or they may be age and immunity specific and specific for travellers to regions
with high incidences of particular infections.
v
Routine vaccinations for children
Notable
vaccines for children among preventable causes of meningitis include:
·
The
mengingococcal vaccine against type C meningococcus
·
Pneumococcal
conjugate vaccine (PCV) that protects against pneumococcus infection. The
pneumococcal polysaccharide vaccine covers over 23 strains.
·
Viral
causes like measles and mumps by the Measles, Mumps and the Rubella vaccine
·
DTaP/IPV/Hib
vaccination that protects against Hemophilus influenza type b, diphtheria,
whooping cough, tetanus and polio
·
Childhood
vaccination with Bacillus Calmette-Guérin or BCG has been reported to significantly
reduce the rate of tuberculous meningitis
All
children should receive these vaccines as a part of their childhood vaccination
programme.
v
Vaccines for elderly and those with
suppressed immunity
Those
over 65 and those with diseases that decrease immunity are in need for coverage
against certain organisms that may cause meningitis. Notable among these is the pneumococcal conjugate vaccine that
protects against pneumococcal meningitis. PCV is administered specifically in
certain groups (e.g. those who have had a splenectomy, the surgical removal of
the spleen).
v
Vaccines for travellers
Those
who are travelling to regions with high incidences of infections leading to
meningitis need to be vaccinated before they travel. Their vaccine needs to
include those against groups A, C, W135 and Y of the meningococcal bacteria and pneumococcal conjugate vaccine against
pneumococcal infection.
High
risk areas include Africa especially if the person is planning on a trip longer
than a month, decides to go hiking or backpacking, visiting local rural areas,
or attending the Hajj or Umrah pilgrimages in Saudi Arabia.
v
Antibiotics for prevention of meningitis
Antibiotics
like Rifampicin are administered for the short term among all persons exposed
to meningococcal meningitis. In cases of meningococcal meningitis, prophylactic
treatment of close contacts with antibiotics (e.g. rifampicin, ciprofloxacin or
ceftriaxone) can reduce their risk of contracting the condition. Unlike vaccines, antibiotics do not
protect against future infections on exposure to the infection.
2.12. Prognosis
Meningitis,
especially which is caused by bacteria, is a life threatening condition and
needs urgent treatment.
v
Complications of meningitis
Complications
are more common after bacterial meningitis and very rare after viral
meningitis. Complications with meningitis may be temporary or permanent. They
may be short or long term. Complications
of meningitis include:
·
Around
a quarter of people with meningococcal disease may develop septicaemia or blood
stream infection and develop several complications.
·
Hearing
loss is a commonly dreaded complication. Loss may be partial or complete.
Before being discharged from the hospital or within four weeks of being well
enough to take the test, patients need a hearing test.
·
There
may be problems with memory and concentration.
·
There
can be short or long term problems with co-ordination and balance.
·
Problems
with speech and vision. There may be partial or complete loss of vision.
·
There
may be gangrene if there is septicaemia due to meningitis. This leads to
production of toxins in the body that kills the healthy tissues especially of
the fingers, toes or a limb. The limb may need to be amputated due to gangrene.
·
Mental
ailments and problems like depression, anxiety weakness and fatigue may be
detected as a complication of meningitis.
v
Complications of meningitis in children
·
When
new-borns are affected, there is a risk of cerebral palsy. This leads to a set
of symptoms affecting movement and co-ordination.
·
Since
meningitis commonly affects children there may be learning difficulties that
may be temporary or permanent.
·
Many
children with meningitis may develop epilepsy that leads to repeated seizures.
Children
after a bout of meningitis may:
·
become
“clingy” or suffer anxiety when left alone
·
develop
disturbed sleep
·
bed-wetting
·
aggression
or irritability
·
moody
·
have
nightmares
·
develop
temper tantrums
·
feel
low and develop a fear of doctors and hospitals
Overall
there may be behavioural and learning problems in children after a meningitis
episode.
v
Prognosis of bacterial meningitis
Untreated
bacterial meningitis is almost always fatal. With treatment the risk of death
is reduced.
In
new-borns the risk of death with treatment is 20 to 30%, in older children it
is around 2% with treatment. The death risk is higher for adults even with
treatment at 19 to 37%. Many adults may go on to develop disabilities like
deafness (14%) and memory loss (10%).
CHAPTER III
CLOSE
3.1. Conclussion
Meningitis
is a serious inflammation of the meninges, the membranes (lining) that surround
the brain and spinal cord. The infection may be caused by bacterial, viral,
fungal origin, parasites, or because of the other disease, and it leads to the
meninges becoming inflamed (swollen). This can cause serious damage to the
nerves, brain, and the spinal cord. The most common cause is a virus and bacteria.
Viral
meningitis is generally less severe and often disappears without specific
treatment, while bacterial meningitis can be quite serious and may result in
brain damage, hearing loss, or learning disabilities in children. The infection
may even cause death.
3.2. Suggestion
Meningitis is a contagious disease that is dangerous if left
untreated. Treatment of meningitis must be adapted to the causes of the
disease. In order to avoid this disease, we should do preventive measures such
as with vaccinations and
prophylactic or preventable antibiotics and medications among those who have
been exposed to the infection.
REFERENCES
