Acute meningoencephalitis
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Acute Meningoencephalitis
Intern. Sunder Chapagain
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Acute Meningoencephalitis
• meningoencephalitis is an acute inflammatory process involving the meninges and, to a variable degree, brain tissue.
• Acute Bacterial Meningitis• Acute Viral Meningoencephalitis
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Acute bacterial meningitis
• Etiology
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Aseptic meningitis
• Viral– Enterovirus (Echovirus, Coxsackie virus, Polio)– Herpes Simplex Virus-2– Mumps: The commonest complication– Lymphocytic choriomeningitis virus
• Fungal (in imuunocompromised)– Cryptococcus neoformans– Histoplasmosis, Candidiasis, Blastomyces
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• Parasitic– Toxoplasmosis– Cysticercosis– Amoebiasis
• Miscellaneous– SLE– Leukemia– Lymphoma
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Risk Factors• Age• Low socioeconomic status• Head trauma• Splenectomy• Chronic diseases• Children with facial cellulitis, periorbital cellulitis, sinusitis and septic
arthritis• Maternal infection and pyrexia at the time of delivery.
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Clinical featuresNewborn & Infants: non-specific• Fever • Irritability• Lethargy• Vacant stare• Poor tone• Poor feeding• High pitched cry• Bulging anterior fontanelle• Convulsions• Opisthotonus
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Older children
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• Seizures• Alteration in mental status• Hypotension, fever or Hypothermia,
Tachycardia (Septic shock)• Bleeding, Renal dysfunction (DIC)
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Increased intracranial pressure (ICP)• Papilledema• Cushing’s triad
– Bradycardia– Hypertension– Cheyne-Stokes Breathing
• Projectile vomiting• Headache
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Physical examination•Neck rigidity•Focal neurological signs•Ptosis•Cranial nerve palsies•Bulging fontanel
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TB meningitis• Children 6 months – 5 years• Local microscopic granulomas on meninges• Meningitis may present weeks to months after
primary pulmonary process• CSF:
– Profoundly low glucose– High protein– Acid-fast bacteria (AFB stain)– PCR
• Steroids + antitubercular agents– (2HRZE+ 10 HR) WITH steroid for 4-6 weeks
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Stages
• Stage 1: stage of invasion– Low grade fever, loss of appetite, vomiting,
headache, photophobia, irritable, restless• Stage 2: Stage of meningitis
– Neck rigidity, focal neurological deficits, isolated cranial nerve palsies, loss of sphincter control
• Stage 3: Stage of coma– Loss of consciousness, altered respiratory pattern,
dilated pupils, ptosis, ophthalmoplegia, coma
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Neisseria meningitis(Meningococcemia)
• Neisseria meningitidis: serotype Grp B commonest
• Endotoxin causes vascular damage vasodilatation, third spacing, severe shock
• Severe complication:Waterhouse-Friderichsen syndrome: massive haemorrhage of adrenal glands secondary to sepsis: adrenal crisis-low B.P, shock, DIC, purpura, adreno-cortical insufficiency
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Morbiliform, non blanching petechiae to purpura involving mostly extensor surfaces Tumbler test
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Investigations• Complete blood count• C- Reactive Protein• Renal function test• Serum glucose• Blood culture and
sensitivity• If tubercular suspected
– PCR – Chest X-ray– Mantoux test
• Arterial blood gas• Fundoscopy• CT scan
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CSF analysis
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Management
Medical emergency• Early diagnosis essential• Immediate optimum treatment• Intensive supportive therapy• Rehabilitation• Prophylaxis to family• Notification to Public Health
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Treatment
• Managed in Intensive Care Unit• Manage airway, breathing and circulation first• Management of raised ICP• Fluid management• Dexamethasone: only in Pneumococcal and H.
Influenzae B, given 1-2 hours before antibiotics• Antibiotics• Inotropes: increasing aortic diastolic pressure
and improving myocardial contractility
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ICP treatment• 3% NaCl, 5 cc/kg over ~20
minutes• May utilize osmotherapy
(Mannitol) - if serum osmolarity <320 mOsm/L
• Mild hyperventilation– PaCO2 <28 may cause regional
ischemia– Typically keep PaCO2 32-38
mm Hg• Elevate head end of bed by
30o
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Fluid management• Restore intravascular volume & perfusion• Monitor serum Na+ (osmolality, urine Na+):
– If serum Na+ <135 mEq/L then fluid restrict (~2/3x), liberalize as Na+ improves
– If severely hyponatremic, give 3% NaCl • SIADH
– 4 - 88% in bacterial meningitis– 9 - 64% in viral meningitis
• Diabetes insipidus• Cerebral salt wasting
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Antibiotics
• Best started within 60 min• Empirical therapy• Meningococcal meningitis
– Benzyl penicillin 400-500,000 units/kg/day q 4 hour• Pneumococcus/ H. influenza
– Ampicillin (if penicillin susceptible) 300 mg/kg/day IV q6 hour
– Ceftriaxone (if penicillin resistant) 100-150 mg/kg/day q12 hour
– Cefotaxime 150-200 mg/kg/day q8 hour– Vancomycin 60 mg/kg/day
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Meningitis - Treatment duration• Gram negative organisms: 21 days• Pneumococcal (ampiclox/ceftriaxone): 10-14 days• H influenza: 7-10 days• Meningococcal: 7 days• No growth: 7-10 days
• The CSF should be sterile within 24–48 hr of initiation of appropriate antibiotic therapy.
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Dexamethasone use in meningitis• Consider if
– H. influenza & Streptococcus pneumoniae – > 6 wks old
• Dose: 0.6 mg/kg/day in 4 divided doses for 2 days• MOA:
– local synthesis of TNF-, IL-1, PAF & prostaglandins resulting in BBB permeability, meningeal irritation
• incidence of hearing loss• May adversely affect the penetration of antibiotics into CSF• May decrease fever, giving false impression of improvement
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Prophylaxis
• Rifampicin: – Children 5mg/kg bd x 2 days– Adults: 600 mg bd x 2 days
• Pregnant contact:– Cefuroxime IM x 1 dose
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Meningitis – Early complications• Encephalitis• Septic shock• DIC• Abscess• SIADH• Subdural effusion or
empyema ~30%• Dural sinus
thrombophlebitis• Stroke
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Intermediate• Hydrocephalus • Cranial nerve palsy
Late• Cerebral palsy• Hearing loss• Learning disability
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Acute Encephalitis• Encephalitis is an acute inflammatory process
affecting the brain• Viral infection is the most common and important
cause, with over 100 viruses implicated worldwide• Symptoms
– Fever– Headache– Behavioral changes– Altered level of consciousness– Focal neurologic deficits– Seizures
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Etiology
Non-Arbo viral• Herpes viruses (sporadic)
– HSV-1, HSV-2– varicella zoster virus– cytomegalovirus– Epstein-Barr virus– human herpes virus 6
• Adenoviruses• Influenza A• Enteroviruses, poliovirus• Mumps• Rabies
Arbo-Viral (epidemic)• Flaviviridae
– Japanese encephalitis– St. Louis encephalitis– West Nile
• Togaviridae– Eastern equine encephalitis– Western equine encephalitis
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– Herpes simplex virus (HSV) • the most common etiology of acute sporadic
encephalitis– Arboviruses – arthropod-borne virus
• outbreaks in summer time…mosquitos and ticks– Varicella zoster virus (VZV)
• immunosuppressed patients
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Japanese encephalitis
• Most important cause of arboviral encephalitis worldwide
• Transmitted by culex mosquito, which breeds in rice fields
• Commonly involve Basal ganglia: Extra pyradimal symptoms
• Post-immunization: Measles, Mumps
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Herpes Simplex Encephalitis
• Primary infection: On the mucosa of oropharynx, mostly asymptomatic
• Following primary infection, a latent infection in trigeminal ganglion
• Inflammation and necrotizing lesions in – Inferior and medial temporal lobe– Orbito-frontal lobe– Limbic structures
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• Evolve over several days or acutely• Fever, headache, confusion, stupor, coma,
seizures, status epilepticus• Personality changes, irritability, delirium• Temporal lobe seizures: Gustatory or olfactory
hallucinations, anosmia
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CSF Analysis• Increases CSF pressure• Cell count: 10-500 cells/mm3
• Lymphocyte predominance • Erythrocytes (in 80% of the cases) • Normal CSF findings in 10%
• Xanthochromia: Due to lysis of RBC• Glucose (mg/dl): normal or low • Protein (mg/dl): >50 mg/dl• HSV PCR: For the first 24-48 hours, detecting HSV DNA
by PCR in CSF: – specific (100%) and – sensitive (75-98%)
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Neuroimaging
• Contrast Enhanced MRI• Sensitive for early period HSV encephalitis• Edema in orbitofrontal and temporal regions
• CT Scan– Less sensitive than MRI
• EEG– If seizures are the features
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Treatment
• If shock/hypotension exists, crystalloid infusion
• If unconscious, provide airway/breathing• Seizure, lorazepam 0.1 mg/kg, IV• Acyclovir IV, 14 – 21 days
– Neonates and infant: 60 mg/kg/day in 3 divided doses
– Children: 30 mg/kg in 3 divided doses• Reduce ICP: restrict fluid, hyperventilation• Acute psychosis: Haloperidol
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References
• Nelson Textbook of Pediatrics 20th edition• Essential Pediatrics, OP Ghai, 8th Edition• Harrisons textbook of Internal Medicine• AAP Guidelines 2016
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Thank You