Infections of the CNS: Meningitis

 There are four main causes of infections of
CNS
 Bacterial
 Viral
 Fungal
 Protozoal
Dr.L.Surbala(MPTNeurology)

 Fungal infections
 Cryptococcal meningitis
 Brain abscess
 Spinal epidural infection

 Protozoal infections
 Toxoplasmosis
 Malaria
 Primary amoebic meningoencephalitis

 Bacterial infections
 Tuberculosis
 Leprosy
 Neurosyphilis
 Bacterial meningitis
 Brain abscess
 Neuroborreliosis

 Viral infections
 Viral meningitis
 Eastern equine encephalitis
 St Louis encephalitis
 Japanese encephalitis
 West nile encephalitis
 Herpes simplex encephalitis
 Rabies
 California encephalitis virus
 Varicella-zoster encephalitis
 La crosse encephalitis
 Measles encephalitis
 Poliomyelitis
 Slow virus infections, which
include:
 Subacute sclerosing
panencephalitis
 Progressive multifocal
leukoencephalopathy
 AIDS

INTRODUCTION
 It is an acute inflammation of meninges of brain
& spinal cord present with characteristic
combination of pyrexia, headache & meningium
(confusion or altered consciousness)
 The inflammation may be caused by infection
with viruses, bacteria, or other microorganisms,
and less commonly by certain drugs
 It can be life-threatening because of
inflammation's proximity to brain & spinal cord;
hence condition is classified as a medical
emergency

CLINICAL FEATURES
 Acute onset of illness
 High grade of fever
 Severe headache
 Nuchal rigidity & pain
 Irritability & drowsiness
 Photophobia & phonophobia

 Features of rapid ICP (normally between 6 and 18 cm
water)
 Projectile vomiting, blurring of vision, altered sensorium &
convulsions, loss of pupillary light reflex, & abnormal
posturing
 In infants up to 6 months of age, bulging of fontanelle
 Septic shock & septicimia
 Cranial nerve damage
 Acute renal failure
 Meningitis caused by meningococcal bacteria may be
accompanied by a characteristic rash
 consists of numerous small, irregular purple or red spots
("petechiae") on trunk, LE, mucous membranes, conjuctiva, &
(occasionally) palms or soles

COMPLICATIONS
 Meningitis can lead to serious long-term
consequences
 deafness
 epilepsy
 hydrocephalus
 cognitive deficits
 if not treated quickly

TYPES
 Pyogenic / bacterial miningitis
 Tubercular miningitis
 Viral meningitis

PYOGENIC BACTERIAL MENINGITIS

PYOGENIC BACTERIAL MENINGITIS
 Causative organism
 Neonates – E-coli, proteus
 Children – Haemiphillus influenzae type B, Neisseria
meningitidis (Meningococcus)
 Adolescent - N meningitidis
 Adult – streptococcus pneumoniae

 Route of entry
 Direct contact of the CSF by Contaminated lumbar
puncture, Sinusitis, Trauma
 Ottitis media
 Through the blood stream
 Incubation period
 4- 24 hours

PATHOGENESIS
 The large-scale inflammation that during meningitis
largely be attributed to response of immune system
 Immune cells of brain (astrocytes and microglia),
respond by releasing large amounts of cytokines,
hormone-like mediators that recruit other cells &
stimulate other tissues to participate in an immune
response.

 The blood-brain barrier becomes more permeable,
leading to "vasogenic" cerebral edema (swelling of
brain due to fluid leakage from blood vessels)
 Large numbers of WBC enter CSF, causing
inflammation of meninges, & leading to "interstitial"
edema (swelling due to fluid between cells).
 In addition, walls of blood vessels become inflamed
(cerebral vasculitis), which leads to a decreased
blood flow and a third type of edema, "cytotoxic"
edema

 The three forms of cerebral edema all lead to an
increased ICP together with low BP often
encountered in acute infection,
 Brain cells are deprived of oxygen & undergo
apoptosis (automated cell death)

SIGNS
 Positive kernig’s sign & Positive brudjinski’s
 Kernig's sign is assessed with patient lying supine, with hip
& knee flexed to 90 degrees.
 Positive Kernig's sign - pain limits passive extension of knee
 Brudzinski's sign – if positive, flexion of neck causes
involuntary flexion of knee & hip.
 Jolt accentuation maneuver helps determine whether
meningitis is present in patients reporting fever &
headache
 The patient is asked to rapidly rotate his head
horizontally; if this does not make the headache worse,
meningitis is unlikely
 Papillary oedema

INVESTIGATIONS
 Blood analysis
 TC is increased
 DC- neutrophillia
 ESR- normal
 Hb- normal
 CSF analysis
 Glucose decreased
 Protiens increased (100-200mg/dl)
 Cells – neutophillia (>90%)
 CT or MRI scan is recommended prior to lumbar
puncture in suspects of risk

 Gram stain to identify the organism
 Culture & sensitivity test
 Postmortem
 The findings are widespread inflammation of pia
mater and arachnoid layers
 Cranial nerves & spinal cord, may be surrounded with
pus

PREVENTION
 For some causes of meningitis, prophylaxis can be
provided in long term with vaccine
 against Haemophilus influenzae type B
 Meningococcus vaccines
 against Streptococcus pneumoniae with pneumococcal
conjugate vaccine (PCV)
 Childhood vaccination with Bacillus Calmette-Guérin (BCG)
 Short-term antibiotic prophylaxis is also a method of
prevention, particularly of meningococcal meningitis
 rifampicin, ciprofloxacin or ceftriaxone can reduce their
risk of infection , but does not protect against future
infections

MANAGEMENT
 High dose intravenous antibiotic
 Penicillin, Cephalosporin
 Rifampicin, norfloxacin, erythromycin
 Mannitol to decrease the raised ICP
 Corticosteroids can also be used to prevent
complications from overactive inflammation
 IV fluids should be administered if hypotension or
shock are present
 Mechanical ventilation may be needed if level of
consciousness is low, or if evidence of respiratory
failure

 Seizures are treated with anticonvulsants
 Hydrocephalus may require insertion of a
temporary or long-term drainage device
(cerebral shunt)

TUBERCULAR MENINGITIS
 It can be seen as a part of primary TB in
children & a part of secondary TB in adults
 The primary focus being in the lung

PATHOGENESIS
 TB bacilli reached all parts of body & remains
dormant in meninges
 When immunity is less the foci or bacilli will
rupture in CSF
 Produce TB meningitis & lots of exudates
 Obstruction of CSF circulation
 Damage to lower cranial nerves

CLINICAL FEATURES
 Gradually progressive disease
 Gradual onset of fever associated with
headache, general weight loss & weakness
 Loss of appetite
 Raised ICP
 Feature of lower cranial nerve paralysis (IX, X,
XI, XII)
 Difficulty in speaking, swallowing etc

INVESTIGATIONS
 Blood analysis
 TC nearly normal
 DC – lymphocytosis
 ESR elevated
 CSF analysis
 Turbid & cloudy
 High protien (500mg/ dl)
 Boderline increase in glucose
 Cell are increased (lymphocytosis)
 Gram stain: gram positive
 ZN stain: AF bacilli
 CT scan with contrast: exudates can be seen

TREATMENT
 Anti – tubercular drugs
 Corticosteroids
 Mannitol

VIRAL MENINGITIS
 It is also known as aseptic meningitis
 Clinical presentation is similar to that of acute
pyogenic meningitis

INVESTIGATION
 Microbiological findings shows no microorganisms
 CSF glucose is normal
 Boderline increase in CSF cells (lymphocytes) &
protiens
 Gram stain is of no importance
 Polymerase chain reaction (PCR) amplify small traces
of DNA & detect presence of bacterial or viral DNA
in CSF
 Assist in distinguishing various causes of viral meningitis
(enterovirus, herpes simplex virus 2 and mumps in those
not vaccinated for this)
 Serology (identification of antibodies to viruses) may
be useful in viral meningitis

TREATMENT
 Viral meningitis typically requires supportive
therapy only
 Most viruses responsible for causing meningitis
are not amenable to specific treatment
 Herpes simplex virus & varicella zoster virus may
respond to treatment with antiviral drugs such
as aciclovir

 Mild cases of viral meningitis can be treated at
home with conservative measures such as fluid,
bed-rest, & analgesics.
 Prognosis is good
 Gradually recovers without any treatment

PT ASSESSMENT
 History of presenting illness: acute or gradual onset of
illness, high grade fever
 Past history
 Infectious history, trauma, spinal anaesthesia, lumbar
puncture, sinusitis, ottitis media
 Vital signs: temperature, BP, HR, RR
 Observation:
 abnormal posturing may be seen
 Abnormal respiration
 Attitude of limb
 Examination
 Level of conciousness, orientation, memory, speech
 Cranial nerve examination: signs of damage of lower cranial
nerves

 Sensory screening: sensations may be intact
 Motor assessment
 ROM, tonicity, reflexes, muscle power
 Chest examination: important in TB meningitis
 Respiratory assessment
 Gustatory examination: swallowing
 Bladder & bowel involvement
 Functional assessment
 Special test: kernig, brudjinski
 Investigations: blood & CSF examination, CT or MRI,
gram stain, serology

 Problem list

PT MANAGEMENT (GOALS)
 Psychological support
 Positioning strategies & prevent bed sores
 Prevent chest complications
 Promote vital function
 Prevent DVT
 Promote integration of sensory input
 Postural correction
 General fitness exercise

PSYCHOLOGICAL SUPPORT
 Maintain a non threatening positive attitude
 Good support
 Gain confidence of the patient
 Counseling of family members & patient
 Give information as necessary only

POSITIONING STRATEGIES & PREVENT BED SORES
 Proper positioning with pads & cushions
 Use of water bed or foam mattress
 Regular inspection of the skin
 Use cotton clothing to absorb sweat
 Avoid dragging during transfer
 Regular turning & changing position

PREVENT CHEST COMPLICATIONS
 Breathing exercise, postural drainage &
suctioning as required
 Cervical & thoraxic mobility exercise
 Thoraxic expansion exercise
 Strengthening of respiratory muscles

PROMOTE VITAL FUNCTION
 Improve respiratory capacity with positioning &
tech s/a glossopharyngeal breathing exercise in
respiratory paralysis
 Keeping the neck in slight flexion improves
respiratory capacity
 Specific positioning increase air entry in targeted
lobes

 Massage & mechanical pressure provides reflex
stimulus to improve peristalsis (kneading/
stroking)
 Facilitate swallowing with positioning, right
selection of food texture, oromotor stimulation
 Maintaining cardio respiratory endurance with
active exercise of possible muscle work

PREVENT DVT
 Active & passive ankle & toe exercise
 Active limb exercise
 Limb elevation
 Early mobilization as soon as possible
 Propped up position in bed & bed mobility
exercise

PROMOTE INTEGRATION OF SENSORY INPUT
 Stimulation by combined proprioceptive, visual &
auditory input
 Cues & commands
 Demonstration of activity
 Sensory re education if necessary
 Training in different environment

POSTURAL CORRECTION
 Proper positioning in the lying, sitting & all
functional position
 Use of braces, sitting & standing frames can be
helpful in children
 Stretching & strengthening of key postural
muscles
 Endurance training

GENERAL FITNESS EXERCISE
 Early mobilization & early propped up position
 Moving around the bed
 Regular exercise with bouts of 15-20 min session
for 3-4 times a day
 Then progress to 30-45 min of exercise
 Maintenance can be done by 45- 60 min session
of exercise 3-5 times/wk

Infections of the CNS: Meningitis

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