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Symptoms : 95% with 2 of 4
- Fever (77%)
- Headache (87%)
- Conscious change (69%)
- Neck stiffness (31%)
- Photosensitivity
- Seizure
Meningitis PE :
Fever, conscious change, Neck stiffness (Nuchal rigidity)
頸部僵硬 : 躺著無法用下巴碰胸口, 嚴重時甚至左右轉就會痛
Kernig's sign, Brudzinski's sign --> Only in 10% patients
IICP signs : Headache, Vomiting, Papilledema
Cushing reflex : HTN, Bradycardia, Respiratory depression
Kernig 先把腳彎 90度 ( Hip flexion )
然後 Knee extension, Extension 過程中有痛就 positive
Meningeal sign in : Meningitis, SAH
需要先做 CT 再 LP 的病人 :
最重要的精神是 : 不能延遲給抗生素
When bacterial meningitis is considered,
never withhold empiric antibiotic therapy in order
to collect the CSF sample
Never delay administration of empiric antibiotic therapy
for neuroimaging or to perform LP,
because antibiotic treatment takes precedence over definitive diagnosis
If the LP is delayed (e.g., CT, coagulopathy, thrombocytopenia, agitation)
and meningitis is strongly suspected,
administer antibiotics without delay !
Sterilization of the CSF is possible within 2 hours of
initiating parenteral antibiotics in meningococcal
and 6 hours in pneumococcal meningitis,
highlighting the importance of timely LP.
If suspicion is great despite negative initial CSF results,
admit for empiric antibiotic treatment and consider repeat LP
Bacterial :
S. pneumoniae (30-60%) :
From bacteremia (評估有無 IE), 呼吸道, Skull base fracture
合併 Pneumonia, AOM
N.meningitidis (10-35%) 腦膜炎雙球菌
年輕人,群聚感染, petechia or purpura
Meningococcal meningitis (caused by Neisseria meningitidis)
H.influenzae (< 5%)
L.monocytogenes (5-10%)：
Consider L. monocytogenes in older adults and alcoholics
老人,酗酒, immunocompromised
污染的乳製品, Malignancy
GNRs (1-10%)
Staphylococci (5%) : CSF shunt (S.epidermidis),
Neurosurgery or Head trauma (S.a)
Virus :
- Enterovirus (most common)
- Herpes simplex virus (HSV 2 > 1)
- Human immunodeficiency virus (HIV)
- Varicella-zoster virus (VZV)
- CMV
- Mumps
- Encephalitis virus (arbovirus)
Fungus : Cryptococcus neoformans
TB
Lyme disease
Syphilis
N. meningitidis commonly colonizes the upper respiratory tract,
but does not commonly cause invasive disease in the Western hemisphere
Endemic regions, such as the African meningitis belt (Sub-Saharan Africa)
- Ceftriaxone + Vanco + Ampicillin
- Acyclovir
Add acyclovir 10 mg/kg IV if HSV encephalitis is suspected
- Dexamethasone
Lab : HIV
CSF : Indian ink, pneumococcus Ag
PCR (HSV, VZV, Enterococcus), AFS
VDRL/RPR
Dexamethasone 10g IV Q6H 2-4 days
--> Suspect pneumococcus or GCS 8-11
- 降低 Neuro complication and mortality
- 要在給 anti 前或是和第一劑一起給 Block TNF production
- Should not be given to patients who have already received antimicrobial therapy
because it is unlikely to improve patient outcome ~
Administration of dexamethasone to patients
with presumptive pneumococcal meningitis
before or with the first dose of antibioticscan reduce CSF inflammation,
reduce the risk of morbidity and mortality in adults,
and reduce hearing loss and other neurologic sequelae in children.
The recommended dosage of dexamethasone
is 10 mg IV Q6H for 3 days for adults.
Monitor serum sodium level serially to detect SIADH or cerebral salt wasting
Bacterial meningitis is spread by droplets,
and risk for developing bacterial meningitis after exposure
is estimated to be 500 - 800 times higher than the general population.
Chemoprophylaxis can decrease transmission of
N. meningitidis by 89% in close contacts
For individuals who have been exposed to patients
diagnosed with N. meningitidis and H. influenzae.
Not recommended for patients diagnosed
with pneumococcal meningitis
Initiate chemoprophylaxis within 24 hours of contact.
Rifampin 10 mg/kg to a maximum of 600 mg Q12H for 4 doses,
ciprofloxacin 500 mg orally once, or ceftriaxone 250 mg IM once
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