Meningitis, brain abscess. Encephalitis etc

Meningitis Inflammation of the meninges Classified into aseptic and septic Aseptic : not bacteria. Virus or secondary to lymphoma, leukemia or brain abscess Septic : bacteria Most common : Neisseria meningitidis, Haemophilus influenzae, Streptococcus pneumoniae Factors that increase the risk of meningitis : viral URI, otitis media, mastoiditis

Pathophysiology Infection through the blood stream as a consequence of other infections Or by direct extension – traumatic injury to the facial bones or secondary to invasive procedures Aids may predispose to meninges – mostly S.pneumoniae The bacteria in the blood stream cross the blood-brain barrier and cause inflammation of the meninges Inflammatory cells from the meninges spill into the csf and the cell count in the csf increases

Complications of meningitis Visual impairment Deafness Seizures Paralysis Hydrocephalus septic shock

Clinical Manifestations Headache (severe) Fever (these two are initial symptoms)(high throughout the illness.) Signs of meningeal irritation : neck rigidity positive Kernig’s sign positive Brudzinski’s sign photophobia A rash – N.meningitidis infection. Skin lesions develop, ranging from a petechial rash with purpuric lesions to large areas of ecchymosis. Disorientation Memory impairment Meningism is the triad of nuchal rigidity, photophobia (intolerance of bright light) and headache. It is a sign of irritation of the meninges, such as seen in meningitis, subarachnoid hemorrhages and various other diseases. "Meningismus" is the term used when the above listed symptoms are present without actual infection or inflammation; Nuchal rigidity — the inability to flex the head forward due to rigidity of the neck muscles. Brudzinski’s sign — the involuntary lifting of the legs in meningeal irritation when lifting a patient’s head. Kernig’s sign — the resistance and pain when knee is extended with hips fully flexed. Patients may also show opisthotonus—spasm of the whole body that leads to legs and head being bent back and body bowed forward. Also known as: Babinski's reflex Babinski’s test Associated persons: Joseph Jules François Félix Babinski Description: A pathological reflex where the great toe extends and flexes toward the top of the foot and the other toes fan out when the sole of the foot is firmly stroked. Normally, the great toe is flexed when the sole of the relaxed foot is stroked. Babinski’s reflex is normal in children up to about two years of age. The persistence in older people is a sign of damage to the corticospinal tract. Because this tract is right- and left-sided, a Babinski’s reflex can occur on one side or on both sides. An abnormal Babinski’s reflex can be temporary or permanent.

Behavioural changes As the disease advances – lethargy Unresponsiveness Coma Seizures ↑ ICP – decreased level of consciousness and focal motor deficits – later herniation and cranial nerve dysfunction and depression of centres of vital function Septicemia – high fever, extensive purpuric lesions intravascular coagulopathy (DIC). Death

Assessment and diagnostic findings Lumbar puncture – CSF culture and sensitivity, Gram’s staining, CSF analysis : the presence of polysaccharide antigen supports the diagnosis of bacterial meningitis.

Prevention Vaccinating against meningococcal meningitis – college freshmen, people living in dormataries Prophylactic treatment of people in contact with meningitis cases – rifampin, ciprofloxacin, ceftrioxone Na.

Medical Management Penicillin antibiotics Cephalosporins (eg ceftrioxone Na., cefotaxime Na) Vancomycin, in combination with rifampicin for resistant strains Steroids 15 minutes befor the antibiotics Dehydration and shock treated Phenytoin for seizures Increased ICP is treated as necessary

Nursing Management Patient is usually critically ill Neurologic status and vital signs are continually assessed. Pulse oximetry and arterial blood gas values monitored Respiratory support if needed Increasing ICP compromises the brain stem. Arterial blood pressures monitored – to predict shock and prevent cardiac or respiratory failure

Nursing Management Rapid IV fluids may be needed If fever + reduce temperature – (fever  increased metabolic demand) Monitor body weight, serum electrolytes and urine volume, specific gravity and osmolarity, esp. if the syndrome of inappropriate antidiuretic hormone secretion is suspected.

Nursing Management Protect from injury secondary to seizure activity or altered level of consciousness Prevent complications associated with immobility, such as pressure ulcers and pneumonia Institute droplet precautions until 24 hours after the initiation of antibiotic therapy (oral and nasal discharge is considered infectious) Communicate with the patient’s family and allow them to see the patient. Give them moral support

The rash in meningitis caused by Neisseria meningitidis typically has petechial and purpuric components

The characteristic skin rash (purpura) of meningococcal septicemia, caused by Neisseria meningitidis