Meningitis

Welcome to PT 635 Pathophysiology of Complex Patient Problems This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors - Students from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Lead Editors - Your name will be added here if you are a lead editor on this page.  Read more.

Definition/Description

Meningitis is an infectious disease of the central nervous system that causes inflammation of the meningeal membranes. All three meningies may become involved, dura matter, arachnoid, and pia matter. The pia matter and arachnoid layers become inflamed and opaque. The first two layers of the cortex and the spinal cord become inflamed as well. As a result of the inflammation many complications may occur. There is an increased risk of infarctions and cortical veins may develop thrombosis. In addition, blockage of the flow of CSF may occur secondary to scar tissue. This blockage is most common at the base of the brain. CSF blockage may result in subarachnoid cysts or hydrocephaly resulting in a headache, considered a cardinal sign. The disease may present as acute (over a period of hours or days), subacute (more than two weeks), or chronic (more than one month).

Aseptic and Bacterial meningitis are the most common forms of acute meningitis. Aseptic meningitis is usually a result of fungi, viruses, parasites, bacteria, or in some cases a noninfectious inflammation. This form of meningitis is usually self-limited. Bacterial meningitis is a much more serious illness and if goes untreated is fatal. Progression is very rapid and is distinguished by purulent CSF. 

Prevalence

The prevalence of meningitis has greatly decreased over the last fifteen years due to the development of vaccines. The second most common bacteria that causes acute bacterial meningitis, meningocicci, is present in the nasopharynx of approximately 5% of the population. Close contact or respiratory droplets may spread the bacteria. Of the population that has the bacteria, only a small fraction develops meningitis and the most prevalent age range is from birth to one year. As individuals move through the late adolescence development stage, they experience a second period of increased vulnerability. In adulthood, bacterial meningitis usually is limited to individuals who have conditions that inhibit the immune system. Bacterial meningitis is usually associated with This form of meningitis appears more frequently in populations that are in close living quarters such as college dormitories, military barracks, and boarding schools.

Characteristics/Clinical Presentation

Headache, fever, and rigidity of the neck are the most common symptoms that present with the onset of meningitis. Pain in the posterior thigh or lumbar region may also be noted. Meningitis causes inflammation of the meningeal membranes, as a result nerve roots may endure tension as they pass through the inflamed membranes. Passive ROM of the neck into flexion will become painful and limited. Extension and rotation may be painful as well, but to the extent of in the direction of flexion. In some cases passive neck flexion may produce flexion of the hips or knee, this is known as Brudzinki’s sign and is usually only seen in the most severe cases. Another sign that is usually seen in the most severe cases is the Kernig’s sign, which is defined as passive extension of the knee while the hip is flexed that produces restriction.

In cases when meningitis is not treated immediately (especially bacterial meningitis), the parenchyma within the brain may be involved. As a result individuals may present with lethargy, vomiting, seizures, papilledema, confusion, coma, focal deficits, and cranial nerve palsies.

(PIC of Brudzinki’s sign and kernig’s)

Associated Co-morbidities

Predisposing conditions of meningitis include sinusitis, mastioditis, and otitis. These conditions may require specialized treatment. Damage or removal of the spleen increases the risk of pneumococcal disease which may lead to acute bacterial meningitis. Conditions in which an individuals immune system may become compromised increase the risk and severity of meningitis, such as HIV.

Medications

Quick introduction of antibiotics is crucial when acute meningitis is suspected to prevent progression of the disease and increase the chance of recovery. If a patient presents with the cardinal signs and symptoms of meningitis antibiotics are immediately started after blood cultures are drawn. If the patient is not severely ill and the diagnosis of meningitis is questionable introduction of antibiotics is held until results from CSF stains are determined. Once CSF gram stains are determined targeted antimicrobial treatment may begin. Duration of antimicrobial treatment is determined by CSF sterilization. Organism specific antibiotics used to treat acute bacterial meningitis may be found in Table 1. The table lists the common organisms that result in acute meningitis along with the age appropriate antibiotics.

Table 1: Common antibiotics used to treat specific acute bacterial meningitis. Adapted from The Merck Manual of Diagnosis and Therapy.

Organism	Age Group	Antibiotic
Unknown	Infants less than 1 month	Ampicillin Cefotaxime Gentamicin
	Children over 1 month of age and Adults	Ampicillin Cefotaxime Vancomycin
Gram-positive organisms (unidentified)	Children and Adults	Ceftriaxone Vancomycin Ampicillin
Gram-negative bacilli (unidentified)	Children and Adults	Cefazidime Gentamicin
Haemophilus influenza  type b	Children and Adults	Ceftriaxone
Meningococci	Children and Adults	Penicillin G plus ceftriaxone
Streptococci	Children and Adults	Vancomcin Nafcillin these drugs may be prescribed with or without rifampin
Listeria sp	Children and Adults	Ampicillin Gentamicin Trimethoprim-sulfamethoxaxzole
Enteric gram-negative bacteria  (Escherichia coli, Proteus sp, Klebsiella sp)	Children and Adults	Ceftriaxone  Gentamicin
Pseudomonas	Children and Adults	Ceftazidime Cefepime These may be used with the addition of aminoglycoside

Staphyococci

Children and Adults

Vancomycin  Nafcillin May be prescribed with or without rifampin

In addition to antibiotics, medications to control and relieve the symptoms of meningitis are introduced as well. Alterations of CSF flow may be controlled using steroids. Inflammation of the subarachnoid space that is linked to mortality and morbidity is reduced with the use of dexamethasone. Antiseizure medication is used to control seizure activity. Viral meningitis is not as severe as bacterial and most patients recover within one to two weeks. Symptoms, nausea and headache, are controlled using the proper medications.

Diagnostic Tests/Lab Tests/Lab Values

add text here

Causes

add text here

Systemic Involvement

add text here

Medical Management (current best evidence)

add text here

Physical Therapy Management (current best evidence)

add text here

Alternative/Holistic Management (current best evidence)

add text here

Differential Diagnosis

add text here

Case Reports

add links to case studies here (case studies should be added on new pages using the case study template)

Resources

add appropriate resources here

Recent Related Research (from Pubmed)

see tutorial on Adding PubMed Feed

References

see adding references tutorial.