E-Viral Meningitis. Meningitis; symptoms of meningitis: headache, ever, neck stiffness, nausea and vomiting, photophobia rash (if meningococcal), brudzinski and kernig sign positive. What are they? Brudzinski's, the patient lies supine (flat) flexion of the neck elicits flexion of the hip. Kernig's; The thigh is bent at the hip and knee at 90 degree angles and subsequent extension in the knee is painful. Remember Kernig’s equals knee, brudzinski’s is the other one. Meningitis can be viral or bacterial, viral is not as serious and only requires supportive treatment. The easiest way to differentiate is through an LP; a viral LP, will have normal glucose levels, normal or high protein levels (because virus are basically just proteins so they may raise the count but they are also bloody small so the may not), and high lymphocytes because lymphocytes fight viruses. Bacterial meningitis will have low glucose (because bacteria eats glucose), high protein count (due to the extra cells and thus extra protein, either due to cell breakdown or increased flow across the compromised BBB), and high neutrophils because they fight bacteria. So just recap that, viruses; normal glucose, normal or high protein, high lymphocytes, bacteria; low glucose, high proteins, high neutrophils, subarachnoid xanthochromia.
If you must always CT someone before you LP them or you could cause them to cone and kill them. Coning is when the cerebellum goes through the foramen ovale.
If it is bacterial then we want to know what sort of bacteria, the most common sorts are
Group B Streptococcus, Streptococcus pneumoniae (AKA pneumoccus) , Escherichia coli, Listeria monocytogenes
In Infants and Children
Streptococcus pneumoniae, Neisseria meningitidis (meningococcus), Haemophilus influenzae type b (Hib), Group B Streptococcus
In Adolescents and Young Adults
Neisseria meningitidis, Streptococcus pneumoniae
In Older Adults
Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae type b (Hib), Group B Streptococcus, Listeria monocytogenes
There are now vaccines for Neisseria meningitidis, Streptococcus pneumoniae, Haemophilus influenzae type b (Hib) so it’s important to ask about vaccinations.
Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae type b (Hib), Group B Streptococcus are all encapsulated which is notable as people with asplenia or functional asplenia (like people with sickle cell), and children (who can’t make antibodies to polysaccharides) are more susceptible encapsulated bacteria.
Empirical treatment for an adult is ceftriaxone, unless you suspect meningococcus in which case its benzyl penicillin.
Empirical treatment in Children less than two months old, no steroids, Cefotaxime AND benzylpenicillin and Gentamicin in case of gram negative
In Children over 2 months ceftriaxone or cefotaxime and dexamethasone
Meningitis is incredibly serious and any contacts need to be traced and treated.
Remember: fever, headache, rash, photophobia, neck stiffness, take two blood samples for cultures and then start IV Benpen and ceftriaxone, if you're in a GP setting the IM Benpen on the spot.